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CONTINUING PROFESSIONAL DEVELOPMENT
COUNSELLING IN PRACTICE
with a sprain or strain, application
of a topical NSAID or rubefacient
may be considered before using an
Paracetamol, ibuprofen and aspirin are
available combined with a low-dose
weak opioid such as codeine in
OTC products to treat acute pain.
These combined analgesics contain
codeine phosphate in strengths of
8--15 mg.16 There is no conclusive
evidence that codeine phosphate
(8--15 mg) combined with paracetamol
or ibuprofen have any benefits
over non-opioid analgesics alone.17
Although the effective dose of codeine
has not been determined, it is generally
believed to be above 30 mg.10,18 If the
patient is not achieving pain relief
from paracetamol and/or NSAID,
consider referral for consideration
of treatment with a single opioid
preparation at a therapeutically
Are there any adverse e ects
from these medicines?
Paracetamol is generally considered a
safe analgesic. It has a low incidence of
adverse effects compared with other
drugs.19 As paracetamol is available
in many brands, formulations and in
combination preparations, care needs to
be taken to avoid hepatotoxicity from an
NSAIDs are associated with a range
of serious side effects including
gastrointestinal (GI) ulceration or
bleeding, nausea, salt and fluid
retention and hypertension. As side
effects are dose dependent, NSAIDs
should only be used for short periods
of time (up to 3 weeks) and as directed
to reduce the risk of GI side effects.10,13,19
Adverse effects may also be reduced by
combining NSAIDs with paracetamol
allowing the use of a lower dose.13
Certain patients (e.g. those with
cardiovascular disease, GI bleeding
or active peptic ulcer disease, and the
elderly) are at greater risk of adverse
effects from NSAIDs and use should
Should I see my doctor?
Acute pain can develop into chronic
pain.8 If the pain is persisting after
adhering to the recommended pain
management plan, the patient should be
referred for further medical review.
Neck pain can infrequently be a sign of a
serious injury or underlying disease. Ask a
patient initially presenting with neck pain7:
• Have you had a fall or injury recently?
• Is there a history of rheumatoid
arthritis in your family?
• Do you have a temperature or signs of
• Have you lost weight recently?
• Have you experienced any weakness
in your hands or feet or voice?
• Did you feel a ripping or tearing
sensation in your neck?
• Do you have chest pain, shortness of
breath or sweating a lot?
These questions may highlight
a more significant problem such
as musculoskeletal problems
(e.g. rheumatoid arthritis, osteoarthritis,
osteoporosis, fibromyalgia), cervical
spondylosis, cervical intervertebral
disc lesions and prolapse, spinal
stenosis, infection of the spine (e.g.
osteomyelitis), bone cancer that involves
the spine, trauma (e.g. whiplash),
torticollis and non-musculoskeletal
causes (e.g. cardiovascular, respiratory
and upper GI causes, acute upper
respiratory tract infections, meningitis).
If any of these conditions are
suspected, refer the patient for further
How can I prevent neck pain from
Good posture, such as keeping the
head centred over the spine, helps
reduce some strain on the neck muscles.
Suggestions to improve posture and
prevent neck pain include5:
• take regular breaks and stretch back
and neck muscles
• set the top of the computer screen at
• support arms rather than letting them
drop by your side
• when sitting, position knees slightly
lower than the hips
• avoid clenching your teeth
• practise posture-correcting exercises
• use a pillow at the correct height with a
contoured surface to support the neck
• use a firm mattress
• avoid stomach sleeping which can
place strain on the neck.
Relaxation techniques and regular
exercise are also important in preventing
stress and tension in the neck muscles.
Maintaining general fitness helps
prevent further exacerbations of
neck pain by improving muscle tone
Where can I nd more
Pharmacists can refer consumers
wanting more information about acute
neck pain to the following resources:
• PSA Self Care Fact Cards -- Pain relievers
and Relaxation techniques
• myDr Neck pain: treatment. At:
• Patient.co.uk: Nonspecific neck
pain. At: www.patient.co.uk/health/
Cynthia's sti neck
Cynthia began experiencing stiffness in
her neck and reduction in her range of
neck movements about two days ago.
After questioning, you found she had
no referral triggers such as a recent fall,
raised temperature, weight loss, weakness
or chest pain. She rated her pain
5-out-of-10 on a visual analogue scale.
As Cynthia's neck pain has recently
developed, and she is not suffering
from any other medical conditions, it is
most likely she has non-specific (acute)
neck pain. Cynthia mentioned she has
been studying and may have awkwardly
positioned her neck for sustained
periods of time. She also mentions she is
Re-assure Cynthia that although her neck
pain is currently acute, it should ease
over the next 1--2 weeks.
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