We seem to be in a lot of pain, at least if our consumption of drugs designed to relieve it is anything to go by.
Judy Mullan, a professor at the University of Wollongong’s School of Medicine with extensive experience as a pharmacist, knew anecdotally that people buying over-the-counter medicines rarely considered the side effects. She confirmed her suspicions by doing research with popular drug brand Nurofen, which contains the anti-inflammatory ibuprofen, as well as Nurofen Plus, which blends it with the analgesic codeine.
“Everyone who bought a pack in a pharmacy did a written survey,” she says. “We asked what the active ingredient was, and many respondents answered correctly, although a large proportion thought paracetamol was also in the product. We asked what was the safest maximum dose and a lot of people got that wrong. And we asked about potential side effects and less than half recognised that they had any side effects.”
Mullan says the people surveyed were well educated and health-literate. She has since repeated the study with Panadol, which contains the active ingredient paracetamol. And she has collaborated with the University of Auckland to do Facebook-based research with Nurofen For Children. Again, half of consumers didn’t realise the drug had side effects.
“Even though all the information is on the packet, people will say, ‘No I’ve had this before, it’s fine.’”
In fact, NSAIDS (non-steroidal anti-inflammatory drugs) such as ibuprofen can worsen asthma symptoms and should be avoided by those with stomach ulcers and sufferers of gastric reflux. They may not be the best choice for patients with kidney disease, heart disease or high blood pressure. Meanwhile, codeine can result in drowsiness and, like other opioids, may be addictive, and too much paracetamol causes liver damage.
“When they are advertised, we’re told they help with headaches, period pain or back pain. None of the advertising suggests we should look out for side effects.”
Mullan found that almost one in five people weren’t sure if they should check with their doctor to find out whether over-the-counter drugs were safe to take alongside prescription medicines.
“The ones in trouble are those with osteoarthritis or chronic pain conditions who are taking their medication diligently as prescribed. Then a friend will recommend an over-the-counter medicine that worked for them and they’ll start taking it not realising it’s a similar class of drugs and it’s putting them over the recommended dose,” says Mullan.
It is particularly easy to overdo paracetamol since it is included in other products, such as cold and flu medicines, and people don’t realise they are doubling up.
“Often if they do get side effects, they don’t make the link with the over-the-counter drug they’re taking.”
There are many different brands of painkillers, and the elderly in particular can get confused. Mullan is collaborating with UK researchers in a study looking at people who inadvertently take a number of different products containing paracetamol and ibuprofen.
Some people swallow too many painkillers on purpose. Research at Wellington Hospital found that from 2007-2012, paracetamol accounted for nearly a quarter of overdoses, with most being deliberate self-harm and 8.6% accidental therapeutic overdose.
The answer isn’t to stop over-the-counter sales of painkillers altogether, because of the inconvenience of having to get a prescription for every headache or bout of period pain. Sales of medication containing the mild opiate codeine, such as Nurofen Plus, are already subject to controls, with pharmacists having to consult the buyer, and there have been calls in Australia and New Zealand to ban over-the-counter sales of codeine-containing drugs.
Making other painkillers less freely available is an option – in Sweden, paracetamol can’t be bought in supermarkets. Reducing the packet size and limiting the number of packets that can be sold in a single pharmacy visit have also been touted as solutions.
“I don’t think there is one simple answer,” says Mullan. “But the labelling on packets needs to be clearer and simpler to understand, advertising ought to address potential side effects as well as all the wonderful things these pills do, and doctors need to ask patients if they are taking anything other than their prescribed medication. If you target all these aspects, it might make a difference.”