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Best painkillers for acute pain

Posted by medconsumers on September 10, 2011

Which oral painkillers are the most effective for acute pain when taken as a single dose? The answer comes from a new review of 350 studies that evaluated commonly used oral painkillers taken in various combinations and at different doses. These studies have a combined total of about 45,000 participants whose acute pain was due to “tissue…damaged either by an injury or as a result of surgery.” Although the review came to a largely encouraging conclusion about painkiller effectiveness, it offered this caution: “No drug produced high levels of pain relief in all patients.” A trial and error approach was advised for finding the right fit for people in acute pain.

Three classes of oral painkillers were the focus of this review. The first two are sold over the counter: acetaminophen (brand name: Tylenol) and non-steroidal, anti-inflammatory drugs, aka NSAIDs (some examples: ibuprofen, naproxen, aspirin). The third, known as opioids (codeine, oxycodone), are sold only by prescription in the U.S.

The Cochrane review was led by Dr. R. Andrew Moore of the Oxford Pain Research Unit at Oxford University, U.K., and published this month in the Cochrane Library. This was a massive undertaking because it is a review of 35 previously published Cochrane reviews of clinical trials in which the participants achieved at least 50% pain relief over a 4-6 hour period. The trials in these reviews explored various drug/dose combinations to see which worked the best in people with similar levels of pain. Ultimately, 46 drug/dose combinations were found to be supported by reliable evidence.

The goal of this new review was to find which painkiller or combination of painkillers worked best when taken as a single dose.

Most study participants had had surgery and were transitioning from intravenous pain relief to oral treatment for pain, or they had had wisdom teeth removed. The studies were short-term, lasting 2 to 20 hours. When pain did not start to diminish after about an hour, another drug was taken. With the exception of those taking an opioid, the rate of adverse drug reactions was no greater among the drug-treated participants than those assigned randomly to take a placebo. (By the way, no matter what drug or other treatment is being studied, some clinical trial participants who are randomly assigned to take a placebo report feeling better. In this review, 18% of those taking a placebo reported pain relief.)

Good pain relief was achieved in 70% of people who took a single dose of two over-the-counbter drugs:  acetaminophen 500 mg plus ibuprofen 200 mg. In a telephone interview, Dr. Moore, the lead author of the Cochrane review, said, “We’ve already published a paper on this exact combination and here in the U.K. you can buy it as one tablet. But when I’m in the U.S., I buy a great big pack of each at the cheapest price at the pharmacist or someplace like Wal-Mart, and I take one tablet from each. We know that this is the cheapest way of getting pain relief.” But, he cautioned, this combination won’t work for everyone.

When compared with placebos,  a single dose of one of the following drugs and combinations provided 50% pain relief for four to six hours : ibuprofen 400 mg, diclofenac (some brand names: Voltaren, Cataflam) 50 mg, codeine 60 mg plus acetaminophen 1000 mg, ibuprofen 400 mg, diclofenac 50 mg, celecoxib (Celebrex ) 400 mg, and naproxen 500 or 550 mg. Only 35% benefitted from taking 1000 mg aspirin plus acetaminophen 600 mg.

The smallest percentage (14%) of participants received significant pain relief from codeine. When Dr. Moore was asked about the well known adverse effects of opioids, such as nausea, vomiting and constipation, he said, “78% of the study participants who took codeine did not experience these adverse effects.”

From  the Cochrane review entitled, “Single dose oral analgesics for acute postoperative pain in adults,” which was funded by the Oxford Pain Research Trust.

Maryann Napoli, Center for Medical Consumers©

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