Combination Pain Relief

For pain management, we'd normally say it is best to start with the mildest pain relief and work your way upwards to the strongest if necessary. When managing your pain over the counter, we recommend you follow the pain relief ladder.

• Paracetamol is the first step on our pain relief ladder because it has relatively few risks or side effects if taken as instructed. As well as being a painkiller, paracetamol is also effective at lowering a fever.
• The next step in our pain relief ladder is to swap paracetamol for ibuprofen. Paracetamol is preferred over ibuprofen as it’s considered safer, but they offer a similar level of pain relief. Ibuprofen is an NSAID which means it has an anti-inflammatory effect making it a useful tool for inflammatory conditions. NSAIDs should always take them with food. This is because they carry the risk of gastrointestinal bleeding, which means those with a history of bleeding or a stomach ulcer, or the elderly, should avoid them.
• The next step if ibuprofen alone is ineffective is to try both paracetamol and ibuprofen together. Products such as Nuromol combine the two medications.

The next step on our pain relief ladder is to try a weak opioid such as codeine. In some countries including the UK, codeine is only available over-the-counter in combination with other painkillers (namely paracetamol, ibuprofen, or aspirin). Co-codamol contains paracetamol and codeine in combination. Codeine is a stronger painkiller than paracetamol and ibuprofen. It is safe to take paracetamol, ibuprofen, and codeine altogether. Alternatively, you can just take co-codamol. Side effects from codeine can include constipation, drowsiness, and feeling dizzy, sick, or slightly out of it. Certain people seem more susceptible to this “wooziness” than others. It is also possible to become addicted to codeine if you take it for too long. Codeine also carries a risk of dependency, where you feel unwell when you go without the medication. For these reasons, it is best to speak with your doctor before taking co-codamol or any other codeine-containing painkiller for longer than three consecutive days (especially if you are taking the full recommended dose for the product).

As mentioned above, some over-the-counter products combine an NSAID (namely ibuprofen or aspirin) with codeine. Nurofen Plus (ibuprofen and codeine) and Codis (aspirin and codeine) are examples. Aspirin can be used as an alternative to ibuprofen in our pain relief ladder, but it has fallen out of favour as a preferred pain relief option due to its side effects. It’s still regularly used at a low dose to reduce the risk of heart disease, but this is an anti-platelet action rather than anti-pain or anti-inflammatory.

Paracetamol and dihydrocodeine (found over-the-counter under the brand name Paramol) is an alternative medication you can try in our pain relief ladder in place of co-codamol. Dihydrocodeine (like codeine) is also a weak opioid. However, dihydrocodeine is thought to be about twice as strong as codeine. Like with co-codamol, it is best to speak with your doctor before taking paracetamol and dihydrocodeine for longer than three consecutive days (especially if you are taking the full recommended dose for the product).