When I was growing up in the 1960s and 1970s, painkillers were kept in a glass bottle in the bathroom medicine cabinet. When you had a headache, you would wait until you got home and then open the dusty bottle and shake out two pills: round, powdery discs with bevelled edges and a bisect line - a groove cut into the pill so that you could snap it in half for a reduced dose. You'd swallow the pills, either aspirin or paracetamol, with a glass of water. They felt uncomfortably large in the throat and had a bitter taste. The bottle, which contained 50 pills, hung around for months, even years.
Now, when I feel a headache coming on, I pat my pockets to see if I have any painkillers on me. The time between pain and treatment has shrunk to almost nothing. These days, the pills do not come in bottles, but in blister-packs in bright, shiny boxes. When I leave the house, I sometimes run through a checklist - keys, wallet, phone, painkillers. The packets, some of which are plastic and shaped like mobile phones, are cheerful and glossy; elegant enough to put on a table in a restaurant, they look like lifestyle accessories. You take them with you when you leave the house, partly for convenience and partly because you know that, if you leave them lying around, someone else will pocket them.
Painkillers are no longer hard to swallow; the pills have smooth edges, and some have a glossy coating of hard sugar, like Smarties or M&M's. Some of them are mint- or lemon-flavoured. If your throat objects to tablets, you can take caplets, which are longer and thinner, or "liquid capsules", which are soft and gelatinous, like vitamin pills, or powder, which is poured from a sachet into a glass of water. You could conceivably take a painkiller while you were out jogging, or running for the bus.
Painkillers are also more widely available than they used to be. We have been able to buy aspirin and paracetamol over the counter for some time now, but in 1996 restrictions on the sale of ibuprofen - the newest, raciest painkiller - were relaxed, making it available in supermarkets, newsagents and corner shops, as well as from the pharmacist. This was part of an NHS drive to save money by taking pressure off doctors and pharmacists; as citizens, we have been taught to be self-medicating when it comes to pain. The change came about after Galpharm, a British pharmaceutical company, made a successful application to the Medicines Control Agency for a licence to have ibuprofen moved from the pharmacy to the "general sales list". After that, painkiller advertising, marketing and packaging moved into a different league.
Inevitably, we are also spending more on painkillers than ever. I'd buy them as a matter of course, with my groceries. I found myself wanting to buy smart painkillers, in the same way that I might buy smart jeans or decent coffee. For me, and for many people I spoke to, the temptation is to catch headaches early, nip them in the bud. We have become enthusiastic self-medicators. In 1997, according to the market research firm Euromonitor, the British painkiller market was worth £309m. In 2001, it was worth £398m. In other words, it grew by almost 30% in just four years, probably the biggest hike since the German company Bayer opened the first US aspirin factory in 1903. Euromonitor predicts more growth: by 2006, it estimates that the market will be worth £483m.
Recently, I found myself in someone's house with a slight headache. No problem, he said. He had stocked up on painkillers - he thought he had four packets, a total of 48 pills. But he couldn't find them; the packets had all gone. Three people were living in the house. "I just bought them a couple of days ago," he said. That was the moment I decided to write this article.
How do you decide what type of headache you have? Is it an Anadin Extra headache, or an Anadin Ultra headache? Is it a Nurofen headache, or a Nurofen Plus headache? Can you cure it with tablets, or do you need liquid capsules?
In an ordinary shop, you can buy three basic types of painkiller - aspirin, which has been around for a century; paracetamol, which emerged as a popular alternative after the war; or ibuprofen, which was invented in the early 1960s and has been a pharmacy medicine since 1983. Ibuprofen is slightly gentler on your stomach than aspirin, but it does not thin your blood to the same extent.
Aspirin and ibuprofen reduce pain, fever and inflammation, while paracetamol reduces only pain and fever. Paracetamol is gentle on the stomach, but can damage the liver if you take too many. Paracetamol is also the suicide drug; you can die a painful death by knocking back as few as 25. (For this reason, the government has taken steps to reduce packet sizes; since 1998, you have been able to buy packets of no more than 16 in supermarkets, or 32 in pharmacies - though there is nothing to stop you from going to more than one shop. The multibillion-dollar paracetamol industry in the US has thus far resisted all attempts by the Food and Drug Administration to reduce packet size.) Aspirin and ibuprofen are potentially less harmful: most people would survive a cry-for-help dose of around 50 aspirins, or even 100 ibuprofen tablets.
When it comes to headaches, ibuprofen is my drug of choice. (I'm not alone: according to Euromonitor, ibuprofen now has 31% of the market, and is growing exponentially. Aspirin has a 7% share, and paracetamol 13%; the rest of the market is made up of combination painkillers.) I also, I have noticed, have strong brand loyalty. When I go to the supermarket, my eye is drawn to the row of shiny silver packs with a chevron and a target design - Nurofen. Nurofen claims to be "targeted pain relief".
Targeting a headache costs me around 20p a shot. On one level, I am aware that the active ingredient in a single Nurofen tablet, 200mg of ibuprofen, is exactly the same as that in a single Anadin ibuprofen tablet, or an Anadin Ultra, a Hedex ibuprofen, a Cuprofen or, for that matter, a generic own-brand ibuprofen tablet from Safeway, Sainsbury's or Tesco. On another level, Nurofen's targeting promise appeals to me. It feels hi-tech, almost environmentally sound. It makes me think of stealth bombers dropping smart bombs down the chimney of the building they want to destroy, with minimum collateral damage.
Are our headaches getting worse, or do we just think they are? I went to see Dr Raj Munglani, a consultant in pain management, in his office at Nuffield hospital in Cambridge, to find out what he thought. Munglani is a pleasant-looking man in middle age who drives a top-of-the-range Volvo between his home in a village outside Cambridge and the various hospitals in East Anglia where he practises.
Munglani believes that our society tolerates less pain than ever before. Modern life requires you to be pain-free; there just isn't time to lie around waiting for a headache to go. Young people are more impatient than older people; when they feel pain, they want something done about it, immediately. Generally speaking, the younger the consumer, the stronger the painkiller they are marketed: Anadin Original is pitched at people over 45, Anadin Extra at people between 25 and 55, and Anadin Ultra at people between 19 and 32. Of course, there is a limit to this sliding scale: Nurofen for Children (six months and over) contains 100mg of Nurofen, half the adult dose.
Is any of this surprising? We live in an age of quick fixes. These days, we expect everything to get faster - cars, lifts, food. When we suffer psychological distress, we take Prozac and Seroxat. More people are having their wisdom teeth extracted under general anaesthetic. Caesarean section is on the increase. Half a century of the NHS has softened us up, and the sheer success of modern medicine has made pain something of an anomaly. We work out, we take vitamins: we can't really be doing with headaches. We see pain not as a symptom - an alarm system to warn us of illness - but more as an illness in itself. When the alarm comes on, we just want it turned off.
Our parents and grandparents "worked through" their pain; they gritted it out. God, it was said, would never give you a pain you couldn't bear. In those days, pain had a moral, even a religious dimension. Pope John Paul II has said "suffering contains, as it were, an appeal to man's moral greatness and spiritual maturity" - but today few of us want to be martyrs. Look at the ads on TV, and on buses and trains in any major city: painkillers will get you back to work, help you keep your job, deal with the kids; with painkillers, you can cope.
I had a slight hangover the day I visited Munglani, which seemed to be getting worse. I'd nearly missed my train, and found myself repeatedly clenching my jaw in the taxi. I'd planned to buy some Nurofen before I got on the train, but had run out of time.
Munglani explained the anatomy of my headache. The alcohol I had drunk had dehydrated the inside of my skull. Consequently, the dura, the Cellophane-like membrane that encases my brain, was no longer fully supported. Cells inside my skull were being traumatised, and had responded by releasing tiny amounts of arachidonic acid; this acid, having seeped out of my cells, had turned into a set of chemical compounds called prostaglandins. And these prostaglandins were hurting me; they were telling nerve endings in my head to tell my brain that my cells were traumatised. My brain, in turn, was trying to get my attention, and succeeding. I was in pain. It felt as if something inside my head was being gently pulled away from my skull, which it was.
When you take aspirin, or paracetamol, or ibuprofen, the drug works by deactivating a chemical called prostaglandin H synthetase, the catalyst that turns arachidonic acid into prostaglandins. So even though your cells are still traumatised, your brain is no longer aware of the trauma. Your brain is being fooled. This process was discovered in aspirin in the 1970s by John Vane, a scientist working at the Wellcome Foundation, who went on to win the Nobel Prize in 1982. (Aspirin was first synthesised in Germany in 1899, and so had been on the market for more than 70 years before anybody knew how it worked.)
"Pain," said Munglani, "is what the patient says it is." All sorts of things can make you feel headachey, including muscle contractions on the scalp or the back of the neck, dehydration from drinking too much alcohol or caffeine, staring at your computer screen for too long, looking at bright lights, colds and flu, grinding your teeth, anxiety at the prospect of getting a headache. Sometimes, prostaglandins are produced when there is no apparent trauma. You might feel pain because something has subtly altered the balance of your brain chemistry, or simply because your mood has changed; you might be producing an uneven amount of serotonin or dopamine.
You might, most worryingly, have a headache because you take too many painkillers, a condition known as "medication overuse headache". A study published in the British Medical Journal last October found that "daily or near-daily headache is at epidemic levels, affecting up to 5% of some populations, and chronic overuse of headache drugs may account for half of this phenomenon". Low doses daily appeared to carry greater risks than larger doses weekly.
Of course, most pharmaceutical research is sponsored by pharmaceutical companies, which are understandably reluctant to explore the negatives. But what research there is suggests that analgesics, when used frequently, chronically reduce levels of serotonin, and increase levels of pain-signalling molecules. Earlier this year, the New York Times reported that a German study had found that even a two-week course of Tylenol (an American brand of paracetamol) "causes a drop in serotonin-receptor density in rat brains", an effect that is reversed when the rats are taken off the painkillers. If you keep fooling your brain into not feeling pain, your body will eventually fight back and make you feel more pain. And then you'll want more painkillers; it's a vicious circle.
Imagine this as a business proposition. You buy a cardboard tub of fluffy white powder for around £100. Then you turn the powder into a quarter of a million pills, which you sell at 10p per pill. Every cardboard tub you buy makes you a profit of £24,900. The powder is pure ibuprofen. The pills are painkillers. The company is Boots, which owns a subsidiary called Crookes Healthcare, which manufactures Nurofen. Sounds good, doesn't it? Of course, there are overheads - you have to invent the drug, spend years on expensive clinical trials, build a factory, and hire people to make the pills, tell the public about the pills, and design the packs so they look attractive on the shelves. "It takes 10 years and £200m to get a new drug accepted," said Dr James Walmsley, a senior medical adviser to Boots. Even so, it's clearly worth it. (I asked two Boots employees how much the company would pay for a 50kg tub of ibuprofen. "About £100," they agreed. Later, a press officer emailed me to say she couldn't officially comment on the cost.)
Boots' head office, and the factory that makes many of its painkillers, are on a campus that lies a few miles outside Nottingham. Every day, trucks full of raw ingredients arrive at one end of the factory, and trucks leave the other end with the finished product - tens of thousands of cardboard packs, destined for 90 countries. This is D-95, one of the biggest painkiller factories in Britain, working 24 hours a day. If you've ever popped a Nurofen tablet, or a Nurofen caplet, or a Nurofen Plus, or a Nurofen liquid capsule, or a Boots own-brand generic ibuprofen tablet (the active ingredient is the same), or a Boots own-brand aspirin or paracetamol tablet, the pill you swallowed will have been made here. This is Headache Central.
"Six hundred people work here," said Catherine McGrath, who described herself as "shift manager, analgesics". She explained that the factory works seasonally, making cold remedies in the autumn to meet winter demand, and hayfever remedies in the spring. Headaches are a year-round phenomenon. "There's a constant demand for painkillers," McGrath told me.
Before the fluffy white powder becomes a hard, glossy pill, it must go through many different stages. First, it is mixed with "excipients", ingredients that have no painkilling role. Each Nurofen pill, for instance, contains 200mg of ibuprofen, but also maize starch, sucrose, calcium sulphate, stearic acid and shellac. These things hold it together, bulk it out, make it taste nice and help it disintegrate when it reaches the stomach.
If you swallow a Nurofen tablet, Boots' employees will have mixed it, granulated it, sieved it in a colander the size of a dining table, dried it using a contraption like a hand-drier in a public loo, but 20ft tall, blown it upwards into a series of giant "socks", milled it in a vast grinding machine, "pinched" it to remove excess air, punched it into the shape of a pill, weighed it, checked it for metal deposits, coated it in sugar 16 times until the edges are smooth, printed it with a logo on an old-fashioned printing press, blister-packed it and boxed it in an attractive box.
The factory is large and sterile, like a setting in a JG Ballard novel - big, barn-like spaces, dull, neutral colours, large rooms full of vats. The thing that gets you is the scale. This is about making millions and millions of pills - to cure tension headaches in France, migraines in Germany, hangovers in Holland, Belgium, Denmark, Sweden. Naturally, after a few hours in this environment, a headache started creeping up on me. I patted my pockets. Nothing. It is not possible to take a pill in the factory itself.
McGrath and I watched hundreds of ibuprofen caplets pouring down chutes. "Lovely and slinky," she said, "nice to go down your throat."
Stewart Adams, the inventor of ibuprofen, lives modestly in a compact modern house on the outskirts of Nottingham. On the sideboard in his living room there is a silver Nurofen pack, cast in metal, with the names of the first Nurofen advertisers on the back. He won an OBE for services to science in 1987, and his name is on the ibuprofen patent. But Adams has derived no great material reward from his invention - no house in the country, not even a lifetime supply of painkillers. When he gets a headache, he goes to the corner shop just like the rest of us.
A sprightly, talkative 79, Adams came upon ibuprofen when he was working as a research scientist for Boots in the late 1950s, looking for a drug to reduce inflammation in patients with rheumatoid arthritis. Looking back on his career, he says he was "very disappointed". He had found a headache remedy that was more potent than aspirin, with fewer side-effects - but he hadn't found a cure for rheumatoid arthritis.
His operation was very small - "a man and a boy". Typically, his research budget was between £4,000 and £5,000 a year. Adams discovered that aspirin reduced the swelling caused by ultraviolet light on the skin. Working with an organic chemist called John Nicholson, he began looking for aspirin-like compounds that might have fewer side-effects on arthritic patients. "It was a bit hit and miss," he told me. (This was long before John Vane had discovered how aspirin worked.)
"We weren't as clearcut in our thinking as we might have been," said Adams. He and Nicholson looked at hundreds of chemical compounds. They put several drugs through clinical trials, testing them on arthritic patients. One drug produced a nasty rash in a large percentage of the patients; another produced a rash in a smaller, but still significant, percentage. A third, ibufenac, an acetic acid, caused jaundice. "We had to sit back and have another rethink," said Adams.
During this long process of trial and error, Adams synthesised a version of ibufenac that was not an acetic acid but a proprionic acid - ie, related to propane rather than vinegar. He assumed it would be toxic but, surprisingly, it wasn't: it had a short half-life in the tissues. It was like aspirin, only you could take more of it. Adams and his colleagues began taking the compound, ibuprofen, when they got headaches. "We knew it was analgesic, because we were taking it well before it got on the market," he says. He remembers making a speech at a conference after a few drinks the night before, having dealt with his hangover by taking 600mg of this new drug he had invented.
When Boots patented ibuprofen in 1962, Adams could have had little idea what he had invented - an analgesic that would compete with aspirin; a drug that, once its control had passed into the hands of the marketing men, would change the way we consume painkillers for ever. For the rest of his career, Adams continued with his efforts to find a cure for rheumatoid arthritis, without success (although ibuprofen has important uses in its treatment). Holding the original patent in his hands, Adams said, laughing, "We didn't get anything. I think, in fact, we were supposed to be given a pound for signing away our signatures, but we didn't even get that."
Now that painkillers exist in a no man's land between medicine and product, they don't need someone to prescribe them - they need someone to market them. Don Williams, the man currently responsible for the design of the Nurofen pack, works in Notting Hill, west London. His office is just what you'd expect - minimal furnishings, varnished, blond-wood floors. In the upstairs lobby there is a shopping trolley full of products designed by his company, Packaging Innovations Global: Double Velvet loo paper, Head & Shoulders shampoo, Pot Noodle - and Nurofen. A former session guitarist from Middlesbrough, Williams is tall and slim, with wonderfully tasteful casual clothes and a fashionably shaved head. "That's our philosophy," Williams said, looking at the trolley. "That's what we believe in. Getting things in trolleys. At the end of the day, that's what we're paid for."
Packaging Innovations began designing Nurofen packs about five years ago. "There are very few brand icons that visually communicate what they actually do," Williams said. The target design is "directly related to the brand promise". Two years ago, the Brand Council, an advertising industry panel, named Nurofen as one of 100 British "superbrands", one that "offers consumers significant emotional and/or physical advantage over its competitors that (consciously or subconsciously) customers want, recognise and are willing to pay a premium for".
One of Williams' innovations was to place the target in the centre of the pack, with a chevron radiating out to the sides. He also wanted more of the silver foil on the packs to be visible. Consumers, he told me, are visually literate - they see the pack design before they read the words. When he took over the design of Benson & Hedges' cigarette packs, Williams made sure that every pack was gold, even the packs containing low-tar cigarettes, which had previously been silver. "We believe that brand identities should be recognised at a distance," he said, "even through half-closed eyes, or sub-optimal conditions, or in peripheral vision." In supermarkets, says Williams, "We want a blocking effect on the shelf. The chevron links all the packs together, so you get a wave effect." As I left, he said, "I get more kicks out of seeing a pack in a bin than on a shelf."
Are we taking more painkillers than we should? Dr Timothy Steiner, a dry, precise man and consultant physiologist at Charing Cross hospital in London, thinks so. He believes that one in 30 people suffer chronic daily headaches as a result of painkiller overuse. So what constitutes overuse? In a paper on headaches published in the British Medical Journal last year, Steiner wrote that it was hard to generalise, although "the regular intake of three or more analgesic tablets daily on more than two days a week are suggested arbitrary limits". He won't quite say that "medication overuse headache" is something the pharmaceutical industry is reluctant to explore. What he does say is that when the Proprietary Association of Great Britain (PAGB), which represents the pharmaceutical companies that make over-the-counter medicines, set up a working party to investigate the possibility that painkillers might be causing headaches, the working party was disbanded. That was in July 2000. Steiner looks at me as if to say: this is a fact; you can make of it what you will.
I later spoke to Sheila Kelly, executive director of the PAGB, to get the industry perspective. Does she think the market is growing too fast? Kelly said she had figures only up to 1997. She doesn't say so, but that is the year when the market really began to take off, the beginning of the big painkiller push. Kelly believes that "medication overuse headache" has been confused with some cases of migraine. "It's not the analgesics that cause the headaches," she said. "These people have a propensity towards migraine. It's a coincidence. It's become a non-issue, I think."
Sitting behind his desk in his neat office, Steiner disagrees: he thinks that "medication overuse headache" is a "huge public health issue". He explains the cycle: "Over-consumption of painkillers leads to aggravation of the headache condition. Headaches and analgesic use become more frequent, one driving the other. Patients, instead of taking painkillers for the headache they've got, take painkillers for the headache they fear they're going to get.
"If painkillers reduce the sensitivity of pain pathways, there is likely to be, over time, a physiological compensation for that, which results in those pathways becoming more sensitive, leading to the requirement for more analgesia. Pain pathways are there for a good reason. They're there to protect us from causing injury to ourselves."
Once these compensating mechanisms come into effect, says Steiner, "people begin to look for something stronger". They might go for codeine, an opioid drug related to morphine that can be bought over the counter in pharmacies, though not in supermarkets. Nurofen Plus contains codeine, as do Solpadeine, Panadeine and Co-codamol. "Once codeine is there as well," says Steiner, "not only are you taking something that will cause chronic daily headache, but something that can be addictive."
Steiner, by the way, says he finds the notion that Nurofen "targets" pain "an interesting claim". If there is targeting, he says, "It's not a process that the drug is responsible for. It's a process that the body is responsible for."
Robert, a 34-year-old writer, has been addicted to painkillers for 10 years. Typically, he takes 24 Solpadeine tablets - a mixture of paracetamol, codeine and caffeine - a day. Yesterday, he tells me, he took three packets: 36 pills. This is, of course, an extreme case of overuse, and Robert's doctors have warned him that he risks permanent damage to his liver. Without painkillers, he feels "just awful. You just feel terrible. You go cold turkey. You feel like crap."
Taking painkillers, he says, "has become ingrained in my day, my routine". He remembers how it started. He had bad headaches, and his mother suggested Solpadeine. You might remember an ad for Solpadeine in which a man puts two cartridges into a shotgun, one representing paracetamol and one representing codeine, and blasts a clay pigeon, which represents the pain. "Bang! Instant relief!" says Robert. "It worked. I also noticed a slight chemical shift in my body. I wasn't high, but it felt very calming, very good. I can't say I rushed out and robbed some grannies. But I kept taking the tablets." When his headaches came back, they were worse than ever. That was when he began to take the tablets pre-emptively.
For years, says Robert, he felt desperate and alone. He felt like a "freak". A couple of years ago, he started surfing the internet, desperate for help, and found, to his surprise, that hundreds of people were posting messages on websites, such as over-count.org.uk. They make salutary reading. Every story is almost exactly the same. People take painkillers because they feel pain. At first, they feel better. But then they start to feel more pain than they felt before. Sometimes, they start by taking ibuprofen, or aspirin, or paracetamol. But the real problem is almost always that they are addicted to codeine.
"Even as I write this, I have tears streaming down my face," writes one addict. "I am willing to try anything to get rid of these tablets," says another. "All my veins are hot and rushing," writes a third. "It's lush. But it's not worth it. I don't want this addiction any more. I don't want to spend all my money on analgesia. "
As Steiner says, "There is a lack of education about what painkillers are. They are medicines, which have effects that are wanted, and a variety of unwanted effects." These unwanted effects can include gastrointestinal bleeding, stomach ulcers, kidney and liver failure. Taking a painkiller might also encourage you to exercise when you shouldn't, aggravating existing injuries. In 2000, a report published by scientists working in Oxford and Geneva estimated that 2,000 people a year were dying in Britain as a consequence of long-term painkiller misuse; Andrew Moore of the Oxford chronic pain clinic, who co-authored the report, estimated that side-effects and treatment arising from long-term prescription aspirin and ibuprofen use were costing the NHS between £170m and £250m a year.
Steiner believes that, while the medical establishment is beginning to understand the problems of painkiller overuse, there is a lack of awareness among GPs. "That's right," says Robert. "The medical establishment doesn't have a proper system to deal with painkiller addiction. It's not like heroin -if you're addicted to an illegal drug, you can enter a detox programme. But if you're addicted to a legal drug, it's different. It's harder for them to admit that a legal drug can be so addictive."
The only method, says Steiner, is withdrawal. If you want to check into a detox clinic, as former painkiller addicts Matthew Perry and Winona Ryder did, you'll almost certainly have to pay for it yourself. Cold turkey is the only answer. "My experience," says Steiner, "is that people who try to taper off usually fail."
Before I started researching this article, I took several painkillers a day - sometimes four, sometimes six. Sometimes eight or 10. This was before I stopped drinking. I would knock back three or four first thing in the morning, to deal with my hangover, which had not been entirely knocked out by the two or three I had taken the night before. I remember the fuzzy, headachey dash to the corner shop when I woke up with no painkillers, and the painkillers I took in the evening before going to the pub, when I was beginning to feel better.
Was I harming myself? Probably. Might I have ended up like Robert? It's difficult to say. With painkillers, as with other drugs, everybody is affected differently. Why did I take so many painkillers? Partly, of course, because they reduced pain - but, more worryingly, I took them because I liked them. I take them only occasionally now.
This is what happens when a medicine becomes a product. It begins to seem more attractive, more desirable. It comes, almost literally, with a spoonful of sugar. In a sense, the marketing man becomes the doctor. As the late pain expert Patrick Wall wrote, "A crucial component in all analgesics, no matter how they work, is the patient's belief that it works." Nurofen works for me partly because I believe it does.
What does the future hold? More painkillers. More pain pathways becoming desensitised. Packaging that looks more and more attractive. New pill shapes. Faster-acting pills. And then what? A big marketing push in the developing world, domestic advertising restrictions, health warnings appearing on packets. There may come a time when people will be wearing patches to wean themselves off painkillers, or chewing low-dose ibuprofen gum - and what a marketing opportunity that would be.
