We all know what it is to feel pain. That is, acute pain, such as hitting the door with your finger or touching your knee.
Chronic pain is different. It could be triggered by arthritis, a back injury or an operation from which you never fully recover.
According to the British Pain Society, chronic pain affects more than two fifths of the adult population in the United Kingdom, which means that around 28 million adults live with pain that has lasted three months or more.
And every year, according to a recent Public Health England report, about five million are prescribed opioids, pain relievers that can be as potent as Class A medications.
In fact, the latest data suggests that patients are being prescribed more than double the amount of opioids they had 20 years ago.
There is no doubt that opioids have a vital role to play in cancer pain, end-of-life care or to relieve pain after an operation. But that does not begin to explain the increase in prescription we have seen in recent years.
However, if you are taking opioids, you should not stop without talking to your doctor.
Beliefs of past decades
So what are opioids? Originally, they came from the sap of the opium poppy plant, which has been used for thousands of years both recreationally and to treat pain.
Morphine and heroin are opioids. They act on opioid receptors in the brain, blocking pain signals from the rest of the body.
In fact, they are probably the best tool doctors have for numbing acute pain, such as a broken bone or an infected tooth.
The disadvantage of long-term opioid use is that it increases the risk of constipation, memory loss, addiction and even accidental death from overdose.
One reason for the massive increase in opioid prescription is the mistaken belief that people with pain are very unlikely to become addicted. This is certainly what I was taught in medical school in the 1980s.
But according to Dr. Jane Quinlan, a pain management consultant at Oxford University Hospitals Trust, this widespread belief was based on fallacies that took hold in the 1980s.
“Two things happened,” she says. “One of them was that the evidence came from palliative care, when observing patients at the end of life and that they had pain, to say that administering to patients with such high-dose opioids was safe because they did not become addicted “.
“Almost at the same time, a letter was published in the New England Journal of Medicine that said patients who were in the hospital and who received opioids for a short time rarely became addicted.”
This 100-word letter was not a peer-reviewed investigation, it was simply an observation.
But their tentative conclusions were inflated by pharmaceutical companies that began aggressively promoting the use of opioids as a safe and effective way to treat all types of pain.
‘Red Hot Poker’
Unfortunately, many patients soon discovered that this is not true.
Karen, who in 2014 slipped a disc in his spine bending down to pick up a book, was one of them.
“It was like having a red-hot poker, placed between the vertebrae,” she says. “Painful, very painful.”
Over the next five years, Karen received increasingly potent opioids, starting with tramadol and ending with morphine. But they failed to resolve the pain.
What they really did, according to Karen’s husband, Ray, was to turn “my beautiful, lovely and active wife into a zombie.”
Karen’s case is not unusual. Family doctors, according to national guidelines, were encouraged to continue increasing the dose until the patient felt no pain.
The problem is that, when it comes to chronic pain, opioids are often not as effective.
In fact, another leading pain expert, Dr. Cathy Stannard, estimates that less than one in 10 people receiving opioids for long-term pain will benefit from them.
They are also “dangerous and often expensive,” according to Dr. Stannard, who recently reviewed the evidence on the benefits of long-term opioid use.
“They should start only with caution and with higher dosage limits and continue only with demonstrably reduced pain, ideally for mild or painless pain,” she says.
“If the opioid does not work after a decent trial, six weeks should be enough, it should be suspended.”
“People who already take opioids are often not sure if opioids are working or not, but they certainly still have a lot of pain.”
“They should be encouraged to reduce the dose slowly and safely to get a better idea of how useful the pain medication is.”
“If I give him a medicine for blood pressure and his blood pressure stays high, nobody would say it’s not working.”
“But if I give you an analgesic and you come back and say ‘I’m still in pain’, what do we do? We double it.
“You come back and say,” I still have pain, “and we double it again.
“If he gives it and it doesn’t work, stop him. That’s what he would do with any other drug, so why don’t we do that with opioids?”
The good news is that GPs are increasingly aware of the dangers and there is now a big push to help patients taking high-dose opioids reduce or even stop taking their medications.
That is beginning to bear fruit: after 20 years of relentless growth, the prescription of opioids has stabilized nationwide.
And since 2017, in most places, it actually began to fall, although there are still large regional differences in prescription levels.
And there are alternatives to control chronic pain.
For Karen, the group therapy sessions and the support of his family have allowed him to leave the opioids. Now, she doesn’t take anything stronger than paracetamol.
Horizon: addicted to painkillers? Britain’s opioid crisis is on BBC Two on Thursday, January 16 at 9:00 p.m. and then available on BBC iPlayer.