If there existed a simple pill to get rid of any pain without side effects there would be less need for health care practitioners, and many of us would be happily out of work.
Unfortunately every pain killer (or analgesic), whether bought over the counter or prescribed by your doctor, has side effects. How the different types of analgesics work, how they can be safely combined, and their side effects is often misunderstood by dancers and non-dancers. Dancers are more likely to suffer from long-term complications of regular use due to their increased risk of injury, early joint problems and young age.Just as individuals have different responses to similar injuries, with varying amounts of pain, they also react differently to analgesics, in their effects and side effects. In the last few months two analgesics, co-proxamol and rofecoxib (Vioxx), have been withdrawn from the UK due to concerns about their safety. This article aims to inform the reader of the different types of analgesics, how they can be combined safely for maximum effect, their side effects and the importance of not taking different drugs of the same type. This article only deals with analgesic medication. There are many other methods for dealing with both acute and chronic pain:
Pain Management Without Drugs
- Rest, Ice, Compression, Elevation for acute injuries (RICE)
- Transcutaneous Electrical Nerve Stimulation (TENS)
- Hot / Cold
“Always Read The Label”
Familiar words? All drugs contain information, either on the bottle or on an information sheet about dosage and frequency of administration. It also usually provides a guide to the lower dosage to be taken by children.
Groups of Pain Killers (Analgesics)
- Maximum adult dose: Maximum 4g daily (1 gram 4 times a day).
- Side effects: Safe drug and side effects rare, but can seriously damage the liver and kidneys in overdose.
Paracetamol is available from many shops without prescription. It is often an ingredient in other medications such as cough and flu remedies. It acts as an analgesic and antipyretic (reduces temperature).
Only one medication containing paracetamol should be used at any one time, because of the risk of overdose. Paracetamol in overdose can cause irreversible liver damage and death with even a small overdose of as few as 20 to 30 tablets taken in a day. Taking more than the recommended dose does not increase the amount of pain relief because of a ceiling effect.Only one medication containing paracetamol should be used at any one time, because of the risk of overdose. Paracetamol in overdose can cause irreversible liver damage and death with even a small overdose of as few as 20 to 30 tablets taken in a day. Taking more than the recommended dose does not increase the amount of pain relief because of a ceiling effect. Paracetamol also acts to increase the effectiveness of other analgesics, especially codeine derivatives. Codeine alone is less effective than codeine with paracetamol. Co-proxamol: Low dose paracetamol mixed with another codeine-like drug called dextropropoxyphene, has been shown to have a higher risk of overdose with only a similar relief from pain as normal strength paracetamol. It has been withdrawn from sale in the UK.
Non-steroidal Anti-inflammatory Drugs (NSAIDs)
- Maximum adult dose: Varies depending on type.
- Side effects: Stomach irritation / ulcers, nausea, diarrhoea, kidney damage, and occasionally bleeding.
Ibuprofen is the best-known NSAID, and the only one available over the counter without prescription. All NSAIDs act to reduce inflammation, reduce temperature and relieve pain, but some are more effective and stronger than others. They should not be taken by asthmatics. NSAIDs have also be shown to slow down the healing of fractured bones, and so should, where possible, be avoided in that situation. Different preparations are available, such as oral tablets, suppositories, injections and topical gels.
List of NSAIDs (Proprietary versions in brackets)
- Ibuprofen (Nurofen)
- Diclofenac Sodium (Voltarol)
- Ketoprofen (Orudis)
- Mefenamic Acid (Ponstan)
- Meloxicam (Mobic)
- Naproxen (Arthroxen, Naprosyn)
- Piroxicam (Feldene, Brexidol)
- Celecoxib (Celebrex)
- Rofecoxib (Vioxx)
The combined use of NSAIDs taken by different routes is not advisable. A topically used NSAID is absorbed by the body systemically, substantially increasing the risk of side effects.NSAIDs are useful in the treatment of inflammation related problems such as arthritis, tendonitis and acute muscle strains, and in such situations can be better than an opioid. (see 3, below) They work best when taken regularly in the acute setting for as long as symptoms persist. Different NSAIDs should never be used together, due to the increased risk of bleeding and stomach irritation. People on long-term NSAIDs are sometimes given a second drug which protects the stomach, this can either be as a separate tablet or a combined tablet, such as Napratec, a combination of naproxen and misoprostol, as stomach protector.
A more specific type of NSAID, called COX 2 inhibitors, are available by prescription, including celecoxib, rofecoxib and meloxicam. These have fewer gut side effects.Rofecoxib: Unfortunately recently withdrawn as it is associated with increased risk in certain cardiac patients. There is some concern that the other COX 2 inhibitors may have similar problems.
- Maximum adult dose: max 4g daily (300–900 mg every 4–6 hours when necessary).
- Side-effects: Generally mild and infrequent but high incidence of stomach irritation/ulcers; reduced blood clotting (thus used in people with heart problems), can cause an acute asthma attack in asthmatics.
Aspirin is a good mild pain reliever which, like paracetamol also brings the temperature down. It should not be given to people under 16, those with asthma or stomach ulcers, or anyone already taking anti-inflammatory medication. The blood thinning effects mean that it’s prescribed for people with heart disease, and it tends not be used often for it’s pain relieving properties, taking a back seat to the other analgesics.
Asthma: NSAIDs or aspirin can cause severe asthma attacks in some asthmatics. If you are asthmatic and have never taken either, it is best to consult your doctor prior to taking them.
- Maximum adult dose: Varies depending on type.
- Side-effects: Nausea and vomiting (particularly in initial stages), constipation, itchness and drowsiness; larger doses produce respiratory depression and drop the blood pressure.
This group of analgesics were originally derived from the opium poppy, hence their name. They have a wide range of strengths, ranging from the mild e.g. codiene, through tramadol and pethidine to the strong and well-known morphine. They are better at relieving a dull chronic pain than an acute injury pain, due to their method of action. They do not have the anti-inflammatory or anti-pyretic properties of other analgesics.
The common weak opioids are codeine phosphate and dihydrocodeine. These may be combined with paracetamol as mentioned previously. Only the weakest combinations are available over the counter, the others are prescription only.Laxatives are often used to counteract the constipatory side effects of opioids.
Suggested Guidelines for Use
Whether for a simple headache the morning after, or a serious ankle sprain, it is always best to take an analgesic with the fewest side effects to start with em.e. Paracetamol.
If occasional paracetamol is not helping with the pain, then it is worth taking it regularly em.e. 1gram every 6 hours. Regular administration will keep the concentration of paracetamol in the blood above the level your body needs to reduce pain and avoid side effects.If pain persists first try taking an occasional NSAID when the pain is at it’s worst. If this is not effective, then take the NSAID regularly, and continue to take the paracetamol. With continuing pain, either ibuprofen can be replaced with a stronger NSAID, or a weak opioid can be added, such as codeine. If a paracetamol-opioid preparation such as co-dydramol is taken, it is then essential to stop taking the single paracetamol tablets as well. If despite the use of all three types, the pain is still uncontrollable, then the NSAID and/or opioid can be replaced by a stronger type. It is always worth taking the paracetamol as well. However now is probably the time to: “Consult your doctor!”
Consider the Cause
The most important caveat with the above guideline is to always be aware of the cause for the pain. In the same way that the quickest and best relief of a burn is to remove the hot object, it is equally important to identify and treat the cause of pain.
While the mild analgesics you can obtain over the container help relieve pain, they will not act to mask it. Stronger prescription-only analgesics can act to mask the cause of pain. This may be helpful if you absolutely must dance for one particular event. However, in the long-term, pain is a message from your body that something is wrong. Ignoring it firstly doesn’t allow the body to heal, and secondly, can worsen the damage and the long-term outcome.Injury management for a dancer is multi-factorial, and highly dependent on the injury. It should involve the careful use of rest, focussed exercise and input from a physiotherapist or health practitioner. Pain management using analgesics provides comfort for the dancer while they are healing in the acute setting and to control their symptoms in the chronic pain setting.
Hopefully this article has shown that a quote from a dance teacher that “Dancers think that if 2 are good, then 4 must be better” is not only wrong, but why it is wrong. It is always better to err on the side of caution. If you have any concerns, consult your doctor, who should be able to offer objective advice.
Dr Joshua Burrill is a Radiology Registrar and Consultant Anaesthetics Pain Medicine, St Mary’s Hospital, Praed Street, London W2 1NY.