Nonprescription Analgesics: Balancing Evidence, Safety, and Global Access

Session Title: Nonprescription Analgesics: Balancing Evidence, Safety, and Global Access

Topic: CLINICAL SCIENCE

Description: Nonprescription analgesics are among the most frequently used medicines worldwide, and essential for pain relief and self-care. Yet their use often diverges from best evidence and may be associated with harms and misuse with stark inequities in global access.

This workshop brings together multidisciplinary experts to discuss current evidence regarding nonprescription analgesics with three integrated aims:
(1) Evaluate current, robust evidence for what works and what doesn’t work among common nonprescription analgesics and combinations;
(2) Discuss the harms and risks with nonprescription analgesics, including misuse of codeine-containing products and harms associated with paracetamol; and
(3) Explore context-appropriate strategies for the needs of low- and middle-income countries (LMICs) and the limited generalisability from high-income countries.

Efficacy of nonprescription analgesics
We will examine efficacy of nonprescription analgesic considering head-to-head and indirect comparisons, dose and formulation effects (including fast-acting NSAID formulations), and where combinations add value—or do not (e.g. limited incremental benefit of low dose codeine combinations). For example, ibuprofen typically outperforms paracetamol at standard doses for acute pain conditions and fixed dose ibuprofen and paracetamol combinations demonstrate the greatest efficacy in postoperative dental models. Combination analgesics containing caffeine confer a modest but clinically relevant benefit, particularly for headache and post-surgical dental pain. Use of nonprescription analgesics for chronic conditions (e.g. osteoarthritis) will be addressed with appropriate caution regarding modest benefits and tolerability.

Are nonprescription analgesics as safe as perceived?
With our research and clinical expertise, we will present a clear, balanced overview of harms associated with paracetamol. Beyond hepatotoxicity in overdose, we will discuss the evidence for cardiovascular, renal and gastrointestinal side effects, and contextualise these with NSAID risks, always ensuring ‘the lowest dose for the shortest period’. We will directly address misinformation in public discourse—specifically, recent claims linking paracetamol to autism—considering why observational associations do not establish causation and risks of untreated fever/pain in pregnancy.
Furthermore, as misuse and dependence on nonprescription codeine remains a global concern, we will discuss the evidence for misuse with nonprescription codeine containing analgesics and review strategies adopted to prevent misuse; including the value of restricting availability to prescription only, pack size limits, using prominent warnings on packaging, and behavioural interventions.

LMIC perspectives on nonprescription analgesics
In many LMICs, the use of nonprescription analgesics is driven by affordability, informal supply chains and workforce constraints. We will highlight scalable solutions such as strengthening community pharmacy regulation, embedding continuing professional development, and aligning national formularies with the World Health Organization Model List of Essential Medicines. Examples from Malaysia, Thailand, and Indonesia will illustrate regional challenges and successes. Emerging digital health tools, including mobile-based pharmacovigilance reporting and patient-education apps, will be discussed as cost-effective supports for rational self-care.

Format and outcomes
Three concise, evidence rich talks will be followed by a moderated panel discussion applying findings to real-world scenarios (such as musculoskeletal pain, dental pain and migraine). Interactive live polling will capture availability and highlight concerns of nonprescription analgesics globally. Participants will leave with evidence-based strategies to promote safe, equitable nonprescription analgesic use across diverse healthcare contexts.

Speakers

Roger Knaggs University of Nottingham
United Kingdom

Roger is a clinical academic pharmacist. His current position provides teaching and research opportunities whilst maintaining regular clinical practice. Roger’s main research interests focus on the appropriate use of analgesic medicines and associated clinical outcomes and healthcare utilization.

He aims to promote the importance of pain within pharmacy and the role of pharmacy within pain management. Roger was the inaugural chair of the United Kingdom Clinical Pharmacy Association pain management group.

He is the current President of the British Pain Society after having been Vice President, Honorary Secretary, a co-opted and elected Council member. In 2019 he was appointed a member of the Advisory Council on the Misuse of Drugs (a Scientific Advisory Committee to the UK Government) and is the Chair of their Technical Committee. In addition, he has associations with several other healthcare policy and government organisations in the UK, including the Faculty of Pain Medicine, Care Quality Commission and NICE.

Roger has chaired the European Pain Federation (EFIC) COVID-19 taskforce since March 2020.

Stephanie Mathieson University of Sydney
Australia

Dr Stephanie Mathieson (PhD) is a Senior Research Fellow at The University of Sydney. Her research programme focuses on strategically evaluating, testing and implementing the latest evidence on medicines for pain management to improve clinical outcomes and reduce environmental impact. New knowledge from her research has profoundly changed how drugs are recommended for safer pain medicine use. Her gabapentinoid research has informed 19 international guidelines and policy recommendations, improving the pharmacological management of patients with back pain, sciatica, stenosis and neurogenic claudication. Evidence from her deprescribing research has enabled better policy recommendations for managing opioid cessation in Australia and internationally. Her research has been published in leading medical journals, including the New England Journal of Medicine, The BMJ and Annals of Internal Medicine, across various study designs. She serves on several committees, has presented at numerous national and international conferences, and supervises several Higher Degree Research students.

Athirah Bakhtiar Monash University Malaysia
Malaysia

Athirah Bakhtiar is an Associate Professor and Course Coordinator for the Bachelor of Pharmacy (Honours) program at Monash University Malaysia, and a registered pharmacist with professional experience spanning hospital, community, and academic practice. Her work focuses on pharmacy education, evidence-based practice, and strengthening the role of pharmacists in primary care and patient-centred medication management.

A recipient of the 2024 Monash Malaysia PVC Award for Excellence in Education (Educational Leadership), Athirah has led educational initiatives that integrate clinical reasoning and evidence-based decision-making into pharmacy training. She has also facilitated pain management workshops for pharmacy students in collaboration with PainWISE Australia, focusing on the safe use of nonprescription analgesics, appropriate referral, and the role of community pharmacists in supporting patients with musculoskeletal pain.

Athirah also contributes to the Healthy Spine Program as a member of its Clinical Advisory Committee and as a Clinical Facilitator, working alongside multidisciplinary teams to strengthen pharmacists' roles in the early identification of musculoskeletal pain, appropriate initial management, and timely referral. The program also works with government agencies and corporate partners to extend evidence-based musculoskeletal health education to communities across Malaysia.

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