Chris Smyth, Health Editor
The Sunday Times
Gerry Gajadharsingh writes:
“We are indeed seeing many patients with chronic (long term) pain presenting with the complication of medication overuse. But I think there’s a big difference between an acute problem (recent or short term), where short-term medication can often be helpful as part of an overall treatment strategy, versus chronic pain syndromes where long-term medication often becomes part of the problem, there are many mechanisms behind this including rebound pain, i.e. when the medication wears off the pain increases and the patient takes more medication.
Chronic pain is a very complex phenomenon and includes the increasingly recognised concept of central nervous system sensitisation, the nervous system gets hardwired to keep the chronic pain going. The medical profession and patients, have from many years, sought to explain physical health problems and mental health problems as being different things. It is rare that I see a patient presenting with a so-called physical problem that doesn’t have underlying psychological factors that impact on their physical problem and indeed patients who present with so-called mental-health problems often have underlying physical factors that impact on their mental health problem.
Often the medical profession (and patients) are looking for “the one thing”. If the Dr can find “the one thing” then hopefully they can provide a solution. Patients are increasingly presenting with complex problems, chronic pain being one of them. Often receiving numerous failed medical interventions, they or indeed the clinicians trying to help them seem to run out of options. I often find the aetiology (cause of the problem) is multifactorial, i.e. there may be several factors that impact on the patients’ problem. Therefore, paying attention to “the one thing” is so often ineffective.
The challenge for many patients with chronic pain, is accepting that there is a psychological component to their ongoing pain. It is accepted that about 10% of brain/ nervous system activity is on a conscious level, which means that 90% of brain/ nervous system activity is occurring on a subconscious level. This part of the nervous system is called the autonomic nervous system, it controls everything that’s going on within our body. Monitoring Heart Rate Variability (HRV) gives us a good idea as to how the patient’s autonomic nervous system is behaving in real time. Taking them through different challenges (getting them to think about different situations) can for the first time give them an insight as to how their thoughts can impact their physiology, immediately!
Low HRV tends to correlate with a stressed nervous system, high HRV tends to correlate with a more relaxed nervous system. Many of my patients have low HRV, I can show them this in a non-invasive way which helps me explain how their nervous system may well be driving their pain. Much chronic pain involves the neuromusculoskeletal system, when the nervous system is stressed tense it activates heart, lungs, liver and muscles, essentially keeping muscles unnecessarily tense. Relaxed breathing techniques can be so important to provide patients with the tools to help support their autonomic nervous system.
Many patients simply don’t believe that stress, anxiety or underlined depression impact on their pain. I think it’s true that many patients get an impression that sometimes if the problem is not responding to normal medical intervention and the doctor starts to talk about stress, it is perceived that the problem is not been taking seriously or that they simply are not being believed. We need to find a way of convincing patients that this belief is simply not true. There are very few patients who I meet who are imagining their symptoms.
The research below focuses on opioid medication, including codeine, morphine and tramadol (being a similar type of drug to heroin is why they are so addictive). The research also focuses on prescription medication, of course many patients can obtain codeine over the counter, however on most boxes of medication there is now a warning alerting the patient that codeine can be addictive and to not take the more than three days without consulting a health care practitioner.
There are of course numerous other medications, initially designed for short-term use that patients are also overusing long-term. NSAID, tranquillisers/ muscle relaxants and PPI’s to name but a few.
The aim is to find better solutions for patients to minimise the need for these medications, patients need to be more open as to the things going on in their lives and their lifestyles that will may well be impacting on their ongoing chronic symptoms. Clinicians need to be trained to understand how these factors impact on the patient presentation, the physiological mechanisms behind it and the ability to gently explain these mechanisms to patients to help them develop more viable options.”
Hundreds of thousands of people are hooked on painkillers prescribed by their doctors in what experts fear is a growing public health problem.
Prescriptions for opioid drugs such as codeine and tramadol have doubled in the past decade as GPs feel pressured into doling out pills known to be useless for chronic pain. Little attempt is made to help people stop taking brain-dulling medicines, leaving them at long term risk of breathing problems, heart attack and death.
Doctors are being urged to persuade patients to try psychological means of dealing with pain, while the NHS is facing demands for services to help people break their dependence.
In the US, tens of thousands of people now die of overdoses after lax prescribing helped to create an opioid epidemic. Recreational use of painkillers is thought to be less of a problem in Britain, where most people who become addicted to opioids suffer from chronic pain.
However, while the drugs work for short-term pain such as that caused by broken bones, they do little for people suffering from long-term pain that is not caused by tissue damage.
Cathy Stannard, a consultant in pain medicine in Bristol, said: “We do have a really big public health problem. Medicines are prescribed for pain far more than is warranted by their effectiveness.”
She said that much long-term pain had a strong psychological element and many people were using opioids “to blunt the nastiness of life” even though medicine did not really help with the pain.
“We see a lot of patients take these drugs to cope. They blur the thoughts of previous trauma and that’s the driver for people to carry on despite them getting no relief. Some say, ‘It’s like taking Smarties, it doesn’t do anything — but I’ve got to do something.’ We need a real public message that if these drugs don’t do anything, just come off.”
Figures from NHS Digital show that 24 million opioid painkiller prescriptions were issued last year, up from 12 million ten years ago and just 3 million in 1991. Estimates of numbers dependent on painkillers vary from about 250,000 people to 5 million.
Opioids have long been used effectively to ease the pain of patients dying of cancer but Dr Stannard said that in the 1990s the drugs began to be used much more widely as people demanded relief from chronic problems.
“GPs know it’s the wrong thing to do but feel bad they can’t do anything else. Patients are really distressed and as health professionals we feel really bad if we can’t do anything. In a ten-minute consultation there’s not time to discuss any other treatment options.”
Andrew Green, prescribing policy lead for the British Medical Association, said “any GP will recognise that they are prescribing far more than they did” and that painkiller addicts came “from all walks of life”.
He added: “It’s regretfully easier to prescribe than not to prescribe, especially in a busy working environment. If you’re saying to patients, ‘I don’t think painkillers are the best thing,’ you need an alternative. And none exists.
“Trying to explain about long-term pain and why painkillers are not a good idea are some of the most challenging conversations GPs ever have.
“It’s very easy for patients to interpret that as disbelieving them or being unsympathetic.” He said that doctors needed help in convincing patients not to start opioids in the first place as well as clearer guidelines on how to break the habit gradually to avoid withdrawal symptoms.
“A lot of patients feel let down by the NHS. They have taken a drug as prescribed and found themselves addicted. Then they look for help to come off these medicines and there isn’t any.”
Harry Shapiro of the DrugWise information service said that prescription painkiller dependence was now a bigger problem than addiction to illegal drugs. “It is a public health crisis that is hidden in plain sight. There’s a heck of a lot of ordinary people who are dealing with this problem.”
He said the £293 million that the NHS spent on prescribing painkillers would be better used in dedicated services to help people give them up. “If you’re an ordinary person, an accountant or a taxi driver, taking pills you want to come off, you don’t want to go to a traditional [drug] service and sit in a waiting room with heroin addicts. People desperately need to feel they’re not on their own.”
Rosanna O’Connor of Public Health England said the agency was developing “tailored responses” to an emerging problem, adding: “Addiction to prescribed and over-the-counter medicines is a concern. It remains important that all health professionals make every contact count and are alert to possible signs of misuse and dependence.”
FACTFILE
- Opioid painkillers are a class of drug related to heroin that interact with opioid receptors on nerve cells, and include medicines such as morphine, oxycodone and tramadol
- 24 million prescriptions were written last year, with tramadol and codeine most widely used
- Benzodiazepine tranquillisers such as Valium and Xanax are also highly addictive, with anywhere from 250,000 to a million people thought to be hooked
- Doctors were warned four years ago to curb the use of “benzos” after The Times exposed the plight of people hooked for years on medicines that are only meant to be taken for a few weeks