There are no drugs for chronic pain that are really effective. Opioids are helpful for treating acute pain and for those suffering pain at the end stages of their life, but there is no data at all to support their use for long-term pain. Patients who take these medicines often find that the effect seems to wear off with time and increasing the dose doesn’t help.
Despite this, thousands of people in the UK are taking prescribed opioids to manage chronic pain for long periods of time, and they end up suffering from the side effects of the drugs without getting any of the benefits.
So why don’t doctors stop prescribing drugs that don’t work? Pain is complex and some patients with chronic pain may also have complicated emotional needs, mental health issues and sometimes a history of addiction which makes it tough to give up their medicines. If a patient with pain is distressed, we want to help. When there isn’t time to explore things in detail it can be easier for the patient and the doctor to write a prescription. It’s important to stand back and make a considered decision and this shouldn’t be done in a hurry. This is important as research shows that people who are likely to run into problems with their medicines are more likely to be prescribed opioids for pain .
There is a widespread belief that stopping opioids is hard because of withdrawal symptoms. This can happen but if managed carefully the symptoms are bearable and short lasting. Often withdrawal is less arduous than coping with the normal side effects of the medication.
In my own pain clinic, it is crucial that a patient understands why it might be important to stop medicines. A full pain assessment, takes into account his or her physical history, emotional history, identification of social support and any other issues they might have had with drugs or alcohol. Most long-term opioid users I see are still in pain. This tells the patient and me that the medicines aren’t working and allows a conversation can to start about risks of treatment and whether the medicine may be making the problem worse.
Once a patient can see that the drugs are not alleviating the symptoms, she or he will usually agree to try reducing the dose or stopping. If doses are high patients might need support to help them get through this period of adjustment, and this should ideally be available. Clinical Commissioning Groups are beginning to see that investing in support at the right time saves money on prescribing drugs, other health care use and doctors’ time over the long term. More importantly, providing appropriate services reduces a patient’s exposure to treatment-related harms. Intensity of long-term pain relates less to the degree of injury of pathological damage than the level of anxiety and distress felt by the patient and so patients need help to deal with these contributors to their pain.
We need to approach pain in a holistic way to ensure that patients’ needs are fully met. Pain treatment isn’t just about medicines. Advice about exercise and interventions to help patients make adjustments to living with pain including mindfulness and appropriate emotional support for people who need it would lead to far fewer people using long-term medicines.
Dr Stannard is speaking at an event at the Royal Society of Medicine, Substance Abuse: Everybody’s business on Tuesday 11th October 2016.