In the fight against pain, increasing the dose does not help. Doctors need new tools
Growing concern about the prescription of drugs that cause dependence has been backed up by a recent report from Public Health England (PHE). The agency discovered that in 2017-18, 13% of adults in England received at least one prescription for opioids such as morphine or oxycodone (although this represented a slight downturn in prescribing after a long upward trend). Other drug classes were implicated too, with 25% of adults prescribed one or more of the following drugs: benzodiazepines (such as Valium), z-drugs (sleeping pills such as Zopiclone), gabapentinoids (gabapentin or pregabalin, prescribed for neuropathic pain) or antidepressants.
The fear is that the UK is following in the footsteps of the US, where overprescribing is said to have led to a full-blown “opioid crisis”. But where does this leave those who live with severe or chronic pain and are dependent on opioids to function day-to-day? GPs, like me, and pain specialists need lots of time and a toolbox of interventions to properly treat those who suffer. But in the current cash- and time-poor environment, is it any wonder that they dole out prescriptions instead?
There are difficult conversations to be had at all levels of our health service, right down to the intimate exchanges that happen between GP and patient
The scale of the problem in the US is terrifying: in 2017, more people died from opioid overdoses than Aids-related illnesses at the peak of the epidemic. And an unprecedented fall in life expectancy from 78.8 in 2014 to 78.5 in 2017 is attributed to a surge in opioid-related overdoses and suicides. The US is the most severely affected country due to a combination of patients in pain wanting a solution, doctors trying to help, pharmaceutical companies’ pursuit of profit, aggressive TV advertising, poor regulation, patchy healthcare and socioeconomic factors that lead desperate people to seek desperate measures.
We might like to think that something of this scale couldn’t happen in the UK but there’s no room for complacency. Pain management specialist Anthony Ordman says opioids are not as effective against pain as one might think. “We used to think that morphine must stop all pain, but it can sustain and amplify it by causing inflammation in cells in the spinal cord and brain,” he says. After six to eight weeks, he says, opioids can lose their efficacy and unwanted side-effects such as sedation and constipation become a problem.
There are alternatives to classical opioids but there’s no panacea. One, buprenorphine, acts on different receptors and may cause less addiction. The non-opioid drugs gabapentin and pregabalin are prescribed for nerve pain but have become so widely misused that they were reclassified as class C controlled drugs in April 2019. Ordman says that five to six people may have to take these drugs for one person to feel the benefit. “People feel good on them and get hooked,” he says. But they can cause cognitive and other problems.
The market is huge and the need for novel drugs with less addictive potential is clear, but Ordman says that because pain is not a sexy subject, it has a low profile among those who decide on health spending. Bringing new drugs to market is a long and expensive business, and pharmaceutical companies are prioritising biological drugs – such as those that modify the immune system – and genomic research.
It’s not all gloomy: drugs that disrupt pain pathways in potentially less harmful ways are in development, and medical cannabis can be prescribed by specialists (though at the moment it is only licensed for nausea and vomiting after chemotherapy and some rare forms of epilepsy in the UK). There is a move to make medical cannabis more readily prescribable but a recent Commons select committee report concluded that we needed more evidence of its effectiveness and safety before relaxing the current guidance.
The chances are that we will never have the perfect painkiller. Ordman says the very word raises unrealistic expectations. “Painkillers will never stop all pain; at best, a drug might reduce pain and allow a person to get on with their life.” Treatment needs to tackle the anxiety and suffering caused by physical discomfort at least as much as the sensation itself. Clinicians should advise patients to “keep moving and keep busy” and that “pain doesn’t mean danger”. If one “painkiller” doesn’t work, it should be stopped before starting something else. A large part of the way some of these drugs work is by suppressing anxiety about pain. As a result, weaning off opioids, for example, should be done gradually over weeks or months, not cold turkey, because otherwise that anxiety bubbles up, with a corresponding intensification of pain.
The place where all these complex problems meet is the GP’s surgery. The answers are not entirely within the doctor’s gift, of course: the PHE report found that poorer people and those in the north-east and north-west of England were more likely to be at risk of long-term drug use, pointing to broader societal questions. But in an ideal world, doctors like me would at least be able to offer a range of talking therapies such as cognitive behavioural therapy, physiotherapy, acupuncture and treatments involving electrical stimulation, as well as measures to tackle the worry and isolation that are the hallmarks of chronic pain. In my experience, those conversations don’t always play out well. People who live with chronic pain can become defensive if asked to consider weaning themselves off drugs that they’re dependent on. Suggesting to someone who feels paralysed by pain that they need to get out for a walk can sound offensive, patronising and uncaring.
It’s certainly not a binary choice; opioid and other pain-relieving drugs have their place. But prescribing is out of control and cannot continue at these levels. There are difficult conversations to be had at all levels of our health service, right down to the intimate exchanges that happen between GP and patient. Simply handing out a repeat prescription is not the answer.