The main focus of today’s post is to review the most popular prescription painkillers in the UK. I previously reviewed the popularity of different drugs in the UK, which may interest you: Top 15 most prescribed drugs in the UK & most popular antidepressants in the UK. Most popular prescription painkillers (UK) will be ranked according to the volume of prescriptions issued in the last 12 months by GPs in the UK. Prescribing data was extracted from Openprescribing.net, a website which process information from the NHS in England, making information on prescribed drugs more accessible. I will make a short comment on each drug to give a better understanding of the context.
Most popular prescription painkillers the UK
Included in the list below are 19 most prescribed painkillers in the UK. The latest data that is available was used to provide 12-month prescription volume (Nov ’19—Oct ’20).
The volume of prescriptions: 17,453,897
Cost to NHS: £66,522,927
Paracetamol is one of the most commonly prescribed drugs in the UK. Paracetamol is the most popular prescription painkiller in the UK, despite its availability over the counter. In 2017 NHS published 10 point efficiency plan, which was included in the NHS Five Year Forward View with efforts to reduce prescribing of drugs which are available over the counter. This strategy has not been very effective in terms of paracetamol prescribing. The decrease in paracetamol prescribing between 2017 and 2020 (same periods) was only by 7% (18788491 prescriptions in 2017 vs 17,453,897).
Paracetamol can be purchased in shops and supermarkets (quantity limited to two-pack of 16 tablets) or from the pharmacy with maximum legal quantity sold for up to 100 tablets or capsules.
The volume of prescriptions: 14,991,500
Cost to NHS: £76,211,293
Co-codamol contain a combination of codeine and paracetamol. Lowes strength of co-codamol is available over the counter (8mg of codeine & 500 mg of paracetamol). A higher strength of co-codamol including co-codamol 15/500 (codeine/paracetamol) and 30/500, are prescription-only medicines (POM).
When looking at prescribing statistics for co-codamol in recent years, there has not been much change in the volume of prescriptions issued. 4% decrease of co-codamol prescriptions can be observed between 2016 and 2019 (15.6mln in 2016 vs 15.0mln in 2019).
Some people may find a combination of codeine and paracetamol as a better painkiller but at the expense of side effects, which are common with codeine and codeine-containing products.
The volume of prescriptions: 6,725,949
Cost to NHS: £44,745,495
Naproxen is the most common prescription painkiller out of the drug class called non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs are used to help manage pain and inflammation. Naproxen is a prescription-only medication. When NSAIDs are prescribed to manage patient’s conditions, naproxen is considered a first-line due to good effectiveness and low prevalence of side effects (NICE BNF, 2021). Many prescription-only NSAIDs exist. Read more in one of my previous posts – Naproxen alternative drugs.
The volume of prescriptions: 5,920,790
Cost to NHS: £24,080,122
Tramadol is the first sole opioid drug on the list of most popular prescription painkillers in the UK. Tramadol is classified in the UK as a controlled drug (Schedule 3) and is used to manage moderate to severe pain. The most popular form of tramadol is tramadol 50mg capsules; however, tramadol also comes in form tablets of various strength ranging from 50mg to 200mg of tramadol per tablet/capsule.
5. Morphine sulphate
The volume of prescriptions: 5,147,622
Cost to NHS: 32,292,636
Morphine (morphine sulphate) is another opiate drug on the list of most popular painkillers in the UK. Morphine comes in a variety of forms and strengths.
The lower strength of morphine, which is available as an oral solution (morphine sulphate 10mg/5ml) is classified as a controlled drug schedule 5.
Higher-strength of morphine drugs, which is available as tablets, capsules and injections are classified as a controlled drug schedule 2, with more stringent requirements for supply and legal prescription requirements, for example expiry date of prescription. It is also not possible to get an emergency prescription or supply for controlled drugs in the UK.
Some common brands of morphine dispensed in the UK include:
- MST Continus tablets
- Zomorph capsules
- Morphgesic tablets
Morphine can be used to manage acute and chronic pain. A higher strength of morphine is used for severe pain and pain management in palliative care (care of terminally ill people).
6. Codeine phosphate
Volume of prescriptions: 4,968,331
Cost to NHS: £16,786,970
Codeine is another opiate used in pain management. There is a slight increase in codeine prescribing in the UK. A growth of 6.6% of prescriptions for codeine was observed between 2016 and 2019 (4654533 prescriptions in 2016 vs 4960647 in 2019).
Use of codeine in pain management is somewhat controversial, especially when used to treat chronic pain. Little evidence exists to support the effectiveness of opioids in chronic pain. Only a small number of people may benefit from opioid use in term of pain relief. This applies not only to codeine but other opiates, for example, tramadol (NICE, 2019).
Ongoing, long-term use of opioid usually leads to dependence and tolerance (ibid), meaning a drug does not work as it did when the treatment was initiated.
Prescription-only codeine is available in form of tablets:
- Codeine phosphate 15mg tablets
- Codeine phosphate 30mg tablets
- Codeine phosphate 60mg tablets
7. Topical ibuprofen (ibuprofen gel)
Volume of prescriptions: 3,455,112
Cost to the NHS: £11,376,569
See ibuprofen section below for comments on topical ibuprofen prescribing.
- Maximum strength, containing twice as much ibuprofen as Ibuleve Speed Relief Gel
- No stronger ibuprofen gel to fight pain
- Fast, effective, anti-inflammatory pain relief without pills
The volume of prescriptions: 2,368,482
Cost to NHS: £ 42,607,181
Buprenorphine is another opioid analgesic which is classified as controlled drug schedule 3. Buprenorphine is prescribed for moderate to severe pain which is not relieved by other drugs, including other opioids and non-opioid drugs. Buprenorphine comes in the form of:
- sublingual tablets (tablet is placed under the tongue)
- oral lyophilisate,
- solution for injection
- prolonged-release solution for injection and,
- transdermal patch
Patches tend to be the most common form of buprenorphine prescribed in the community. Buprenorphine patches are not suitable for the management of acute pain.
Buprenorphine can also be used in the treatment of opioid dependence. Sublingual tablets and oral lyophilisates are usually used for this indication.
9. Oxycodone Hydrochloride
Volume of prescriptions: 1,804,713
Cost to NHS: £38,136,061
Oxycodone is a controlled drug schedule 2, which is used to treat moderate to severe pain, for example, postoperative pain and manage pain in palliative care. Oxycodone comes in different forms including tablets, capsules and solution for injections.
Volume of prescriptions: 1,646,753
Cost to NHS: £8,998,097
Co-dydramol contains two active ingredients – paracetamol and dihydrocodeine. Although co-dydramol comes in three different strengths, the vast majority of prescriptions are issued for co- dydramol 10mg/500mg (each tablet contains 10mg of dihydrocodeine and 500mg of paracetamol). Other strengths of co-dydramol:
- Co-Dydramol 20/500 mg tablets
- Co-Dydramol 30/500 mg Tablets
Lower strength co-dydramol, which contains 7.5mg of dihydrocodeine and 500mg of paracetamol per tablet, can be purchased from the pharmacy. ‘Over the counter’ co- dydramol is sold as a branded product called Paramol tablets.
Dihydrocodeine produces similar analgesic effect to codeine.
Co-dyramol prescribing is in decline, which is clearly visible in the graph below.
11. Dihydrocodeine Tartrate
Volume of prescriptions: 1,504,990
Cost to NHS: £ 6,599,771
Dihydrocodeine is another opioid analgesic, which is related to codeine. Dihydrocodeine is only available on prescription. Dihydrocodeine comes only in the form of 30mg tablets.
- the volume of prescriptions: 1,332,513
- Cost to NHS: £5,841,065
Topical ibuprofen (ibuprofen gel):
- the volume of prescriptions: 3,455,112
- Cost to the NHS: £11,376,569
Ibuprofen is the second most prescribed NSAID in the UK, after naproxen. Similarly to paracetamol, ibuprofen can be purchased over the counter, including two most common forms of ibuprofen 200mg and 400mg tablets. Ibuprofen 400mg is a pharmacy-only medicine and therefore is not available for customer’s self-selection, for example, in supermarkets.
Prescribing statistics for ibuprofen is categorised according to intended use:
- Ibuprofen used in rheumatic diseases and gout (oral ibuprofen), and
- Ibuprofen used in soft-tissue disorders and topical pain relief (ibuprofen gel)
A considerable decrease in ibuprofen prescribing can be observed in the first category (rheumatic diseases and gout) with a slight decline in topical ibuprofen in the UK. Ibuprofen gel, 5% and 10% is also available over the counter. Despite this, a high level of prescribing for topical ibuprofen is observed in England with little change in prescribing in recent years.
The volume of prescriptions: 973,464
Cost to NHS: 35,732,365
Fentanyl is the most potent opioid analgesic available on prescription. Fentanyl is classified as a controlled drug schedule 2. Fentanyl is about 50-100 time more potent than morphine (Vardanyan & Hruby, 2014).
Fentanyl is usually reserved for pain management, which is not controlled by strong opioid analgesics and breakthrough pain experienced caused by cancer.
14. Diclofenac Sodium
The volume of prescriptions: 487,922
Cost to NHS: 3,103,167
Diclofenac sodium is the third most commonly used NSAID on the list of most popular prescription painkillers in the UK. Diclofenac is frequently prescribed for the treatment of acute gout pain and inflammation in rheumatic disease.
15. Nefopam Hydrochloride
The volume of prescriptions: 277,908
Cost to NHS: £3,852,728
Nefopam is rarely prescribed in the NHS. Nefopam is a non-opioid analgesic with a mechanism of action, which is different from all drugs reviewed so far. Although the mechanism of action is not fully understood, it is though that nefopam affects the reuptake of neurotransmitters, including serotonin, norepinephrine, and dopamine (Kim & Abdi, 2014).
Nefopam is licensed for the relief of acute pain and chronic pain, dental pain, cancer pain and musculoskeletal pain.
The volume of prescriptions: 67,920
Cost to NHS: 993,182
Meptamizol (brand name: Meptid) is the least popular opioid analgesic on the list. The licensed use is limited to short term management of moderate pain.
The volume of prescriptions: 57,929
Cost to NHS: £190,820
Aspirin is rarely prescribed in NHS England for management of pain. Aspirin, which is usually used as a painkiller, comes in the form of 300mg tablets. On the opposite side, a low dose aspirin – baby aspirin, is one of the most commonly prescribed drugs in the UK. A doctor can recommend baby aspirin to prevent heart attack or stroke in people who had such an event.
18. Diamorphine Hydrochloride
The volume of prescriptions: 47,138
Cost to NHS: 1£,410,497
Diamorphine is another opioid analgesic, which is classified as a controlled drug schedule 2. Diamorphine comes only in the form of ampules (for injections). Diamorphine is used to manage acute and chronic pain, which is not relieved by strong opioid analgesics.
19. Diclofenac Potassium
The volume of prescriptions: 13,176
Cost to NHS: 182,362
Diclofenac potassium (an NSAID) has similar licensed used as diclofenac sodium; however, it rarely prescribed in the NHS.
Methadone (brand name: Physeptone tablets) is rarely prescribed in the community to treat the pain. Methadone is classified as controlled drug schedule 2. In community vast majority of methadone is used in the management of opioid dependence.
Most popular painkillers in the UK: summary table
|Drug||Items prescribed||Cost to NHS||Cost per item|
Data source: OpenPrescribing.net Data period: Nov ’19—Oct ’20
The total cost of top 20 most popular prescribed painkillers comes to £419.7mln is the last 12 months. Perhaps the most controversial is the supply of paracetamol, which is still the most commonly prescribed drug to manage the pain. Historically paracetamol has been sold cheaply from pharmacies and supermarkets. In recent months paracetamol prices went up, however, even when used regularly (e.g. daily) the total monthly cost is low.
Kim KH, Abdi S. Rediscovery of nefopam for the treatment of neuropathic pain. Korean J Pain. 2014;27(2):103-111. doi:10.3344/kjp.2014.27.2.103 Available at: https://dx.doi.org/10.3344%2Fkjp.2014.27.2.103 Accessed on 20/01/2021
NICE (2019). Medicines optimisation in chronic pain. Available at: https://www.nice.org.uk/advice/ktt21/chapter/Evidence-context#opioid-medicines-in-chronic-pain Accessed on 19/01/2021
NICE BNF (2021). Non-steroidal anti-inflammatory drugs. Available at: https://bnf.nice.org.uk/treatment-summary/non-steroidal-anti-inflammatory-drugs.html Accessed on 18/01/2021
Vardanyan RS, Hruby VJ. Fentanyl-related compounds and derivatives: current status and future prospects for pharmaceutical applications. Future Med Chem. 2014;6(4):385-412. doi:10.4155/fmc.13.215 Available at: https://dx.doi.org/10.4155%2Ffmc.13.215 Accessed on 20/01/2021