How to use panadol (tylenol, paracetamol, acetaminophen etc) and panadeine forte (which contains codeine as well as panadol) to relieve chronic pain due to cancer (or other causes)

PANADOL AND PANADEINE FORTE
FOR CANCER PAIN
How to use Panadol (Tylenol, paracetamol, acetaminophen etc) and Panadeine Forte (which contains codeine as well as paracetamol/acetaminophen) to relieve chronic pain due to cancer
DISCLAIMERS
This article, written by a senior medical practitioner with
considerable experience in palliative medicine and hospice
care, is offered purely for educational purposes. Nothing in it
should be taken as therapeutic advice for any particular patient.
Mention of any trade (brand) name should not be taken as an
endorsement of the brand or its manufacturer.
CAUTIONS
It is very dangerous to make changes to a patient's medication
without first discussing those changes with the patient's doctor.
The doctor must always know exactly what the patient is
taking, as virtually all medications can cause unwanted side
effects and interact in various ways with other medications.
Importantly, this also applies to "natural", "alternative" or "complementary" therapies, many of which have significant interactions with prescribed medications. So even if you feel that the current pain management is not optimal, never make any changes without first discussing them with the doctor. ABOUT THE AUTHOR
As this is the first article in the Pain Management section at
Wanterfall eBooks, I will very briefly explain my background.
I have been a medical practitioner since 1970, spending the
first ten years as a family doctor and the next twelve as a
Hospice, Palliative Care and Pain Management specialist,
before returning to general, geriatric and palliative community-
based care in 1993. Since 2007 I have mainly been writing
books and articles for a non-medical readership, and publishing
them at Wanterfall eBooks .

SIMPLE MEASURES
Many cases of chronic pain without a curable cause, including
much of the pain caused by advanced cancer, can be relieved
by remarkably simple measures.
In most cases, taking regular doses of the right combination of opioid and non-opioid analgesics is the best starting point. This, together with any appropriate active treatment for the underlying condition, is often all that is required to keep a patient pain free for life. In other cases, more complex pain management techniques are needed to achieve this result.1 TWO WELL KNOWN TABLETS
I have chosen two well known tablets – Panadol and
Panadeine Forte – as my examples, but many alternatives
exist. The same basic principles apply, regardless of which
particular medications are used.
(acetaminophen). This is a very well tolerated non-opioid analgesic. Each Panadol tablet contains 500mg of paracetamol as the only active constituent. Panadeine Forte tablets, from the same manufacturer as
Panadol, contain 30mg of codeine and 500mg of paracetamol
in each tablet. Codeine is a useful, though not particularly
strong, opioid analgesic which can be extracted from opium.
(In practice, it is usually synthesised from morphine instead.)
1 To download a free eBook about the MANY other ways in which cancer pain can be treated, go tAlternatively, that eBook may be read as a series of web pages, starting at
CUT TO THE CHASE?
If you are not interested in what I have to say about why I have
to say what I have to say, you can jump to the tablet-taking
steps, under the heading "Finally – the Tablets" on page 9,
straight away. (If you are reading this onscreen, you can get
there by clickin) However, you will almost always get
better results if you understand why you are doing what you
are doing, so I hope that if you jump to that heading now, you
will come back and read the explanations later.
WHY PARACETAMOL?
Quite simply, I have chosen paracetamol (acetaminophen) as
my example of a non-opioid analgesic because it works
extremely well in combination with opioid analgesics, and
most people can take it without the slightest difficulty.2
WHY NOT ASPIRIN?
Equally simply, I have not chosen aspirin as my example of a
non-opioid analgesic because, although aspirin and other "non-
steroidal anti-inflammatory drugs" (NSAIDs) sometimes work
better than paracetamol (acetaminophen), many people simply
cannot take them at all.
WHY CODEINE?
Again, rather simply, I have chosen codeine as my example of
an opioid analgesic simply because, although it belongs very
firmly in my "second-least-favourite" group of opioid
analgesics, it is usually fairly easy to get hold of (when
combined with a simple analgesic).
At least, that is the case in most countries. In some countries, you would be thrown in jail, with no questions asked, simply 2 For more information about non-opioid analgesics (simple analgesics) see
for possessing medication prescribed by your doctor
containing even a small amount of codeine combined with a
simple analgesic. That is a very important point to note if you
are thinking of travelling!
WHY NOT MORPHINE?
Simpler and simpler! Although I, and most other doctors,
consider morphine to be the best of all opioid analgesics, and
indeed one of the most important medications in existence, in
most countries morphine is much harder to get hold of than
codeine combined with a simple analgesic.
There is another reason, too. In most minds, morphine is much harder to contemplate than codeine combined with a simple analgesic – simply because, in most minds, morphine is thought of as being associated with serious illness and death; neither of which is at all popular, in most minds. Oh, by the way… here is something else that begins with neither: neither of my two reasons for not choosing morphine is even 1% sensible. However, the first is 100% true, and the second is 100% real. I have found truth and reality to be almost indispensable in pain management – a glib statement, perhaps; but an honest one, I assure you. Therefore, I have not chosen morphine as my example of an opioid analgesic in this simple article, even though, in most situations, morphine is the best of all opioid analgesics, and can be used very effectively in the relief of mild, moderate or severe pain, as well as various other distressing symptoms such as cough and shortness of breath.3 3 For more information about opioid analgesics (opioids, opiates) see
MANY ALTERNATIVES
Paracetamol and codeine are, of course, sold under many brand
names, and many unbranded ("generic") products also exist.
For example, in America and some other countries, the best
known brand of paracetamol (acetaminophen) is Tylenol. (As
with Panadol, a Tylenol variant containing some codeine as
well as some paracetamol, and called, at least sometimes,
Tylenol Co, is also available – at least, it is in some countries.)
In addition, various dose forms, other than tablets, are available in the case of most medications. (Common dose forms other than tablets include capsules, caplets, granules, mixtures, solutions, powders, suppositories, enemas, patches, injections, infusions and implants. Many dose forms also have immediate-release and slow-release variants.) Another important point about alternative analgesic products is
that a very small change in name can represent a very
significant change in content. For example, Panadeine Extra,
Panadeine Co, Panadeine-anything-else and just-plain-
Panadeine are not the same as Panadeine Forte. Each
formulation contains a different amount of codeine, as stated
on the label. Similarly, some products containing paracetamol
(acetaminophen) contain an amount other than 500mg.
Therefore, it is always essential to check the exact amount of
each "active" constituent in any medication – as well as
checking that you are not allergic to, or intolerant of, any of the
"inactive" constituents.
FEWER PRINCIPLES
The general principles discussed in this article can be applied
to any opioid and non-opioid analgesics, of any brand or no
brand, and in any dose form whatsoever (though not all dose
forms can easily be halved, and most slow-release preparations
should not be cut or crushed in any case).
However, the specific directions given in this article would have to be modified before being used with any medications other than Panadol tablets and Panadeine Forte tablets. The statements about when and how to take tablets, which are made later in the article, relate specifically to Panadol tablets and Panadeine Forte tablets. MORE ADVICE
I have found the instructions in this article to be effective and
safe for the majority of patients with chronic pain without a
curable cause, whether it is due to cancer or to various other
conditions. However, in some individual circumstances, these
instructions may not be effective or safe.
For example, codeine relieves pain only after being transformed into its active metabolites (one of which is morphine). In some people, codeine metabolism is very slow, resulting in an inadequate analgesic effect and/or a higher proportion of adverse side effects. In some other people, codeine metabolism is very fast, which is often associated with a variable increase in the incidence of adverse side effects. There might also be a specific contraindication, such as a known allergy to a constituent of one of the tablets. Therefore, before following any of the advice given in this article, ask your doctor whether you can safely take the medications described in the manner suggested. HOW TO PROCEED
There are a few general points to cover before considering
actual dosages. Firstly, when used to treat chronic pain,
medication MUST be taken in a way that maintains a
therapeutic level in the blood all the time. This is partly for the
obvious reason that the pain will return if the blood level
becomes subtherapeutic – but it is also because it is much
easier to maintain pain control than it is to achieve it in the first place. When this control is lost as a result of one or more missed doses, the more difficult task of achieving it again has to be repeated – sometimes "from scratch". Secondly, because Panadol and Panadeine Forte tablets each
contain half a gram of paracetamol (acetaminophen) – which
becomes toxic at dosages only a little higher than those usually
recommended – you must always take less of one tablet if you
take more of the other tablet. I will give some examples of
typical ADULT dosages made up by combining different
amounts of Panadol and Panadeine Forte under the next
heading. (Babies and children obviously need quite different
dosages of any medication. Old or sick adults often need
somewhat different dosages, too.)
Thirdly, because chronic pain often responds better after a day or so than it does when the medication is started or increased, you may sometimes need to adjust the proportion of Panadeine Forte downwards, rather than upwards. Finally, "trial and more trial" is the order of the day in the early stages of most pain management situations. ("Trial and error", though not quite as highly recommended as trial and trial, is usually much better than no trial at all!) That said, I think we can (finally) get out the tablets now. I will deal with the taking of the tablets by numbers, and later by letters – simply in the interests of simplicity… (Note that all the dosages mentioned under the next heading
are for ADULT patients weighing at least 40Kg and with
satisfactory liver function.)

FINALLY – THE TABLETS! (DOSES FOR ADULTS)
1. If it works for you, just take two Panadol tablets, each four
hours (or take even less, if less works).
2. If that is not effective, take one and a half Panadol tablets
and half a Panadeine Forte tablet, each four hours, instead.
3. If that is not effective, take one Panadol tablet and one
Panadeine Forte tablet, each four hours, instead.
4. If that is not effective, take half a Panadol tablet and one and
a half Panadeine Forte tablets, each four hours, instead.
5. If that is not effective, take two Panadeine Forte tablets (and
no Panadol at all) each four hours, instead.
6. You may find that you need different combinations at
different times of day. For example, if pain interferes with
sleep, a stronger combination at bedtime is usually a good idea.
7. If you followed step 1, 2, 3, 4 or 5 every four hours around
the clock, you would be taking a total of twelve tablets,
containing a total of 6 grams of paracetamol, per 24 hours –
together with a variable amount of codeine. That should only
be done under medical supervision.
recommendation, which very sensibly leans towards caution, is to take no more than eight tablets, containing a total of four grams of paracetamol, per 24 hours – and not to take codeine at all, unless it is advised by your doctor.4 Various ways to work around this issue will be explained in point 10. 8. If you take more than an occasional dose of Panadeine Forte,
you will almost certainly have to take laxative medication as
well, adjusting the dose (again, by trial and trial, and hopefully
4 Paracetamol toxicity is the foremost cause of acute liver failure in the
Western world. Codeine is a close relative of morphine, and can be very
toxic, or addictive, if used incorrectly. Those are just two of the reasons that
I consider the standard recommendation stated above to be very sensible.

not too much error) so as to prevent constipation. Do not wait
until constipation is severe before taking laxatives!
Constipation is always unpleasant, and sometimes it can cause
very serious complications. Its prevention when taking opioid
analgesic medication is, believe it or not, an enormous topic,
which utterly fascinates most palliative care specialists.
However, you will only have to learn enough about opioid constipation to avoid getting constipated yourself. (You will not learn much about it from this eBook, as I have covered the subject at some length elsewhere.5 Briefly, though, it is often helpful to start a fibre supplement and a good fluid intake immediately, adding stimulant or osmotic laxatives as necessary. It is also important to adjust the copious advice available from all "old wives" – and many other people – according to your own experience. Constipation is an excellent example of the common phenomenon of individual variation!) 9. There are literally hundreds of reasons NOT to take Panadol
or Panadeine Forte. Very few of those reasons have been
mentioned in this article. However, all you really need to know
is whether one of them applies to you. Ask your doctor about
that!
10. Did you notice an important flaw in the logic of points 1
through 5, when you got to point 7? If you take a total of two
tablets each four hours, and are limited to eight tablets per 24
hours, how can you possibly maintain adequate blood levels
around the clock? There is no perfect answer to this question –
but there are many ways to work around it. One of these ways
5 The management of opioid constipation is discussed in my free eBook entitled How Cancer Pain is Treated, starting on page 67 of the current edition (a free download at. Alternatively, you may learn how to treat opioid constipation online at will give excellent results in almost every case. Here are some of the simplest ways to work around this issue: (a) Under medical supervision, it is usually quite safe for an adult with normal liver function to take 12 tablets per 24 hours. (b) You could reduce the total number of tablets in each dose to one and a half, for the first four doses of the day; increase it to three, for the fifth dose; and omit the dose which would otherwise be due in the middle of the night. This, of course, adds up to a total of nine tablets per 24 hours, not eight. In my experience, that is not a problem unless the patient already has a significant degree of liver failure. (Monitoring for any early effects on the liver only requires a simple blood test, which should be done at intervals in any case.) (c) You may already be taking some other medications at bedtime which have a "potentiating" effect on your Panadol and/or Panadeine Forte. If so, you may find that a total of two Panadol and/or Panadeine Forte tablets at bedtime lasts through the night – especially if you have a greater proportion of Panadeine Forte in the bedtime dose. This brings the total number of Panadol and/or Panadeine Forte tablets described in (b) above back from nine to eight. (d) Your doctor may prescribe a completely different analgesic for bedtime use, which contains no paracetamol (acetaminophen) and lasts right through the night. In that case, you can take a total of two tablets, for each of four doses, at four hour intervals, to cover the approximately sixteen hours when you are awake – and none at all, to cover the approximately eight hours when you are asleep. Again, this adds up to a total of eight tablets per 24 hours. (e) There are many other ways in which the simple basic medication regimen described can be modified, in order to avoid excessive amounts of paracetamol (acetaminophen) and also allow a full night's sleep. If you are not getting good results, always talk to your doctor about how to solve whatever problem you are experiencing. 11. It is particularly important to tell your doctor about all the
medications (or anything else) that you take. Paracetamol
(acetaminophen) is found in a huge number of over-the-counter
preparations, and many other substances also influence the
choice of the best analgesic regimen for a particular patient.
12. If your doctor experiences difficulty in achieving and
maintaining excellent pain control for you, ask him or her to
discuss the problem with a Palliative Care or Pain Management
specialist, or simply to refer you to one. That is what Palliative
Care and Pain Management specialists are for.
ONE EXAMPLE
(of an ADULT medication schedule constructed as discussed above)
0700: One Panadol and one Panadeine Forte
1100: One and a half Panadol and half a Panadeine Forte
1500: One and a half Panadol and half a Panadeine Forte
1900: One Panadol and one Panadeine Forte
2300: Different medications as prescribed by your doctor
The actual times shown above can be adjusted to suit you, as long as the doses remain about four hours apart. (Anywhere from three to five hours sometimes works quite well, but closer to four hours is usually better.) SOME EXTRA POINTS
It usually does not matter very much whether Panadol and/or
Panadeine Forte tablets are taken on a full or empty stomach.
However, it is often convenient if the schedule can be arranged
so that most of the day's medications are taken fairly close to a meal time. Some medications, though, are ideally taken at least an hour before food and at least three hours after the previous food intake. Other medications should be taken with or just after food. Taking these things into account, it is often possible to group most medications at or around meal times, and this can reduce the perceived complexity of a medication schedule. On the other hand, adjusting the times of doses purely for the convenience of carers or nursing staff, without taking the correct time intervals and food associations into account, is a sure recipe for achieving suboptimal results. GOOD RESULTS
With good overall care, persistence and common sense, and
with the benefit of expert advice when necessary, any doctor
and patient can collaboratively construct an effective pain
management regimen, without too much in the way of
compromises, in about ninety percent of all cases of chronic
pain due to cancer.
The other ten percent require considerable expertise, and often also involve significant compromises – such as restricted mobility, some residual pain, persistent drowsiness or various other side effects – in order to achieve the best possible results in a difficult situation. In a very few cases, good control of pain can only be achieved
by keeping the patient almost or completely asleep around the
clock. While this is a very simple thing to do, with modern
drugs, it is rarely the best thing to do unless everything else has
been tried first. When it is the best solution to otherwise
intractable pain, absolutely meticulous nursing care is essential,
as pressure sores (also known as bedsores or decubitus ulcers)
and various other problems would otherwise occur.

CONCLUSION
I certainly do not mean to imply that pain management is
always an easy matter. Nor do I wish to minimise the
importance of the many medications other than Panadol and
Panadeine Forte which are used in pain management. However,
many cases do respond to relatively simple regimens – of
which the one discussed above is one of the simplest.
Finally, if any doctor ever tells you that you have "pain for
which nothing more can be done", you should immediately
seek the advice of a Palliative Care or Pain Management
specialist. The method and degree of pain control may well
involve various compromises, which the doctor and the patient
will need to discuss and make decisions about; but there is no
such thing as "pain for which nothing more can be done".
DECLARATION OF INTEREST
Dr Coates receives no financial or other incentives from the
manufacturers of Panadol and Panadeine Forte.
NOT COPYRIGHT
The above article may be freely reproduced, remixed and
disseminated, in any format and any quantity, under its
Creative Commons License. For more information about the
license, see
COMMENTS
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BY THE SAME AUTHOR
If you would like to read other articles or eBooks by Dr Coates,
they are all free to read or download at
Of particular relevance to those affected by cancer pain is the eBook "How Cancer Pain is Treated", which is available as a free download at (Alternatively, that book may be read online, starting at ) Readers with an interest in the emotional effects of potentially life threatening illnesses such as cancer may wish to explore the author's ideas about grief and other painful emotions, starting either ato Readers with an interest in the difficulties often encountered when attempting to communicate about serious illness or other distressing matters may find food for thought in some of the author's articles about communication skills, which are listed at

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