When pain strikes, many people reach for branded over-the-counter (OTC) pain-relief medication such as Panadol or Nurofen instead of their cheaper generic equivalents.
But is there really any difference between what are all just paracetamol or ibuprofen tablets? Do you get a painkiller that's more effective when you pay more?
The short answer is no, not really. But given the plethora of painkillers on the market, it's easy to be fooled.
CHOICE investigated the OTC pain-relief market and found drug companies have successfully convinced consumers to pay nearly nine times more than they have to (based on prices at supermarkets and pharmacies in late February to early March 2020) for a humble ibuprofen or paracetamol tablet.
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12.4 million Australians buy pain relief products each month.
What's the difference between branded and generic medicine?
When it comes to paracetamol and ibuprofen, there's no difference in quality between branded and generic. Whether you pay three cents or 26c a tablet, the same dosage of paracetamol will work in exactly the same way. The same goes for ibuprofen.
This may sound like common sense, but it doesn't seem to be guiding the way we shop for pain-relief drugs.
In fact, we're more likely to choose Panadol or Nurofen, despite the rise of cheaper pain-relief alternatives on sale.
Go with the cheapest. That's what I do.Gregory Peterson, professor of pharmacy at the University of Tasmania
According to a 2019 survey, 12.4 million Australians buy pain relief products each month, with Panadol and Nurofen accounting for more than half those sales.
Beyond branded paracetamol and ibuprofen, OTC pain-relief medicines sold in Australia are made by a limited number of companies. Various drug companies manufacture generic painkillers, to which private labels add their own branding.
For example, from its factories in India, Nova Pharmaceuticals manufactures OTC paracetamol and ibuprofen for Coles (private label) and Woolworths (Help@Hand and Essentials). Each paracetamol tablet contains 500mg of active paracetamol, and each ibuprofen tablet contains 200mg of active ibuprofen.
Although the inactive ingredients may differ, they don't affect the efficacy of the drug (but check with your pharmacist if you have any allergies or intolerances)
Can some painkillers work faster than others?
Many painkillers on pharmacy shelves are marketed as"rapid action" or "rapidly absorbed" on their packaging. Panadol has various "fast" formulations such as Panadol Optizorb and Panadol Rapid. Nurofen also makes similar claims with its Zavance and Quickzorb range.
Most of the hype about 'faster-acting' paracetamol or ibuprofen is just that – hypeDr Louis Roller, associate professor in pharmacy practice at Monash University
Both Nurofen and Panadol's fast-absorbing drugs can cost up to almost double the price of their regular counterparts. But are they really any faster than regular painkillers, and are they worth the mark-up?
"Most of the hype about 'faster-acting' paracetamol or ibuprofen is just that – hype," says Dr Louis Roller, associate professor in pharmacy practice at Monash University.
The sentiment is echoed by Gregory Peterson, professor of pharmacy at the University of Tasmania, who says that "on the whole, there is very little convincing evidence for any differences in speed or efficacy between the various forms of ibuprofen or paracetamol".
There is evidence that liquid capsules are absorbed faster than tablets.
Are liquid capsules absorbed faster?
The variety of premium products can be very confusing for consumers. Nurofen's Zavance liquid capsules are generally the most expensive Zavance product on the market and are claimed to be "absorbed faster than standard Nurofen" – even though they have the same active ingredient (ibuprofen) as standard Nurofen tablets and caplets.
When we asked Zavance's parent company, Reckitt Benckiser, about this, a company spokesperson said it's because the active ingredient is absorbed faster in liquid format capsules than in the standard solid kind.
There is evidence that liquid capsules are absorbed faster than tablets, and Peterson suggests a soluble product, or aspirin, may be faster acting than solid tablets, too. But Roller says that most painkillers, whatever their format, are well absorbed anyway – within 15 to 30 minutes.
Ibuprofen vs paracetamol: What to take when
Panadol and Nurofen are the two main competitors in OTC painkillers, but they actually work differently to relieve pain.
Ever since ibuprofen went on sale in Australian supermarkets in 2004, ibuprofen has given paracetamol some competition. But it's not always the best drug for the job.
Ibuprofen should be avoided by people with stomach ulcers and other gastric problems, high blood pressure, heart failure, asthma or those who are pregnant
In many cases, paracetamol and ibuprofen can be used interchangeably. Although it's still not known exactly how paracetamol works, it's considered safer than ibuprofen for most individuals, according to Peterson. It also costs less.
There are instances where ibuprofen may be a better choice. As an anti-inflammatory, it's preferred for inflammatory injuries such as sprains. And it's also recommended for headaches if you get them several times a week (some painkillers themselves cause headaches if you take them too often – but ibuprofen doesn't).
Conversely, ibuprofen should be avoided by people with stomach ulcers and other gastric problems, high blood pressure, heart failure, asthma or those who are pregnant.
Peterson says there is clear evidence of the better effectiveness of a combination of one paracetamol and one non-steroidal anti-inflammatory drug (such as ibuprofen) for acute pain such as headaches, compared with either drug alone. (This finding doesn't apply to persistent or chronic pain.)
Combinations need to be monitored by a pharmacist because ibuprofen isn't clinically suitable for everyone
Nuramol and Maxigesic are two branded OTC pain-relief products that combine ibuprofen and paracetamol in one tablet. You can also buy generic combination tablets, or simply take separate branded or generic paracetamol and ibuprofen tablets together.
But Roller says these combinations need to be monitored by a pharmacist because ibuprofen isn't clinically suitable for everyone.
What's the right dose of paracetamol or ibuprofen?
For adults and children 12 years and over:
- paracetamol: 4000mg in 24 hours (eight standard 500mg paracetamol tablets or six slow-release 665mg tablets).*
- ibuprofen: 1200mg of ibuprofen in 24 hours (six standard 200mg ibuprofen tablets).
*There is increasing evidence that the maximal safe dosage of paracetamol varies, especially for people who fast or drink alcohol excessively. Speak to your doctor if you have any concerns.
In 2018, low-dose codeine tablets were reclassified to require a prescription from a GP.
This was because "the risks associated with codeine use are too high without oversight from a doctor," said the TGA at the time. "Codeine can cause opioid tolerance, dependence, addiction, poisoning and in high doses even death."
The change hasn't stopped GPs from prescribing codeine for those who may need it. But, for others, regular OTC medications such as paracetamol and ibuprofen can be just as effective without carrying the same risks as codeine.
Are pain-relief medications safe?
A large proportion of the analgesics we found on Australian shelves are made in India (often for non-Indian companies). It's a country where pharmaceutical manufacturing has come under increased scrutiny in the past from the US Food and Drug Administration (FDA).
A large proportion of the analgesics on Australian shelves are made in India
In 2013, Indian drug manufacturer Ranbaxy was found guilty of violating Good Manufacturing Practices (GMP) regulations, as well as making false claims to the FDA and falsifying documents.
Check the number
However, all the experts CHOICE spoke with said OTC pain-relief medicines in Australia are well regulated, and that there's no cause for concern about country of origin.
If it's got the AUST R number on it, which all OTC painkillers such as paracetamol and ibuprofen are required to have, it's been through a rigorous regulation process by Australia's Therapeutic Goods Administration (TGA).
How is pain-relief medication regulated?
According to a spokesperson for the TGA, its laboratories don't test painkillers before approving them for sale, but rather assess them for safety, quality and efficacy, based on information and data submitted by companies.
Drug manufacturers in Australia are also required to demonstrate compliance with GMP, which is usually done through an inspection.
Overseas drug manufacturers must also prove compliance with GMP by means of documentation, or occasionally an on-site inspection if they can't provide documentary evidence. Based on the company's documentation and advice from TGA experts, the TGA decides whether or not to approve the product.
Tips for buying pain-relief medication
- When comparing medicine costs, look at products with the same or comparable active ingredients in the same dosage.
- Generally, the cheapest products come in tablet or caplet form.
- Supermarkets can be more convenient than pharmacies for buying OTC medicines, but they don't always have the variety, higher dosage or larger pack sizes that pharmacies do.
- If you want something faster acting, choose a soluble product or the cheapest liquid capsule.
- According to recent studies, one standard paracetamol (500mg) and one ibuprofen (200mg) combined may work better than either product alone for acute pain, such as headaches, migraines and sprains. More generally, paracetamol costs less than ibuprofen, and is considered to have fewer adverse side effects.
- If you have any allergies or intolerances, speak to an in-house pharmacist or your GP about the ingredients in a painkiller before you take it.