How to make good use of pain medication

Pain medication or badgesics are the first drugs consumed by the French. The most used are paracetamol, ibuprofen, as well as two opioid substances, codeine and tramadol.

While acute pain can affect everyone at one time or another, some people have to endure chronic pain, so qualified when they extend over three months. A recent study by the Inserm 1107 Neuro-Dol team reported that 27 to 32% of the French population would be faced with this situation.

Whether the pain is acute or chronic, how to properly use the drugs to relieve it?

All French people consume painkillers

It can be estimated that in the course of a year, almost 100% of French people will use a pain medication, most often to treat acute pain.

The number of people receiving a reimbursement of a pain medication has increased by 15% since 2004, despite the withdrawal of the market of dextropropoxyphene (Di-antalvic) in 2011. At least 65% of French people were in this situation in 2017.

This increase mainly concerns non-opioid painkillers such as paracetamol. Moreover, these figures do not take into account self-medication in pharmacy (paracetamol, ibuprofen and codeine, the latter being dispensed without a prescription until July 2017) or family (medicine cabinet). Regarding opioid painkillers (derived from morphine), at least 12 million French people will use it during the year, a majority of which for short-term treatments. Finally, over 90% of patients with chronic pain use paracetamol or an anti-inflammatory (such as ibuprofen) and 45% opioid painkillers.

Paracetamol: not more than 3 grams per day

Paracetamol is the first pain medication consumed in France. It is recommended as first-line for mild to moderate pain. As recalled by the Agence du médicament,

"It is a safe and effective medicine under normal conditions of use. But in case of misuse, especially overdose by combining several products containing paracetamol or by non-compliance with their dosage, paracetamol can cause serious damage to the liver in some irreversible cases. The misuse of paracetamol is 1^re cause of liver transplantation of medicinal origin in France. "

A study at the pharmacovigilance center in Nancy showed that only 14% of patients know the risk of hepatic toxicity of paracetamol.

The ANSM also launched in September a public consultation to include on the boxes of these drugs a warning message on this risk.

To reduce the risk of adverse effects, the essential rules of good practice are simple: start with a dose of 500 mg, space the intake of at least 4 to 6 hours, never exceed 3 grams per day, and do not lengthen the duration of treatment in self-medication beyond 5 days. Finally, paracetamol "hidden" in certain medications, especially those used to treat colds or fever, as well as certain opioid painkillers such as codeine, tramadol or opium powder, must be carefully monitored. It may indeed come to add to that taken for pain. Nearly 200 drugs marketed in France contain paracetamol!

Ibuprofen: never during pregnancy

Ibuprofen is a nonsteroidal anti-inflammatory drug used to treat mild to moderate pain. It is the most consumed anti-inflammatory because available without prescription in pharmacy.

The Medicines Agency regularly issues reminders about the rules for the proper use of this type of medicine, the prolonged or high dose use of which may be toxic not only to the kidneys and the digestive system (stomach), but also cardiovascular (hypertension, stroke or cerebral stroke) or for unborn children, if taken during pregnancy.

A recent study by the Neuro-Dol team showed that more than 1% of pregnant women received reimbursements following prescriptions of these drugs of the 6th.^e at 9^e month of pregnancy, period of absolute contraindication. A percentage that does not include self-medication cases.

This work was the subject of information from the ANSM at the beginning of 2017 to remind of this risk and the need to contraindicate the anti-inflammatory drugs, including ibuprofen, during pregnancy.

Since 17 October 2017, a pictogram has been affixed to all the boxes of contraindicated medications during pregnancy, including, therefore, ibuprofen, in order to better inform the pregnant patient in the event of self-medication.

Opioids: preventing addiction and overdoses

The derivatives of morphine, or opioid painkillers, are mainly represented in France by codeine, tramadol and opium powder consumed by 11 million French every year and morphine, oxycodone and fentanyl, taken by one million of French.

ANSM organized an exchange day in May 2017 dedicated to these drugs and the reduction of badociated risks. The two main risks justifying the need to better inform patients about the proper use of these prescription-only drugs are dependence, or addiction, and overdose, or accidental and sometimes fatal poisoning.

In view of the North American opioid crisis, the French situation is to be monitored, as evidenced by the figures of overdoses revealed by the study of the French Observatory of Analgesic Drugs.

To prevent this, the strict respect of the medical prescription is essential by taking care not to overdose his treatment, respecting the duration of it and never sharing these drugs with his entourage.

A national action dedicated to the good use of painkillers

This year, from November 26 to 30, the Ministry of Solidarity and Health is organizing patient safety week on the theme of "the drug wisely". This translates into national, regional or local actions of health actors, in order not only to promote the correct use of medicines, to limit their risks or undesirable effects, to ensure their correct prescription, but also to think their deprescription in case of inefficiency or adverse effects.

This information action on the drug is also in line with the report on improving the information of users and health professionals about the drug, made public on 3 September 2018. It proposes in particular to strengthen the general knowledge of the drug of the general public.

Finally, putting the patient at the heart of the system and making quality of care a priority is at the heart of the health system transformation strategy, the "My Health 2022" plan. This necessarily involves putting in place actions to prevent preventable side effects of drugs. Indeed, it must be remembered that 95% of medical consultations end with an order.

The French Observatory of Analgesic Medicines (OFMA), one of whose missions is to promote the proper use of these anti-pain medicines, proposes with many partners, including the National Agency for the Safety of Medicines (ANSM), the Francophone Association (Patients) to overcome pain (AFVD) and the French Society for Study and Treatment of Pain (SFETD) an original document for users. It takes the essential to take well, and at lower risk, treatment with paracetamol, ibuprofen or a derivative of morphine.

Given the very high prevalence of acute and chronic pain, pain medication is essential in the panoply of therapies. Their proper use is first of all their right prescription by the doctor, or their fair dispensation by the pharmacist. But the information about this good use must also be shared with the patients, who must receive the essential knowledge to guarantee the best benefit-risk ratio of their treatment.

As pharmacological innovation is broken down in the field of pain management, it is necessary to ensure the safety of use of existing drugs, in order to maintain easy access to the greatest number.