How to use PANADOL (Tylenol, paracetamol, acetaminophen etc) and PANADEINE FORTE (which contains codeine as well as paracetamol) to relieve chronic or subacute pain due to cancer or various other causes.

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Disclaimers

This article, written by a senior medical practitioner with considerable experience in palliative medicine and hospice care, is offered purely for educational purposes. Nothing in it should be taken as therapeutic advice for any particular patient. Mention of any trade (brand) name should not be taken as an endorsement of the brand or its manufacturer.

Simple Measures

Many cases of chronic or subacute pain, including much of the pain caused by advanced cancer, can be relieved by remarkably simple measures.

In most cases, taking regular doses of the right combination of opioid and non-opioid analgesics is the best starting point. This, together with any appropriate active treatment for the underlying condition, is often all that is required to keep a patient pain free for life. In other cases, more complex pain management techniques are needed to achieve this result.

Two Well Known Tablets

I have chosen two well known tablets – Panadol and Panadeine Forte – as my examples, but many alternatives exist. The same basic principles apply, regardless of which particular medications are used.

Panadol is a well known brand of paracetamol (acetaminophen). This is a very well tolerated non-opioid analgesic. Each Panadol tablet contains 500mg of paracetamol as the only active constituent.

Panadeine Forte tablets, from the same manufacturer as Panadol, contain 30mg of codeine and 500mg of paracetamol in each tablet. Codeine is a useful, though not particularly strong, opioid analgesic which can be extracted from opium. (In practice, it is usually synthesised from morphine instead.)

Cut to the Chase?

If you are not interested in what I have to say about why I have to say what I have to say, you can jump to the tablet-taking steps by clicking HERE. However, you will almost always get better results if you understand why you are doing what you are doing, so I hope that if you click on that link now, you will come back and read the explanations later.

Why Paracetamol?

Quite simply, I have chosen paracetamol (acetaminophen) as my example of a non-opioid analgesic because it works extremely well in combination with opioid analgesics, and most people can take it without the slightest difficulty.

Why Not Aspirin?

Equally simply, I have not chosen aspirin as my example of a non-opioid analgesic because, although aspirin and other "non-steroidal anti-inflammatory drugs" (NSAIDs) sometimes work better than paracetamol (acetaminophen), many people simply cannot take them at all.

Why Codeine?

Again, rather simply, I have chosen codeine as my example of an opioid analgesic simply because, although it belongs very firmly in my "second-least-favourite" group of opioid analgesics, it is very easy to get hold of (when combined with a simple analgesic).

At least, that is the case in most countries. In some countries, you would be thrown in jail, with no questions asked, simply for possessing medication prescribed by your doctor containing even a small amount of codeine combined with a simple analgesic. That is a very important point to note if you are thinking of travelling!

Why Not Morphine?

Simpler and simpler! Although I, and most other doctors, consider morphine to be the best of all opioid analgesics, and indeed one of the most important medications in existence, in most countries it is much harder to get hold of than codeine combined with a simple analgesic.

There is another reason, too. In most minds, morphine is much harder to contemplate than codeine combined with a simple analgesic – simply because, in most minds, morphine is thought of as being associated with serious illness and death; neither of which is at all popular, in most minds.

Oh, by the way… here is something else that begins with neither: neither of my two reasons for not choosing morphine is even 1% sensible. However, the first is 100% true, and the second is 100% real. I have found truth and reality to be almost indispensable in pain management – a glib statement, perhaps; but an honest one, I assure you.

Therefore, I have not chosen morphine as my example of an opioid analgesic in this simple article, even though, in most situations, morphine is the best of all opioid analgesics, and can be used very effectively in the relief of mild, moderate or severe pain, as well as various other distressing symptoms such as cough and shortness of breath.

Many Alternatives

Paracetamol and codeine are, of course, sold under many brand names, and many unbranded ("generic") products also exist. For example, in America and some other countries, the best known brand of paracetamol (acetaminophen) is Tylenol. (As with Panadol, a Tylenol variant containing some codeine as well as some paracetamol, and called, at least sometimes, Tylenol Co, is also available – at least, it is in some countries.)

In addition, various dose forms, other than tablets, are available in the case of most medications. (Common dose forms other than tablets include capsules, caplets, granules, mixtures, solutions, powders, suppositories, enemas, patches, injections, infusions and implants. Many dose forms also have immediate-release and slow-release variants.)

Another important point about alternative analgesic products is that a very small change in name can represent a very significant change in content. For example, Panadeine Extra, Panadeine Co, Panadeine-anything-else and just-plain-Panadeine are not the same as Panadeine Forte. Each formulation contains a different amount of codeine, as stated on the label. Similarly, some products containing paracetamol (acetaminophen) contain an amount other than 500mg. Therefore, it is always essential to check the exact amount of each "active" constituent in any medication – as well as checking that you are not allergic to, or intolerant of, any of the "inactive" constituents.

Fewer Principles

The general principles discussed in this article can be applied to any opioid and non-opioid analgesics, of any brand or no brand, and in any dose form whatsoever (though not all dose forms can easily be halved, and most slow-release preparations should not be cut or crushed in any case).

However, the specific directions given in this article would have to be modified before being used with any medications other than Panadol tablets and Panadeine Forte tablets. The statements about when and how to take tablets, which are made later in the article, relate specifically to Panadol tablets and Panadeine Forte tablets.

More Advice

I have found the instructions in this article to be effective and safe for the majority of patients with chronic pain, whether it is due to cancer or to various other causes. However, in some individual circumstances, these instructions may not be effective or safe.

For example, codeine relieves pain only after being transformed into its active metabolites (one of which is morphine). In some people, codeine metabolism is very slow, resulting in an inadequate analgesic effect and/or a higher proportion of adverse side effects. In some other people, codeine metabolism is very fast, which is often associated with a variable increase in the incidence of adverse side effects.

There might also be a specific contraindication, such as a known allergy to a constituent of one of the tablets. Therefore, before following any of the advice given in this article, ask your doctor whether you can safely take the medications described in the manner suggested.

How to Proceed

There are a few general points to cover before considering actual dosages. Firstly, when used to treat chronic or subacute pain, medication MUST be taken in a way that maintains a therapeutic level in the blood all the time. This is partly for the obvious reason that the pain will return if the blood level becomes subtherapeutic – but it is also because it is much easier to maintain pain control than it is to achieve it in the first place. When this control is lost as a result of one or more missed doses, the more difficult task of achieving it again has to be repeated – sometimes "from scratch".

Secondly, because Panadol and Panadeine Forte tablets each contain half a gram of paracetamol (acetaminophen) – of which a healthy adult can usually only safely take about one gram each four hours – you must always take less of one tablet if you take more of the other tablet. For adults, the end result is usually about two tablets in total, taken approximately each four hours. I will give some examples of typical ADULT dosages made up by combining different amounts of Panadol and Panadeine Forte. (Babies and children obviously need quite different dosages of any medication. Old or sick adults often need somewhat different dosages, too.)

Thirdly, because chronic or subacute pain often responds better after a day or so than it does when the medication is started or increased, you may sometimes need to adjust the proportion of Panadeine Forte downwards, rather than upwards.

Finally, "trial and more trial" is the order of the day in the early stages of most pain management situations. ("Trial and error", though not quite as highly recommended as trial and trial, is usually much better than no trial at all!)

That said, I think we can (finally) get out the tablets now. I will deal with the taking of the tablets by numbers, and later letters – simply in the interests of simplicity…

Finally - the Tablets!

1. If it works for you, just take two Panadol tablets, each four hours (or take even less, if less works).

2. If that is not effective, take one and a half Panadol tablets and half a Panadeine Forte tablet, each four hours, instead.

3. If that is not effective, take one Panadol tablet and one Panadeine Forte tablet, each four hours, instead.

4. If that is not strong enough, take half a Panadol tablet and one and a half Panadeine Forte tablets, each four hours, instead.

5. If that is still not strong enough, take two Panadeine Forte tablets (and no Panadol at all) each four hours, instead.

6. You may find that you need different combinations at different times of day. For example, if pain interferes with sleep, a stronger combination at bedtime is usually a good idea.

7. If you followed step 1, 2, 3, 4 or five every four hours around the clock, you would be taking a total of twelve tablets, containing a total of 6 grams of paracetamol, per 24 hours – together with a variable amount of codeine. That should only be done under medical supervision. The standard recommendation, which very sensibly leans towards caution, is to take no more than eight tablets, containing a total of four grams of paracetamol, per 24 hours – and not to take codeine at all, unless it is advised by your doctor.

(Paracetamol toxicity is the foremost cause of acute liver failure in the Western world. Codeine is a close relative of morphine, and can be very toxic, or addictive, if used incorrectly. Those are just two of the reasons that I consider the standard recommendation mentioned above to be very sensible.)

8. If you take more than an occasional dose of Panadeine Forte, you will almost certainly have to take laxative medication as well, adjusting the dose (again, by trial and trial, and hopefully not too much error) so as to prevent constipation. Do not wait until constipation is severe before taking laxatives! Constipation is always unpleasant, and sometimes it can cause very serious complications. Its prevention when taking analgesic medication is, believe it or not, an enormous topic, which utterly fascinates most palliative care specialists (including me).

However, you will only have to learn enough about constipation to avoid getting constipated yourself. You will not learn much about it from this article, though. Soon, I hope, you will be able to learn more about it from another article in this series. In the meantime, it is often helpful to start a fibre supplement and a good fluid intake immediately, adding stimulant or osmotic laxatives as necessary. It is also important to adjust the copious advice available from all "old wives" – and many other people – according to your own experience. Constipation is an excellent example of the common phenomenon of individual variation!

9. There are literally hundreds of reasons NOT to take Panadol or Panadeine Forte. Very few of those reasons have been mentioned in this article. However, all you really need to know is whether one of them applies to you. Ask your doctor about that!

10. Did you notice an important flaw in the logic of points 1 through 5, when you got to point 7? If you take a total of two tablets each four hours, and are limited to eight tablets per 24 hours, how can you possibly maintain adequate blood levels around the clock? There is no perfect answer to this question – but there are many ways to work around it. One of these ways will give excellent results in almost every case, but the way that suits you best needs to be discovered by experience. Here are some of the ways:

(a) You could reduce the total number of tablets in each dose to one and a half, for the first four doses of the day; increase it to three, for the fifth dose (which will be due at bedtime, if you like eight hours sleep) and omit the dose which would otherwise be due in the middle of the night. This, of course, adds up to a total of nine tablets per 24 hours, not eight. In my experience, that is not a problem unless the patient already has a moderate degree of liver failure. (Monitoring for any early effects on the liver only requires a simple blood test, which should be done at intervals in any case.)

(b) You may already be taking some other medications at bedtime which have a "potentiating" effect on your Panadol and/or Panadeine Forte. If so, you may find that a total of two Panadol and/or Panadeine Forte tablets at bedtime lasts through the night – especially if you have a greater proportion of Panadeine Forte in the bedtime dose. This brings the total number of Panadol and/or Panadeine Forte tablets described in (a) above back from nine to eight.

(c) Your doctor may prescribe a completely different analgesic for bedtime use, which contains no paracetamol (acetaminophen) and lasts right through the night. In that case, you can take a total of two tablets, for each of four doses, at four hour intervals, to cover the approximately sixteen hours when you are awake – and none at all, to cover the approximately eight hours when you are asleep. Again, this adds up to a total of eight tablets per 24 hours.

(d) There are many other ways in which the simple basic medication regimen described can be modified, in order to avoid excessive amounts of paracetamol (acetaminophen) and also allow a full night's sleep. If you are not getting good results, always talk to your doctor about ways to improve things.

11. It is particularly important to tell your doctor about all the medications (or anything else) that you take. Paracetamol (acetaminophen) is found in a huge number of over-the-counter preparations, and many other substances also influence the choice of the best analgesic regimen for a particular patient.

12. If your doctor experiences difficulty in achieving and maintaining excellent pain control for you, ask him or her to discuss the problem with a Palliative Care or Pain Management specialist, or simply to refer you to one. That is what Palliative Care and Pain Management specialists are for.

ONE EXAMPLE OF A MEDICATION SCHEDULE CONSTRUCTED AS DISCUSSED ABOVE

0700:   One Panadol and one Panadeine Forte

1100:   One and a half Panadol and half a Panadeine Forte

1500:   One and a half Panadol and half a Panadeine Forte

1900:   One Panadol and one Panadeine Forte

2300:   Different medications as prescribed by your doctor

The actual times shown above can be adjusted to suit you, as long as the doses remain about four hours apart. (Anywhere from three to five hours sometimes works quite well, but closer to four hours is usually better.)

Some Extra Points

It usually does not matter very much whether Panadol and/or Panadeine Forte tablets are taken on a full or empty stomach. However, it is often convenient if the schedule can be arranged so that most of the day's medications are taken fairly close to a meal time.

Some medications, though, are ideally taken at least an hour before food and at least three hours after the previous food intake. Other medications should be taken with or after food. Taking these things into account, it is often possible to group most medications at or around meal times, and this can reduce the perceived complexity of a medication schedule.

On the other hand, adjusting the times of doses purely for the convenience of carers or nursing staff, without taking the correct time intervals and food associations into account, is a sure recipe for achieving suboptimal results.

Good Results

With good overall care, persistence and common sense, and with the benefit of expert advice when necessary, any doctor and patient can collaboratively construct an effective pain management regimen, without too much in the way of compromises, in about ninety percent of all cases of chronic or subacute pain, whether that pain is due to cancer, or to various other causes.

The other ten percent require considerable expertise, and often also involve significant compromises – such as restricted mobility, some residual pain, persistent drowsiness or various other side effects – in order to achieve the best possible results in a difficult situation.

In a very few cases, good control of pain can only be achieved by keeping the patient almost or completely asleep around the clock. While this is a very simple thing to do, with modern drugs, it is rarely the best thing to do unless everything else has been tried first. When it is the best solution to otherwise intractable pain, absolutely meticulous nursing care is essential, as pressure sores (also known as bedsores or decubitus ulcers) and various other problems would otherwise occur.

Conclusion

I certainly do not mean to imply that pain management is always an easy matter. Nor do I wish to minimise the importance of the many medications other than Panadol and Panadeine Forte which are used in pain management. However, many cases do respond to relatively simple regimens – of which the one discussed above is one of the simplest.

Finally, if any doctor ever tells you that you have "pain for which nothing can be done", you should immediately seek the advice of a Palliative Care or Pain Management specialist. The method and degree of pain control may well involve various compromises, which the doctor and the patient will need to discuss and make decisions about; but there is no such thing as "pain for which nothing can be done".

Declaration of Interest

Dr Coates receives no financial or other incentives from the manufacturers of Panadol and Panadeine Forte.

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