Pain means different things to different people, for example some think of pain as an acute condition that will inevitably get better whilst others see it as a chronic condition associated with degenerative disease or cancer. Disease or tissue injury are only two of the factors contributing to the experience of pain. Measuring pain is subjective and assessment of the patient should take into account cultural conditioning, social contingencies, mood state and expectations.

Prescribing of analgesics should usually follow the WHO pain ladder:

• Step one - simple non-opioid ie paracetamol or a non-steroidal anti-inflammatory drug
  
  
• Step two - an opioid for mild to moderate pain with or without a non-opioid
  
  
• Step three - an opioid for moderate to severe pain with or without a non-opioid.

Paracetamol and Paracetamol Combinations
Prescribing of non-opioid analgesics has increased slightly over the last 5 years, the vast majority of prescribing being paracetamol or paracetamol combination products. There were 2.4 million prescriptions for paracetamol in the quarter to September 2000 at a cost of just £2.5 million. On the other hand there were 2.1 million prescriptions for paracetamol and codeine combinations at a cost of £10.6 million. Chart 3 shows the breakdown of paracetamol and paracetamol combinations for items and cost. Should combinations of paracetamol with an opioid be prescribed? A recent MeReC Bulletin1 reviewed the use of oral analgesics in primary care and concluded that there was little evidence that combinations containing low doses of opioid with aspirin or paracetamol are more effective than aspirin or paracetamol alone. These low doses may still be enough to cause opioid side effects in particular constipation. There is evidence that single oral doses of 60 mg codeine (e.g. for treating post-surgical pain from oral surgery) produce additional pain relief but patients are more likely to experience drowsiness and dizziness. Where there is a need to prescribe both 60mg codeine and paracetamol, it is best to prescribe them separately, as this will allow titration of each component and the costs will also be lower. Once pain control is well established an equivalent fixed dose preparation could be used if compliance is a problem, although the use of combination therapy has cost implications (see Price Chart).

NSAIDs
NSAIDs are commonly prescribed in osteoarthritis. A review by Dieppe et al3 found no good evidence that NSAIDs are superior to simple analgesics such as paracetamol or that any one of the many NSAIDs is more effective than the others in relieving the pain of osteoarthritis. The North of England NSAID Guideline Development Group concluded that initial treatment should be with paracetamol followed, if this fails, by ibuprofen4.

References

1. Anonymous. The use of oral analgesics in primary care. MeReC Bulletin 2000; 11: 1-4
2. Li Wan Po A, Zhang W. Y. Systematic overview of co-proxamol to assess analgesic effects of addition of dextropropoxyphene to paracetamol. BMJ 1997; 315: 1565-157
3. Dieppe P, et al. Osteoarthritris. Clinical Evidence Issue 4, BMJ Publishing Group, December 2000
4. Eccles M, et al. North of England evidence based guideline development project: summary guidelines for non-steroidal anti- inflammatory drugs versus basic analgesia in treating the pain of degenerative arthritis. BMJ 1998; 317: 526-530
5. Gotzsche P. Non-steroidal anti-inflammatory drugs. Clinical Evidence Issue 4, BMJ Publishing Group, December 2000
   
6. Anonymous. Are rofecoxib and celecoxib safer NSAIDs? Drug and Therapeutics Bulletin 2000; 38: 81-85
   
7. Silverstein F.E, et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis. The CLASS Study: A randomized controlled trial. JAMA 2000; 284: 1247-1255
   
8. Anonymous. Managing Migraine. Drug and Therapeutics Bulletin 1998;36:41-44