Late last year, a news analysis piece on the opioid crisis was published. This article examined the over-prescription and overuse of opioids (Mendes, 2019). However, the reasons behind this rise in the use of opioids stem from the pain that many people are living with day in, day out, which is ‘often difficult to treat and can be associated with many different types of tissue injuries and disease processes’ (National Institute for Health and Care Excellence (NICE), 2017).
Identifying the root cause of this problem requires coming face-to-face with a hard truth: an entire culture has been created, perhaps inadvertently, by healthcare organisations, whom we look to for guidance, together with pharmaceutical companies. These have done tremendous work in research and development, but also have interests to serve that extend beyond patients, and health and medical professionals, most of whom are doing their best to help patients with the best knowledge they feel is currently available.
The way we think about pain
Millions of patients across Britain, as well as their families and carers, are affected by chronic pain. Unfortunately, chronic pain can have a devastating impact upon a person's day-to-day life, work, hobbies, mental health, and wellbeing.
Current thinking, developed over many years of doing things one way, pharmacologically, presumes that pain should never be experienced in the modern world of medicine, and that there is a pill that can essentially solve any type of pain.
In large part, this can be traced back to the development of the analgesic step ladder (or pain ladder) by the World Health Organization in 1986, and its inappropriate application to the management of non-cancer-related chronic pain, for which it has never been validated (NICE, 2017).
The WHO pain ladder was created for the management of cancer pain, and is a simple model to aid in slowly introducing and up-titrating analgesics incrementally, starting with non-opioids, and progressing towards mild and then strong opioids, according to a patient's reported pain levels (Ballantyne et al, 2016). NICE (2017) importantly points out that:
‘Using the WHO ladder in people with chronic pain, without taking into account the complexity of the person's individual needs, preferences for treatment, health priorities and lifestyle, may contribute to inappropriate prescribing’.
Why it's broken
There are many reasons why applying this approach to non-cancer chronic pain management has been problematic – some of which were delved into in some detail in a previous column (Mendes, 2019). The consequences include severe as physical and mental side effects, drug misuse, dependence, withdrawal issues, and even drug poisoning.
These are not always taken seriously enough and weighed appropriately against the potential benefits of the drugs being considered. Another issue that requires tackling lies in the lack of clarity in a patient's expectations regarding their pain, their pharmacological treatment and their long-term outlook of living with chronic pain.
The truth is that a patient living with chronic pain requires a holistic approach to their care, which may include some level of pharmacological management, but will also heavily entail non-pharmacological approaches. At present, these do not receive the respect, credit or attention they deserve from the medical community, nor from the patients, who need to believe in them to adhere to them and improve their own quality of life.
Why it's hard to fix
NICE (2017) notes that almost half of people living with chronic pain are also diagnosed with depression, and two-thirds are unable to work outside of their homes. However, there is little long-term support available for people living with chronic pain. In fact, The Pharmaceutical Journal has recently discovered under the Freedom of Information Act that referral-to-treatment times vary widely across Britain, with some patients waiting for more than two years to see a specialist pain management clinic to help them manage their symptoms after being referred by their GP (Connelly, 2020a).
Encouragingly, the clinics do offer a range of services for chronic pain, beyond traditional pharmacological options such as opioid analgesics. For example, interventional procedures, physiotherapy, exercise programmes, psychological therapy and occupational therapy are offered at pain management clinics (Connelly, 2020a) – but as some patients are waiting such a long time to see a specialist, many have lost faith in the medical profession by the time they do, and many have deteriorated so much by the time they see someone, that their options may be limited (Connelly, 2020b).
Furthermore, the culture we live in and have created has people believing the following myths:
- If they are not prescribed medications, their pain is not being taken seriously enough
- Non-pharmacological interventions do not work or require too much time and effort that could be avoided simply by taking medication
- Their pain can be effectively managed in the long term with appropriate medication which can simply be increased when needed.
The true picture
In actual fact, according to a report commissioned by Public Health England (2019), for most people with non-cancer-related chronic pain, opioids cannot provide adequate clinical benefit when weighed up against the risks of dependence, overdose poisoning and harms to others in the community.
NICE (2017) also notes: ‘it is unusual for any analgesic, including strong analgesics like opioids, to completely eliminate chronic pain. The focus of treatment should be on reducing a person's pain with a view to improving their quality of life. Evidence also suggests that non-pharmacological treatment may be effective in reducing symptoms and disability in some people with chronic pain and can also augment and complement analgesic use. Healthcare professionals who are responsible for helping people live with chronic pain should be familiar with the range of such non-pharmacological interventions – including physical and psychological therapies – and the local availability of these services’.
Conclusion
An overarching cultural shift is urgently required, whereby medical organisations, regulatory bodies and educators recognise the importance of nonpharmacological interventions in the prevention and management of disease and pain; increasing public investment is made in such programmes, with research carried out to evidence their effectiveness; and significant action is taken to educate the public and reinforce patients’ awareness regarding their own roles in the management of their health and wellbeing via these types of interventions. These may include but are not limited to exercise, good nutrition, talking therapies, journalling, visioning, meditation, enjoyment of personal hobbies and quality time with loved ones. What will be your role in this shift?
New guidelines from NICE are expected on the assessment and management of chronic pain in August 2020, and on safe prescribing and withdrawal management of prescribed drugs associated with dependence and withdrawal in November 2021.
