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A metric shit ton

By Timothy Cocks Science and the world 09 Jun 2016

Paracetamol and pain: the kiloton problem

“As a unit, the kiloton is most often linked to the explosive yield of nuclear weapons in tons of TNT (an explosive). For drugs, we are more comfortable with milligrams, a unit one million million times smaller. With paracetamol, at a population level, the kiloton unit may be more appropriate: in Europe, paracetamol sales range from under 200 tons in Greece and Portugal to 6300 tons in the UK and 10 000 tons in France

The last few years have seen paracetamol and other commonly used drugs subjected to greater scrutiny, particularly the sharp focus of evidence-based medicine; 2015 and 2016 have seen pivotal new evidence appear. The picture is not quite as rosy as the general view would have us think.

Paracetamol at doses between 500 and 1000 mg is in the least effective quartile of drugs for treating acute post-operative pain.

Paracetamol at doses up to 4000 mg daily is ineffective in back pain.

Paracetamol at doses up to 4000 mg daily is practically ineffective in arthritis. Though marginally better than placebo, paracetamol has little chance of achieving clinically meaningful benefit in osteoarthritis.

No review evidence that paracetamol works for dysmenorrhoea, neck pain, rheumatoid arthritis or cancer pain.

We have considerable evidence that as well as not being particularly effective, neither is it particularly safe.

If paracetamol were an unimportant and little-used drug, none of this might amount to much. But it is not. It is a drug whose use is measured in thousands of tons, has little or no effect in many conditions and has significant adverse events. Maybe it is time to consider the evidence again and think about the possibility of change.”
With the (understandable and appropriate) attention on the catastrophic dangers of opioids it might be easy to overlook problems with apparently safe and effective ‘simple analgesics’. This short editorial makes for sobering reading and suggests that a serious rethink is required.

-Tim Cocks





We’re hitting the road and taking our NOI courses right across this great southern land:

Noosa 17 – 19 June Explain Pain and Graded Motor Imagery (Both courses SOLD OUT)

Wagga Wagga 16-17 July Explain Pain

Perth 15 – 17 October Explain Pain and Graded Motor Imagery


EP3 events have sold out three years running in Australia, and we are super excited to be bringing this unique format to the United States in late 2016 with Lorimer Moseley, Mark Jensen, David Butler, and few NOI surprises.

EP3 EAST Philadelphia, December 2, 3, 4 2016

EP3 WEST Seattle, December 9, 10, 11 2016

To register your interest, contact NOI USA:

p (610) 664-4465



  1. Tim, rheumatologists (and I am one) are in no large part to blame for this. For many years we have been telling our patients that paracetamol is the drug of first choice in the treatment of pain associated with osteoarthritis.

    1. Hi John
      When I had my perforated appendix removed (“scooped out with a spoon” the surgeon told me – I’ll never forget that…) a decade or so ago, I was advised that Paracetamol was a highly effective analgesic as long as I took it every 4 hours – whether I was in pain or not. In years to follow in the clinic I had many patients report hearing this post-surgical mantra. The paracetamol didn’t touch my pain and very few of my patients reported any benefit either.

      Interesting how these medical memes still proliferate despite the subjective experience of individuals providing powerful evidence to the contrary.

  2. davidbutler0noi

    Hi John,

    It is kind of nice hearing you admit that. I also admit that I handed our far too many joint manipulations and I wriggled joints and nerves far too much (and non-judiciously) over my career. It did take me a while to get over the loss of clinical mileage but once I did it was so refreshing.



  3. Well a recent conversation with one of my patients in the planning stage for a joint replacement surgery went along the same line – I think I even said its what everyone ends up doing in the finally stages of pain management when the “grey zone” of management is exhausted (that experimental stage really – have one patient spending $7000 on stem cell treatment to “buy some native hip time”). Perhaps we should be saying that when you get to the point of needing to ramp up the medication, then perhaps you have already started to enter a different phase and you could proceed perhaps earlier than we advise people to do. My question is why they have to be having sleepless nights before they can be operated upon??


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