The Times

Kate Gibbons

Gerry Gajadharsingh writes:

“Whoops, I’ve been using the figure of 5 to 6 million people in the UK who live with chronic pain for several years, the article below suggests more than 20 million people in Britain are thought to suffer from chronic pain. If it is true, that’s almost a 3rd of the UK population, that sounds like an enormous number, whatever the correct number actually is, it is very large, causing distress to many millions of patients and their families, with significant challenges to the clinicians aiming to support these patients.

Quite a large proportion of my complex medical patients present with chronic pain and we are fairly successful in adopting an integrated medical approach to helping these patients. Chronic pain like many other complex medical problems have many different causes, what we call a multifactorial aetiology. Sometimes there is a mix of actual pathology (disease process such as inflammatory disease, osteoarthritis et cetera), with numerous functional problems. Often these patients’ nervous systems are over-sensitised and targeted intervention addressing a variety of functional problems can often allow many of these patients to dramatically reduce their chronic pain medication which as research has shown now for several years, really has almost no part to play in managing chronic pain.

Medication of course continues to be very useful in acute pain presentations and no doubt will be continued to use. The challenge comes in that often these acute pain presentations morph over weeks, months or years into a chronic problem. For many people used to simply taking medication to manage pain, it’s easy to see how they and their medical prescribers, simply take the line of least resistance by dishing out repeated medication.

It is not easy weaning a patient off chronic pain medication, but it certainly can be done in many instances, with the following strategies:

A detailed understanding of the patient’s history, clinical examination, imaging and laboratory findings with a good pathological and functional understanding and then explaining to the patient what is actually going on is really helpful. I’ve lost count of the number of patients who after a diagnostic consultation report feeling much better even when I have performed no or minimal actual treatment. Understanding is the key to managing many complex medical problems including chronic pain and this is true of both the patient and the clinician. 

There is often an inflammatory contribution to pain and patients can be surprised that targeted intervention in regard to their diet in particular can actually make quite a difference. There are other numerous physiological pathways that contribute towards pain, understanding how they work and understanding how diet can intervene in these pathways again can be helpful.

Psychology is often paramount in the article below suggests that at least 50% of chronic pain patients also suffer from coexisting depression. I think it’s a false argument to try to work out whether pain causes depression or whether depression causes pai ,it is extremely rare that I see a chronic pain patients where there isn’t a mixture of physical and psychological things going on.

There is no doubt that some of the chronic pain drugs work via these depression/ nervous system pathways such as amitriptyline or via the central nervous system such as Pregabalin, but should be used sparingly and I really helpful longer term. Helping the patient cope with obvious conscious psychological triggers, but equally important understanding a little more about their subconscious brain and how it influences the autonomic nervous system, which in my opinion is a key factor in helping these patients. Measuring heart rate variability is increasingly available to both clinicians and patients, a low heart rate variability is associated with increasing numbers of disease processes and functional problems such as chronic pain. Understanding and helping patients develop tools to increase their heart rate variability thus achieving better balance within the autonomic nervous systems (usually down regulating the overactive stress part of the nervous system and up regulating the under active relaxation part of the nervous system), again can be very helpful.

The main challenge is often that chronic pain medication will cause rebound pain. When the medication wears off, pain increases, not because more damage has been occurred but simply because of chemical withdrawal. Because pain has increased, the patient takes more medication and before they know it, they’re in a chronic pain situation.

After helping many patients withdraw from chronic pain medication over the years what I’ve learnt is, it’s best done gradually in conjunction with the patient’s prescriber, so they are fully aware of what’s going on, and hopefully supportive of your strategy. As new strategies are adopted by the patient, with the clinicians’ support, medication can gradually be withdrawn. Withdrawal symptoms are common and often not pleasant, and the patient needs significant support through this process with a good understanding of what is actually happening.

It is a complex and sometimes time-consuming process for both the clinician and the patient if a successful outcome is to be achieved, often over a process of several months.

Of course, the ideal situation is to never let patients get into this situation in the first place!”

 

Doctors have been told not to prescribe drugs including paracetamol and ibuprofen to millions of chronic pain sufferers because they can do more harm than good.

There is “little or no evidence” that the painkillers make any difference to the quality of life or psychological distress of the patients, according to draft guidance from the National Institute for Health and Care Excellence (Nice).

More than 20 million people in Britain are thought to suffer from chronic pain, which is defined as lasting or recurring for more than three months.

The guidance from Nice, which advises the NHS on treatments, follows clinical trials that used a range of drugs, from paracetamol to ketamine, to manage chronic pain. Nice pointed to evidence that painkillers can cause harm, including addiction, and advised GPs to prescribe alternative treatments, such as acupuncture and exercise.

The warning does not include taking paracetamol, ibuprofen or other painkillers for targeted relief of recognised pain, injury or to reduce inflammation.

The draft document has been put to public consultation until September 14 and the final guidelines are expected to be delivered by an independent committee early next year.

Chronic pain can have a devastating impact on mental, emotional and physical wellbeing. Almost half of sufferers have a diagnosis of depression. Nice defines chronic pain as having no obvious cause, unlike specific conditions that lead to headaches, low back pain, rheumatoid arthritis and endometriosis.

Often referred to as a silent epidemic, with many cases untreated or misdiagnosed for months or years, chronic pain is difficult to quantify. A recent review estimated 20.6 million sufferers in Britain.

NHS data does not record why a drug is prescribed but the latest figures, from 2017, show nearly 25 million prescriptions for aspirin outside hospital and 20 million for paracetamol. In 2016 £537 million was spent on prescribing painkillers.

Doctors prescribe painkillers that can be bought cheaply over the counter to allow patients to obtain larger supplies, as pharmacies have purchase restrictions. It is also beneficial for those eligible for free NHS prescriptions.

The draft guidance advises supervised group exercise programmes, some types of psychological therapy, or acupuncture to treat chronic pain. It also recommends that some anti-depressants can be considered for people with chronic primary pain.

Nick Kosky, a consultant psychiatrist who chaired the guidance committee, said there was a “mismatch between patient expectations and treatment outcomes” that could result in an over-prescribing of ineffective but harmful prescription drugs. Paracetamol, non-steroidal anti-inflammatory drugs such as aspirin and ibuprofen, benzodiazepines or opioids should not be offered, it concludes.

Antiepileptic drugs including gabapentinoids, local anaesthetics, ketamine, corticosteroids and antipsychotics should not be offered to people to manage chronic primary pain because, again, there was little or no evidence that these treatments work.

Martin Marshall, chairman of the Royal College of GPs, said: “GPs are aware that prescribing pain medication comes with risks, including addiction, and this is something we will discuss with them.

“GPs are open to alternatives, as long as there is evidence of their benefit and effectiveness . . . any Nice guidance that suggests an alternative to medication must go hand-in-hand with adequate access to them at community level in order to really make a difference to the lives of our patients living in chronic pain.”

The charity Pain Concern welcomed the draft guidelines. James Boyce, a project leader and spokesman for the organisation, said: “Treatment options for chronic pain are often limited.

“Pain medications should not be used for everyday treatment. Effective self-management should enable an individual to reduce the impact of pain on their daily lives.”

Cathy Stannard, a consultant in pain medicine who was on the Nice committee, said: “These aren’t rules — they are guidelines. A clinician making a prescribing decision would weigh up the presentation and decide whether there is some underlying painful condition or whether it is pain unrelated to anything else.”

Martin Underwood, professor in primary care at Warwick University, said the guidance sent a “clear statement against the use of nearly all drug treatments” and should “change expectations from GP and specialist consultations”.

He added: “Sensible recommendations are made for non-drug treatment — exercise, talking therapies and acupuncture. Now the challenge for the NHS will be to deliver these at scale for the millions of people with chronic pain.”

Common chronic painkillers and their side-effects

Paracetamol
Over-the-counter paracetamol is offered on a cost-effective prescription often for head or non-nerve pain.

Some studies suggest that long-term use can cause a small increased risk of heart attacks, gastrointestinal bleeds and kidney problems.

Ibuprofen
Non-steroidal anti-inflammatory drugs such as ibuprofen are prescribed for mild to moderate pain linked with inflammation, particularly in the back and neck. If taken for a long time it increases the risk of stomach upset, including bleeding, and kidney and heart problems.

Codeine
An opiate used to treat severe pain that does not work well on its own, so is often prescribed with paracetamol to create co-codamol, which can be bought in low doses, or prescribed in higher doses. It is highly addictive.

Side-effects include liver damage, gastrointestinal issues and depression.

Amitriptyline
Tricyclic antidepressants are used to treat persistent pain, particularly nerve pain and pain that keeps you up at night.

Side-effects include drowsiness and dizziness.

Morphine
Morphine and similar drugs, such as oxycodone, fentanyl and buprenorphine, are the strongest and are for long-term pain.

They are highly addictive, and their use should be monitored by a doctor.