I hope lots of pharmacists and pharmacy technicians watched the ITV programme, Britain on Painkillers: the silent epidemic. Obviously, I would say this, as it’s my area of speciality and I knew some of the people featured in the programme. I think it was a decent stab at addressing the problem we have in the UK with the over-prescription of opioid medicines.
The message was clearly communicated – there is no evidence to support the long-term use of opioids in people with long-term pain (>3-6 months). There is, however, plenty of evidence of the harm these medicines can cause, in terms of side-effects such as endocrine changes, sexual dysfunction, immune dysfunction, depression and anxiety to only skim the surface. In a half hour programme, focussed on England (of course) however, it wasn’t possible to include much on the other ways that people with long-term pain can live better and frequently on modest doses of opioids or none at all.
There was a good description from my friend Dr Frances Cole of the many ways in which pain affects a person and those around them, illustrating why medication alone will never be the solution. This was supported by the stories of two women living with pain, both of whom had developed dependencies on the opioids they had been prescribed. One of whom admitted to manipulating professionals and even friends in order to fuel what became for her, an addiction.
What I didn’t take from the programme itself was that any particular profession or sector was responsible for the problem. It is more that it is a shared issue and one that we will all, professionals and ‘patients’ need to take responsibility for solving.
Following the programme, I took to Twitter to see what people (non-professionals) were saying. Here are some examples:
“Why are doctors giving these powerful drugs out so easily? That needs looking into surely. They’re most likely doing it to get a quick win and get the patient out the door due to laziness and/or time constraints”
“They need to be held accountable, they’re just legalised drug dealers”
“I am furious about tonight’s how on the medication I suffer from CRPS it’s the worst pain a man can feel some of us need opiates in large quantities’
“Watching #britainonpainkillers …being an opioid addict myself, this should be interesting! Doctors are making addicts every day, it needs to stop”
These comments interested me for a couple of reasons.
Firstly, when people refer to ‘doctors’ they almost always are thinking ‘GP’ because that is the doctor they are most likely to see and continue to see if they have pain and that is where the vast majority of prescriptions are issued. It is estimated that only 2-10% of people who live with pain will attend a specialist pain service……ever.
So, the question is perhaps ‘Should GPs be providing support to those people living with pain?’
My answer is YES!
Why yes? Because people who live with pain will seek the support of their Primary Care practice who is close to where they live and generally (and despite all the reports) still easier to access than a specialist service. GPs also do not discharge their population and are obliged to continue seeing and where possible, treating people indefinitely and despite what other services might be inputting.
However, the comments that doctors are responsible for creating addicts or that they are simply handing these medicines out is a cheap and in my opinion uneducated, swipe at professionals who for the most part, are doing their very best. The fact is that all too often, GPs have nothing else to offer. This is due to the lack of viable alternatives. When I say ‘viable’, I could also say ‘acceptable’. This may be an unpopular opinion but people who have pain need to take some responsibility for their management as well.
Yes, GPs and others working in Primary and Community Care should be advising on self-care from the first presentation. They should make people aware of the non-pharmacological methods for living better with pain. They could talk to them about activity, exercise, weight loss, mindfulness and a whole heap of other things too that might support the person in the mid and long-term to live effectively and well. Primary Care practices could (and many have) become involved in Park Runs and promote healthy living to their population in order to stave off pain and other long-term conditions.
They could also make sure that they are regularly reviewing opioid medicines along with all the other analgesics that are prescribed, frequently at the behest of specialists of all disciplines in the acute sector, who make a recommendation and then don’t see the person again.
The fact is, many GPs do try to this, in addition to everything else they and their colleagues in Primary Care try to get done every day. The harsh fact is that self-care and non-pharmacological means of managing pain are not acceptable to everyone – particularly when they first present. Self-care is hard work. Self-care takes time and change can be slow. The good thing about self-care, however, is that it isn’t harmful. Unlike opioids and unlike the other medicines that we seem to have become reliant on.
Pain is a danger signal. Most of us are born knowing that the sensation of pain is a sign that something has happened that needs to be protected against. The feeling of pain lets us know which part has incurred injury, in order, we protect ourselves and act to ensure we don’t inflict further harm. Pain is frightening because we associate it with ‘something bad’ happening, whether that’s due to trauma, surgery or acute illness. However, pain in these instances is for the most part, relatively short-lived. As the body repairs and restores itself, the pain subsides.
However, persisting pain is thought of as over-protective. It frequently isn’t a sign that something is ‘wrong’ but that something has changed. And what has changed is the manner in which the body and the nervous system, in particular, picks up, interprets and responds to signals. Further, there is plenty of evidence to suggest that a substantial proportion of people who live with persisting pain have experienced some psychological trauma in their past. This is likely to have contributed to the hypersensitisation of the nervous system, which then contributes to the development of persistent pain.
All of this can be difficult for practitioners to understand let alone explain to people who are presenting in a distressed or frightened state. Now, do it in 10 minutes and whilst you’re at it, make a plan of how you’re going to support the person and communicate that clearly. Remembering this person is likely to be frightened, distressed, confused or all three and just wanting someone to take the pain away.
It has been estimated that at least 763 full-time GPs are needed each year just to see people who have pain.
So, GPs can’t do this on their own. It takes a village.
Some other comments from Twitter:
“I used to have access to wonderful pain clinic services. Unfortunately, due to the cuts, my postcode doesn’t fit anymore so the majority have been taken away”
“Not enough resources for other remedies had back injury had to wait 12 months for physio so prescribed pain relief”
And there’s the rub. There are not enough services to accommodate all the people who are living with pain and might want or need to access them. Waiting times for Pain Services can be long. Here in Wales, for example, many people are waiting for more than 6 months for their first appointment with further waits even after being accepted by the service. However, relatively few people actually go to a Pain Service, but we already know that people with pain access more Health Care than those without. Each of these points of access should be an opportunity to review how they are coping with the pain. Each of these points of contacts is an opportunity to review their medications and the other methods they use to live with the pain. Each of these contacts is an opportunity to provide education and advice to people about self-care and other ways of living well with pain.
What are Rheumatologists, Orthopaedic Surgeons, Spinal Surgeons, MSK specialists, General Physicians etc doing about pain – it affects all of the people they see in their clinics too. Why are they not being made responsible for changing the way we manage pain? Pain is not simply the preserve of Pain Specialists. Pain is ubiquitous in health care, to every speciality, to every sector and to every profession. It takes a village.
Each time a prescription is dispensed in a Community Pharmacy, people could be asked about how effective they find the analgesics. If doses above the 120mg morphine or equivalent are prescribed, it is an opportunity to query it with the prescriber and to counsel the person on the risks of continuing the high dose. Every time a person is admitted to a hospital on opioids and other analgesics, regardless of the reason for the admission, it is an opportunity to review their analgesics. Perhaps they are the cause of the admission? Everytime a medication review is carried out in GP Practice, any analgesics should be questioned and the opportunity to counsel on safe and effective use taken.
So, who is the cause of the opioid problem in the UK?
All of us – professional and public. We could and should, all do more to support people living with pain and to monitor and advise on medicines safety. Pharmacists should be taking the lead on the medicine’s safety side of things – we are, after all, medicines experts. More and more pharmacists are getting involved in this work, commonly in Primary Care practice but there are also innovative Community Pharmacy schemes where professionals are supporting each other across the interface.
We need to acknowledge that pain is difficult and miserable to live with. People need time to adjust to the idea that the pain might not go away entirely but they can be supported to live better and for the pain to become less prominent in their world. We need public awareness of the normality of pain and the harms of medicines being used to treat it because until people understand that, we can’t assume they will be happy to accept alternatives.
We particularly need to acknowledge that until we have access to evidence-based services, locally – where people with pain are and available when they are needed, that practitioners will prescribe because that is all they might have to offer. General Practitioners are not the cause of the opioid problem in the UK but they will be key to solving it. Instead of looking for scapegoats, let’s look for solutions.
Let’s consider how each one of us can make a small change to our practice that in combination can make a big difference to the population. It takes a village.
Whilst I’m here…
I was also delighted to see Tauheed Ahmed, a pharmacist working in Bristol in pain management and substance misuse feature in the programme. Tauheed runs clinics for people living with persistent pain and it was clear, even from the short clip shown, that he supports people holistically and looks for non-pharmacological ways to do that. It was great to see one of our profession giving the public an insight into the many different ways that pharmacists work and the range of skills we possess. Great work Tauheed!
Emma Davies is an Advanced Pharmacist Practitioner in Pain Management and Chair of the Primary Care Pharmacy Association Pain Group. She is also co-founder of www.livewellwithpain.co.uk, a website that provides free resources and advice to clinicians who want to support people with pain to live better and more effectively.
A link to the programme on the ITV hub is here:
https://www.itv.com/hub/tonight/1a9757a0082 – the programme will be available for another 28 days (as of 22 September 2018)