Simple painkillers (such as aspirin, paracetamol and ibuprofen) are widely bought over the counter and prescribed by doctors. But the stark truth is that most of these medicines don’t work very well.
Professionals can’t be satisfied advising consumers and patients to take ineffective medicines. And consumers and patients can’t be happy that they’re spending cash or NHS resources on something that doesn’t do the job. But those with minor ailments who opt for such drugs aren’t necessarily wasting their money – and may well be saving yours by reducing the burden on health services.
An evidence-based approach to pain relief must consider realistic alternatives. Trials demonstrate that simple over-the-counter (OTC) painkillers, such as paracetamol for low back pain and aspirin for episodic tension-type headaches in adults, work no better than placebo. But in practice, we need to consider how harmful this really is – and what people would do if they weren’t popping their favourite pills.
Cochrane reviews are internationally-recognised systematic reviews. The most recent review of asprin for the treatment of occasional, acute, tension-type headache tells us that patients taking active medication are unlikely to be pain free. However, over half the patients taking aspirin were satisfied with their treatment, as were one third taking placebo.
Similarly, in a Cochrane review of paracetamol for the treatment of acute low back pain, 4g of paracetamol daily was found to be no more effective than placebo.
In both studies, active and placebo treatments had similarly low rates of side-effects.
More placebo, please
This isn’t a good situation, but the placebo effect itself is often overlooked or treated with disdain. Which is a pity – it could be better employed in the fight against pain. A 2002 review of placebo effects in clinical pain killer trials concluded:
If the factors that contribute to placebo analgesia are identified, they could be optimised in clinical practice whereby the general effectiveness of pain treatments could be enhanced.
And placebo effects were greater when studies specifically tried to investigate how placebos work. In another context, a 2009 meta-analysis of anti-depressant trials concluded:
The placebo effect accounted for 68% of the effect in the drug groups. Whereas clinical trials need to control the placebo effect, clinical practice should attempt to use its full power.
Patient demand for pain relief in the UK is clear, around £575m a year is spent on OTC analgesics and another £567m on analgesics prescribed in primary care. The primary care spend includes £90m on products that could be bought OTC and £115m on compound painkillers that are the next step up the pain ladder.
Indeed, people may be willing to pay significant sums for pain relief, which is a measure of economic benefit – a few pounds to relieve everyday pain, tens of pounds to relieve post-operative pain, and hundreds of pounds to relieve chronic pain.
But the current supermarket price for paracetamol is little more than 1p per tablet – and stronger painkillers use codeine and related drugs, which significantly increase the risk of harmful side-effects.
For acute pain, simple safe painkillers are cheap (it’s certainly worth buying generic rather than more expensive branded varieties) and promote active self-management of minor ailments. They may also help to engage the placebo effect. The evidence for effectiveness beyond the placebo effect is mixed (as the Cochrane reviews demonstrate), but doing something does have an effect and painkillers may actively help in some cases.
When people buy these painkillers, they also save the NHS – and taxpayers – the expense of visiting a doctor and having them prescribed. Generic paracetamol costs 19-30p for 16 in the supermarket and 35p on prescription. However, consultation and dispensing costs are considerable.
The spend on OTC painkillers might therefore be like buying a lottery ticket – they will work really well for some people, and rather less well for others. Either way, the losses are insignificant. If there’s a chance that they’ll work for you, then it’s a small price to pay.
The bigger picture
Nevertheless, non-pharmacological actions (for example, rest, fluids, change in activities) are equally or more helpful than painkillers in many cases. So people should buy, obtain or use their painkillers in a supportive environment. For example, non-branded medicines are nearly as cheap in pharmacies as supermarkets, and your pharmacist should be able to talk you through the options and offer other advice, too. Doctors, meanwhile, need more time to explore problems with patients and shouldn’t need to write prescriptions to signal the end of a consultation. Their time could be better spent.
Imagine there was enough evidence to ban the OTC sale and prescription supply of simple painkillers. The supply of tea and sympathy would certainly have to increase. It is likely that the demand for compound pain killers or untested treatments would also increase, which risks more serious harm. There would also likely be an increase in visits to the doctor.
A goal to reduce the use of ineffective medicines is desirable. But we must also consider the alternatives and consequences. The treatment of pain isn’t the only area of clinical practice where hope is maximised over effectiveness. Improving the safety and effectiveness of chronic pain relief is a higher priority than reducing acute painkiller consumption. For now, people will keep using cheap (perhaps even quite expensive) OTC painkillers – and it’s hard to say they’re acting irrationally.