Which painkillers are effective?

Photo of a man taking painkillers (PantherMedia / Monkeybusiness Images)

Osteoarthritis pain can often be treated effectively with anti-inflammatory painkillers. But higher doses are often needed. Due to the possible associated risks, it’s recommended that the painkillers be taken as needed rather than all the time.

Osteoarthritis is typically treated with painkillers known as non-steroidal anti-inflammatory drugs (NSAIDs). These medications have an anti-inflammatory and pain-relieving effect. Examples of NSAIDs include diclofenac, ibuprofen and naproxen. Two other anti-inflammatory painkillers with a similar effect are celecoxib and etoricoxib. These are COX-2 inhibitors (also known as coxibs). They are taken as tablets or directly applied to the painful joint in the form of a gel or cream.

Some NSAIDs can be bought at pharmacies without a prescription – for example, to treat a headache or menstrual pain. To achieve noticeable pain relief in osteoarthritis, though, higher doses are often needed, and they have to be prescribed by a doctor.

NSAIDs and coxibs can relieve pain effectively, but they can also have side effects. The risk of serious side effects depends on your age and any other medical conditions you may have. But anti-inflammatory painkillers aren't suitable for everyone. People who already have other illnesses, like kidney problems or stomach ulcers, may not be able to take them or may have to go for regular check-ups. Sometimes reducing the dose is enough. Other reasons not to take NSAIDs or coxibs may include interactions with certain medications like acetylsalicylic acid (ASA). Alternatively, you can apply a cream or gel with a drug like diclofenac to your knee. Studies show that this can effectively relieve pain in some people with osteoarthritis of the knee. The drug etofenamate is available in the form of a cream or gel too. But its effectiveness hasn't been studied in good-quality studies.

Some people worry too much about the possible risks associated with painkillers. A few also worry about becoming dependent on them. But unlike opiate-based painkillers (opioids), NSAIDs and coxibs have no addictive effect. Other people worry that taking painkillers might prevent them from feeling alarm signals sent by their bodies. There’s no medical reason to worry, though: Chronic pain tells you much less about the condition of your joints than you might think.

It’s best to use anti-inflammatory painkillers in addition to other treatments, like exercise therapy. If you're thinking of taking painkillers right before exercising, it's a good idea to ask your doctor first.

How are NSAIDs and coxibs used?

There are a number of different NSAIDs and coxibs. The table below lists the names and doses of the drugs that are most commonly used to relieve osteoarthritis pain:

Drug

Typical single dose

Maximum daily dose

Celecoxib

100 to 200 mg 

400 mg

Diclofenac

50 to 100 mg (extended release)

150 mg

Etoricoxib

30 to 60 mg

60 mg

Ibuprofen

400 to 800 mg

2,400 mg

Naproxen

250 to 500 mg 

1,000 mg

Experts recommend that you only use these medications when the pain is bad rather than using them continuously. That can lower the risk of side effects.

It’s best to start at a low dose and increase it if necessary. It’s important not to exceed the maximum daily dose of a drug.

What can I expect from NSAIDs and coxibs?

Anti-inflammatory painkillers don’t always make the pain go away completely, but they usually relieve it. A group of researchers from Bern analyzed high-quality studies on the effects of NSAIDs, coxibs, and acetaminophen (paracetamol) in osteoarthritis – a total of more than 70 studies with almost 60,000 participants. The most effective painkillers were diclofenac (150 mg per day) and etoricoxib (60 mg per day). Acetaminophen isn't effective for osteoarthritis.

Whether or not a drug works will also depend on whether you have any other medical conditions and are using any other medication. That’s why it’s helpful to talk with your doctor before starting a treatment. She or he may check your kidney function, among other things, to make sure that you can safely use certain medications.

How common are side effects when taking NSAIDs and coxibs?

The most common side effects of anti-inflammatory painkillers are stomach problems. They range from minor problems like indigestion and stomach ache to more serious problems like gastritis (inflammation of the stomach lining), ulcers, and bleeding in the stomach or bowel (gastrointestinal bleeding). Taking medications with a meal can help.

Medications to protect the stomach, like omeprazole or pantoprazole, can effectively prevent gastrointestinal problems. They are from a group of drugs known as proton pump inhibitors (PPIs) and reduce the production of acid in the stomach. Studies show that this makes gastrointestinal complications relatively rare:

  • When taken for one year together with a PPI, high-dose diclofenac or etoricoxib lead to gastrointestinal complications in 0.2 to 0.4% of people.
  • This risk is higher with high-dose ibuprofen or naproxen, at 0.6 to 1.6%.

Proton pump inhibitors can interfere with the effects of other medications, though. There’s also some evidence to suggest that the long-term use of PPIs can increase the risk of bone fractures.

High-dose NSAIDs and coxibs can also increase the likelihood of developing cardiovascular diseases such as heart attacks and strokes: by less than 1% per year. Naproxen is an exception. In studies, this medication had little influence on the risk of cardiovascular diseases.

What are the possible reasons not to take NSAIDs and coxibs?

Various factors increase the risk of gastrointestinal problems. These problems are more common in people who

  • are over 65 years old,
  • have already had gastritis, an ulcer or stomach bleeding,
  • have a bacterial infection with Helicobacter pylori,
  • drink a lot of alcohol,
  • take blood-thinning heart medicines, for example anticoagulants like warfarin or acetylsalicylic acid (the drug in medicines like "Aspirin"),
  • take corticosteroids (“steroids”),
  • take a selective serotonin reuptake inhibitor (SSRI) antidepressant,
  • take several anti-inflammatory painkillers at the same time, or
  • have certain gastrointestinal conditions like Crohn’s disease or ulcerative colitis.

If your risk of stomach bleeding or other serious complications is very high, it can be a good idea to talk with your doctor about other treatments.

People who have cardiovascular disease or several risk factors for it should also carefully consider the advantages and disadvantages of treatment with an NSAID or coxib. Treating pain with naproxen may be a good option for them since it doesn't affect the heart or the circulatory system.

Is the painkiller metamizole (“Novalgin”) an alternative?

Metamizole is a fever-reducing and inflammation-reducing painkiller similar to NSAIDs. But there are no studies on its effectiveness in people with osteoarthritis or comparing it with other treatments. Although this drug is often used in Germany, it’s not approved for the treatment of osteoarthritis and is not recommended by medical societies.

The use of metamizole is the subject of debate because it can lead to a rare but serious side effect known as agranulocytosis. This side effect causes a big drop in the number of certain white blood cells in the body, which can be life-threatening. Possible signs of agranulocytosis are fever, sore throat, and inflamed mucous membranes. The risk of this side effect is estimated to be far below 0.1%.

Are opioid painkillers helpful in osteoarthritis?

Opioids are prescription painkillers that are used in emergency and intensive care to induce anesthesia and to treat cancer-related pain. Morphine is the best-known opioid drug. Other opioids include buprenorphine, codeine, hydromorphone, oxycodone, tapentadol, tilidine and tramadol.

Opioids can relieve acute pain very effectively. But, contrary to popular belief, this is not true for chronic osteoarthritis pain: Studies now show that they often don’t help in osteoarthritis any better than NSAIDs do. There’s also some evidence that they could become less effective after only a few weeks.

Opioids may be a good choice if several drugs are needed for the short-term treatment of severe pain or to bridge the time until surgery. They’re also an option for people who can’t take NSAIDs.

When it comes to osteoarthritis pain, though, opioids shouldn't be used routinely or for longer time periods. They can cause side effects like constipation, nausea, lack of sexual desire, dizziness, and tiredness, as well as affect your ability to drive. There’s also a low risk of a life-threatening overdose. So it’s very important to follow your doctor’s instructions on how to take them, and not to increase the dose without talking to your doctor first. The same is true for opioid skin patches (fentanyl patches).

Experts recommend not using opioids for longer than one to three months because they can be physically addictive. According to estimates from studies, about 6% of people become addicted after using them for a longer time.

The use of opioids is not recommended for people who already have a headache disorder, fibromyalgia, inflammation of the pancreas, inflammatory bowel disease or an addiction problem.