Alternative Analgesics to Codeine for Acute Pain


As both the public and medical practitioners would know there has been an up-scheduling of codeine in pharmacies. It is no longer available over-the-counter and must be obtained by a script from a doctor.

So, what is left and how effective is it?

The options for acute pain management are paracetamol, anti-inflammatories such as ibuprofen, and combinations of these agents. Some patients may be worried that these will not be as effective for pain relief compared to codeine.

Let us look at the evidence…

Introducing the Oxford League Table of Analgesic Efficacy (as pictured below). This has been put together from trials of pain relief in the acute setting, such as pain relief after wisdom tooth surgery and other settings. Success is defined as achieving a 50% or more reduction in pain from the starting point. How many people need to take the drug before 1 person achieves this amount of pain reduction is a means of assessing the likely usefulness of the medication. Perfection would be where everyone who takes the drug achieves this (unrealistic). Excellent is when 2 people take it and 1 person gets that 50% pain reduction. Not very useful is if, for example, 7 people take it but only 1 person gets 50% or more pain relief. The number of people who need to take the drug for 1 to benefit from it is called the “Number Needed To Treat” or NNT. Thus, in the above examples, the NNT is 1, 2 then 7, respectively.

Here is the table: (Source: Faculty of Pain Medicine (UK):


The left and right side of the horizontal boxes show the certainty that the true result lies inside the box. Think of it as a minimum and maximum chance of the NNT being that number in the entire population. What do we see? We see that aspirin 600/650mg (6th from the bottom) is not quite as good as paracetamol 975/1000mg (9th from the bottom), which by itself is not quite as good as paracetamol + low dose codeine (800/1000 + 60mg) (14th from the top), although that is not quite as good as ibuprofen 200mg (10th from the top). If we jump to the best there is (with a NNT of <2), that is ibuprofen with paracetamol (400 + 1000mg). Nothing comes close to that for pain relief, not even Panadeine Forte.

So, it turns out that far from being a weak analgesic, the combination of paracetamol and ibuprofen is highly effective and actually the best analgesic for acute pain. If it is taken by people (with no contraindications to taking the medication) at the appropriate safe amount as directed on the packet, they should have no concerns about the likelihood of obtaining pain relief. A NNT of <2 is considered a highly effective medication.

References & Further Reading:

  1. “Oxford Analgesic League Table”. Faculty of Pain Medicine (UK). Accessed 22/02/2018 via:
  2. “Opioids and Acute Pain Management”. Faculty of Pain Medicine (UK). Accessed 22/02/2018 via:
  3. “Painaustralia codeine fact sheet – October 2017”. Painaustralia. Accessed 22/02/2018 via:
  4. “Codeine information hub”. Therapeutic Goods Administration (Australian Government, Department of Health) 2018. Accessed 22/02/2018 via:
  5. Moore A, Wiffen PJ, Derry S, et al. “Non-prescription (OTC) oral analgesics for acute pain - an overview of Cochrane reviews”. Cochrane Database of Systematic Reviews 2015.
  6. Moore A, Derry S, Aldington D, Wiggen PJ. “Single dose oral analgesics for acute postoperative pain in adults - an overview of Cochrane reviews” Cochrane Database of Systematic Reviews 2015.

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