Painkillers: Paracetamol, NSAIDs and Using Them Safely
Almost every household keeps painkillers, and almost nobody reads the limits on the box. Two families of drugs account for most everyday use, and they fail in completely different ways.
Paracetamol (acetaminophen)
What it does: reduces pain and fever. It has no meaningful anti-inflammatory effect.
Why it is usually first choice: it does not irritate the stomach, does not affect the kidneys at normal doses, does not raise blood pressure, is safe in pregnancy, and is safe in asthma.
The dose that matters: the maximum for a healthy adult is generally 3-4 g in 24 hours, meaning six to eight 500 mg tablets, with at least four hours between doses. Lower limits apply in liver disease, chronic alcohol use, malnutrition and low body weight.
The danger: paracetamol overdose causes liver failure, and the early hours may feel deceptively normal. The most common route to accidental overdose is combination products — many cold, flu and pain preparations already contain paracetamol, and people take them alongside plain paracetamol without realising. Always read what is in a combination pack.
Paracetamol overdose is a medical emergency even if the person feels fine. An antidote exists and works best when given early.
NSAIDs
Ibuprofen, diclofenac, naproxen, aceclofenac, mefenamic acid, and others.
What they do: reduce pain, fever and inflammation. Better than paracetamol for inflammatory pain — sprains, dental pain, period pain, gout, arthritis flares.
The costs, which are real:
- Stomach: ulcers and bleeding, sometimes without warning pain. Risk rises with age, previous ulcer, steroid or blood-thinner use, and alcohol.
- Kidneys: NSAIDs reduce blood flow to the kidneys. In dehydration, existing kidney disease, or alongside certain blood pressure drugs, this can cause acute kidney injury. Regular NSAID use is a common and avoidable cause of kidney damage in India.
- Heart: most NSAIDs slightly increase the risk of heart attack and stroke with regular use, and they raise blood pressure and worsen heart failure.
- Asthma: a minority of people with asthma get severe bronchospasm with NSAIDs.
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Who should be careful or avoid them: people with kidney disease, heart failure, uncontrolled hypertension, previous ulcer or gastrointestinal bleeding, those on anticoagulants, in the third trimester of pregnancy, and the elderly.
Using them sensibly: lowest effective dose, shortest duration, with food, and never two different NSAIDs together. A stomach-protecting drug may be added where risk is high.
Combinations and what to avoid
- Paracetamol plus an NSAID is a reasonable combination for short-term severe pain, since they work differently.
- Two NSAIDs together give no extra benefit and multiply the harms.
- Fixed-dose combinations with other drugs are widely sold in India; many add little and increase side effects. Ask what is actually in the tablet.
- Topical NSAID gels are effective for localised joint and muscle pain with far lower systemic exposure. They are underused.
Opioids
Tramadol, codeine and stronger opioids have a place in severe acute pain and in cancer pain. For ordinary chronic pain such as back pain they perform poorly and carry dependence, constipation, sedation and overdose risk. They should be prescribed, not bought casually.
Practical rules
- Know exactly what is in every pack you take, including cold and flu remedies
- Never exceed the stated 24-hour maximum
- Do not use painkillers for more than 10-15 days a month for headache, which causes medication overuse headache
- Stay well hydrated if taking NSAIDs
- Tell your doctor about all painkillers you take, including ones bought without prescription
- Store them where children cannot reach them; paracetamol overdose in children is a real emergency
When to see a doctor
- Pain needing daily painkillers for more than a week or two
- Black stools, vomiting blood, or persistent stomach pain while on NSAIDs
- Reduced urine output, swelling of the legs, or unusual breathlessness
- Any suspected overdose, immediately, even if the person feels well
- Pain with fever, weight loss, or neurological symptoms
This article is general health information. Dosing should be confirmed with a doctor or pharmacist, particularly in liver disease, kidney disease, pregnancy and in children.