Step into any newsagents, petrol station or chemists and you face a sophisticated blizzard of marketing from a £500million-plus industry, pushing a fast-moving consumer product in distinctly lifestyle-friendly ways. The fact that many bestselling brands of this product - painkillers - are potentially habit forming and addictive is often forgotten in our consumer culture. Should we be worried? Well, the Australian Government certainly is, and British MPs are mulling the issue too.

Next month an Australian government committee is to consider making popular over-the-counter (OTC) codeine-containing painkillers, such as Nurofen Plus, prescription-only. The National Drugs and Poisons Schedule Committee may put them in a restricted category for drugs at high risk of being abused.

The move is in response to fear of growing abuse of codeine and dihydrocodeine. These morphine-like drugs are included in combination with other analgesics in leading brands such as Nurofen Plus and Solpadeine. A study by Melbourne's Angliss Hospital, in the Medical Journal of Australia in January, called “recreational misuse” of Nurofen Plus a “significant problem”, that causes perforated stomach ulcers. It added: “Misuse of these medications appears to be an emerging cause of significant morbidity in patients with codeine addiction.” An Australian online forum for those addicted to Nurofen Plus claimed earlier this year that 7,000 Australians had now joined it.

In the UK, codeine and dihydrocodeine are available only on prescription as single drugs, but are available over the counter when combined with the non-prescription painkillers, aspirin, paracetamol or ibuprofen, in brands such as Nurofen Plus and Solpadeine. In America, codeine and its relatives are banned in all non-prescription drugs. But codeine-containing drugs are not the only concern. Evidence indicates that many other highly marketed brands, which often contain caffeine as well as a painkiller, may ironically be causing untold thousands of Britons to suffer daily headaches.

The OTC market continues to grow

Thanks to constant brand innovation and niche-marketing, the UK's huge OTC painkiller market continues to grow. Income jumped by nearly a quarter between 2001 and 2006, according to the Proprietary Association of Great Britain, the OTC drug-industry body. The increase, from £406million to £500million, excludes “impulse outlets” such as newsagents and petrol stations, from which about 40 per cent of British consumers claim to get their OTC drugs. Anadin's maker, Wyeth Consumer Healthcare, says that last year it sold nearly 27 million packs of the pills, and adds: “If stacked on top of each other, they would reach over 56 times the height of Mount Everest.” Wyeth's 2006 survey found that for a quarter of women, carrying a painkiller in their handbag is as essential as carrying a mobile or house keys (though of course, women often carry them for period pains as well as headaches).

In 2005, the British regulatory body, the Medicines and Healthcare products Regulatory Agency, decided against introducing prescriptions for OTC drugs containing codeine, saying the reports of misuse were “exceedingly small”. But our casual convenience attitude to painkillers is causing serious concern among coroners and doctors. Last year Simon Nelson, the coroner for Bury, Greater Manchester, called for tougher restrictions on OTC drug sales after Linda Docherty, 49, suffered kidney failure after regularly swallowing up to 64 Nurofen Plus tablets a day.

There are some restrictions on buying OTC painkillers: packs containing codeine should be restricted to 32 pills and sold under a pharmacist's vigilant supervision. But as Docherty's case shows, people can circumvent the rules by visiting several shops or buying from the internet (for example, Pharmacy2u.co.uk's second biggest-selling product is packs of 32 Nurofen Plus for £5.99, while pharmacylink.co.uk offers packs of 60 Solpadeine Plus Soluble for £7.85, promising “fast and discreet delivery”).

In January, Peter Bedford, the Berkshire coroner, cautioned against casual analgesic use after 41-year-old Stewart Wharton died from mixing a “harmless amount” of OTC painkillers with alcohol (just over twice the drink-drive limit). The pathologist's report said: “Although neither drug was present in a high quantity, they produced a respiratory depressive effect and this was the cause of death.”

In the British Medical Journal last year, Chris Ford and Beth Good, two London GPs, called OTC painkiller misuse the “often forgotten” affliction. They wrote how in the previous three months they had seen three patients addicted to Nurofen Plus and called for large-scale research into the extent of the nation's OTC analgesic problem. Likewise, Paul Lambert and Colin Close, doctors at the Taunton and Somerset Hospital, cautioned in the Journal of the Royal Society of Medicine how addictions to Nurofen Plus can easily go undiagnosed, after they spent months treating a 45-year old woman for life-threatening symptoms before uncovering her serious painkiller habit.

Another report in the BMJ, in March, by Robin Ferner, the director of the West Midlands Centre for Adverse Drug Reactions, cautioned that the maximum UK permitted OTC dosage of codeine appears high enough to cause dependency: “There are disadvantages when relatively safe and effective analgesics such as paracetamol and ibuprofen are combined with small doses of opioids that are likely to bring trivial therapeutic benefit but increase the risks of abuse, addiction and adverse effects.”

Such concerns have prompted the Commons all-party group on drugs misuse to launch an inquiry. The group will spend the summer collating its evidence on OTC medicine misuse, for a report to be published at the end of this year. Brian Idden, the Labour MP chairing the inquiry, says: “More than 70 pieces of evidence have been submitted so far. Many GPs don't believe that you can get addicted to OTC drugs, but there are clearly a large number of addicts.” Dr Idden, a visiting professor of chemistry at Liverpool University, adds: “We are trying to get the Government to take the issue more seriously. One thing that sticks out in our evidence so far is that people have great difficulty getting referred by their GPs for adequate help. But it is a poorly studied area. Without pre-empting the result of the inquiry, I think we probably will be calling for more research.”

Indeed, very little research on consumers has been performed in Britain. But one NHS survey of chemists in South Wales, in the Pharmaceutical Journal in 2002, found that two-thirds said they had customers they suspected of painkiller addiction. Among those who have submitted evidence to the inquiry is David Grieve, who runs Over-Count, a charity helping OTC medicine addicts. Grieve, a former police officer who was dependent on cough medicine for 16 years, says the charity has helped more than 17,000 people in the UK and Ireland since it was launched in 1993.

“The people who contact us are just ordinary people who would never buy illegal drugs,” he says. “They are predominantly dependent on codeine-containing painkillers.”

“Women are more at risk”

Grieve says that two thirds of his clients are female, and adds: “Women are more at risk, not least because the makers target women's magazines with pages and pages of adverts. When I looked through men's magazines, I could not find a single painkiller advert. Painkiller marketing on television brackets daytime shows such as Five's The Trisha Goddard Show. But you won't see those ads on sports channels.

“I also see women who have acquired their dependency via mothers and older sisters who have become habitual takers. Solpadeine and Nurofen Plus are narcotics; they make you feel calm, relaxed and at ease with the world, as well as tackling pain. Long after the headache's gone, you can take them to treat your stress and anxiety.”

But Grieve is eager to add, “I don't want to ban OTC painkillers or codeine- containing products. They are useful for many people's personal emergencies.

But at the moment, the makers are telling us loudly about the good things, and reticent about being more open about the downsides. I want to see much more categorical warnings about overuse and symptoms of overuse.” At the moment, he says, manufacturers are keen to avoid giving the impression that they are selling potentially dangerous drugs. “They are subtle in their advertising. The recent marketing campaign for Solpadeine was 'It makes you feel human again'. It did not actually say that they are a painkiller.”

Placebo effect from branded names

High-profile painkiller marketing can have a powerful and strange effect on people, according to Keele University research published in the British Medical Journal in 1981. The investigators gave 835 women identically formulated aspirin pills, either in branded or unbranded packets. The study found that women who took the painkillers with a well-known brand name got 30 per cent more pain relief an hour later. The report suggest that this placebo effect is simply down to the increased confidence that a well-marketed brand can instil.

Thus, big marketing budgets pay big dividends in a world where one drug in four sold by pharmacists is a painkiller. The three basic OTC analgesics available in Britain - aspirin, paracetamol and ibuprofen - are long past their product licenses and so can be made and sold very cheaply. Drug companies have to invent ingenious ways to sell the same drugs. So painkillers are increasingly marketed as lifestyle accessories. Vying with Solpadeine's promise to “make you feel human again”, Anadin launched its Ultra Double Strength pills with a £4 million campaign as the pill “For people who just get on with it”. Seductive packaging is crucial, too: when Nurofen launched its special “mobile” pack (the 20th different Nurofen niche sub-brand) its creators, Design Cognition, said it “reinforced Nurofen as an innovative, aspirational and world-leading brand”. Four months after landing on UK shelves in 2002, it had boosted Nurofen's market share from 23 per cent to 28 per cent.

Continually growing the market has another perverse (but lucrative) result: swallowing more OTC painkillers makes people prone to “rebound headaches”. Dr Andrew Dowson, the director of the headache service at King's College Hospital, London, says: “If you get headaches on a regular basis and take painkillers regularly, you can get more headaches. These occur when the body becomes acclimatised to a frequently used pain reliever and then develops a withdrawal effect when the medication is ceased.”

Added caffeine can mean more headaches

Dowson says that if you are taking more than two or three doses of analgesics a week for headaches, the analgesics may be part of the problem - “You should see your doctor about it. Analgesics should be part of a much wider approach to managing your pain.” He says that some US research shows that if you over-use painkillers that contain caffeine to speed their absorption, daily headaches can be four times more likely.

Neither Reckitt Benckiser nor GlaxoSmithKline, the makers of Nurofen and Solpadeine respectively, wanted to talk directly about these issues, but their trade association, the Proprietary Association of Great Britain, says it welcomes the Commons investigation into the extent of painkiller misuse and adds: “Our advice is that it is very important for people to read and follow the instructions on all OTC medicines. Analgesics should only be used for a few days at a time. If the pain persists, a health professional should always be consulted. For this reason all analgesics are labelled with words clearly stating this.”

But in our hurry-hurry world, many people are often unwilling to commit to making the sort of lifestyle changes that might help their health and forestall stressy headaches, or to address psycho-social problems that rob them of sleep or drive them to drink between hangovers. Instead, they seek an immediate fix via painkillers, disregarding the danger of their habit dropping them into a vicious cycle.

Dr Michael Gross, a consultant neurologist and headache specialist at the Clementine Churchill Hospital, Harrow, says this is a longstanding problem. “In the past, people used to reach for the Valium pills, and maybe they got more benefit from them than they do from paracetamol and codeine, but Valium got abused and was withdrawn,” he says. “So painkillers are what we have to help us with life's complexities and problems, rather than looking at the root causes or having the time to tackle them. Can we blame the pharmaceutical industry for getting into this area and pushing their products?”

HOW DO PAINKILLERS WORK?

Martyn Lobley, a GP, explains

Pain is easier to understand than you'd imagine. Three distinct mechanisms work together to produce pain and each of them can be interfered with to relieve it. At the point of impact, injured tissues release chemicals that stimulate nearby nerve endings. The nerves carry the painful impulse up the spinal cord; finally, the higher centres of the brain register the sensation and perceive it as unpleasant.

Painkillers such as aspirin, paracetamol and ibuprofen reduce the production of pain-mediating chemicals. Morphine-like drugs called opioids (including codeine) work in the brain to dull pain perception.

The nerves that carry the pain impulse also transmit touch and temperature sensations. It's possible to swamp the system by rubbing the injured area, or by applying an ice-pack or hot water bottle.

What to buy

There's no need to pay extra for well-known “household name” products. Non-branded paracetamol 500mg or ibuprofen 200mg tablets are the best option. Some over-the-counter pain relievers contain chemicals that simply hike up the cost; for example, many contain a few milligrams of caffeine per dose, even though there is little evidence that it helps. Combinations of standard painkillers with a low dose of codeine are freely available from supermarkets and pharmacies. But there is little evidence that adding a small dose of an opioid to a full dose of aspirin, ibuprofen or paracetamol results in any significant increase in pain relief.

How do you get addicted?

Patients can become psychologically addicted to any type of painkiller. However, those using opioid combinations run a risk of becoming physically dependent on them. If the same dose is taken regularly, say, more than two or three days a week, tolerance develops, provoking withdrawal symptoms, such as headache.

To get around this, patients increase the amount of opioid taken, which provides only temporary relief. They become locked into a vicious cycle of getting more headaches and taking more painkillers.

Symptoms of addiction

A headache that won't go away can be a sign of painkiller addiction. The only cure for what neurologists refer to as “medication overuse headaches” is to switch to painkillers not containing added ingredients like opioids or caffeine, or going cold turkey and cutting out painkillers altogether.

Dosage

Never exceed the dose recommended on the packet. If you do, seek advice from either a GP (if it has been a gradual increase) or A&E department, if it's a one-off overdose.

FIRST PERSON: “The pills could have melted a hole in my stomach”

Michael Lester* took painkillers nearly every day for 20 years to tackle his regular headaches. Pressure from his wife and a stark warning from his doctor eventually convinced the 42-year-old Londoner that the painkillers might actually be causing his headaches, and were endangering his health.

Lester's dependence on paracetamol began in his late teens, while studying for A levels. “I used to get stress and eyestrain headaches, and my mum would give me tablets to keep me going. She worked in the NHS, so I didn't question it at all.”

By the time he left home for university, the pill-popping had become a regular habit, and a costly one for a student, so he would badger his local corner shopkeeper to sell him paracetamol in discounted bulk-boxes. “My headaches steadily got worse. If I didn't take the tablets, I would get a headache - almost guaranteed.”

He would often start the day with a “preventive” paracetamol and would take them before going out drinking, to avoid hangovers. “I was a typical drug-dabbling student, smoking dope and popping other substances, so paracetamol was the last thing I worried about,” he says.

The habit continued after he left university, although his growing income meant that he could switch from bog-standard paracetamol to branded products. “I became a bit of an expert,” he says. “Some things seemed to work better for different kinds of pain.”

When he married, his wife began to question his habit. “She's a bit of a natural-medicine freak, so I started being covert.”

But as well as headaches, Lester began experiencing bad stomach pains. “When the doctor I saw asked what painkillers I was taking, I decided to tell him all about all it. He went ballistic and said he was surprised that I hadn't melted a hole in my stomach. He made me promise to cut down until I wasn't taking anything for a fortnight. The headaches and stomach pains did abate and I could see I'd got into a bit of a spiral.”

He says he tries to avoid painkillers now. “I keep a pack in my car, in case I really, really need them. I still get the occasional headache, but nowadays I try to put up with it.”

* Not his real name

PAIN RELIEF BY NUMBERS

85% of people find the labels on painkillers confusing

62% of people believe their painkillers do not last long enough

25-45 the age group of most women addicted to over-the-counter medications

29% of Britons would like to buy stronger medications over the counter

37% of Britons say they take painkillers to cure their hangovers

Source: Times database, over-count.org.uk, The Proprietary Association of Great Britain

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