Opioids don’t work well for chronic pain. So why do we prescribe them?

One of the key principles you learn in medical school is that doctors should “do no harm”. But what should doctors do when our patients insist that we do things that we know are harmful? This is the dilemma that thousands of doctors face on a daily basis when tasked with helping patients with chronic pain.

Pain is a universal human experience that alerts us to bodily harm. Most pain is transient and requires no specific intervention other than the passage of time. For more severe acute pain (pain that lasts hours, days or weeks) and cancer pain at the end of life, modern medicine has several very effective treatments – pills, injections and the like. But chronic pain (which persists for months or years) is a very different entity.

Chronic pain is associated with an oversensitive and over-responsive nervous system, the causes of which are a complex interplay of biological, psychological and social factors. There is not necessarily any correlation between the experience of chronic pain and evidence of damage in the body, a phenomenon which is hard to make sense of; why does one person with a terrible-looking scan seem oblivious while another with a totally normal looking scan is rolling around in agony?

As a liaison psychiatrist, patients with chronic pain are often referred to our team when our physical health colleagues feel stuck – all the relevant investigations have been done but they cannot find any bodily damage to account for the patient’s pain. Therefore, it must be a mental health problem, right?

This dualistic thinking that continues to pervade our understanding and response to illness is really unhelpful, leaving patients feeling misunderstood and unheard. Pain is in the brain and as such is always both physical and mental. Excluding the tiny minority of malingerers, the pain that is experienced by patients is very real and can be a source of huge disability and distress.

In trying to manage this distress, I sometimes wonder if doctors have become the victims of our own success. With each decade that passes, we see modern medicine develop increasingly sophisticated and effective treatments, creating an expectation that we will have solutions to all problems. Given that we have very effective treatments for acute pain, the public perception is often that this must also be true for chronic pain. Sadly, this is simply not the case.

In the UK we have a big problem with opioid painkillers, medications such as tramadol, codeine, morphine and fentanyl. It’s not as bad as in the US, where it is estimated that every 11 minutes somebody dies due to opioids, but it’s a big problem nonetheless. In 2017, GPs in England wrote 23.8m prescriptions for opioids, the majority of which would have provided little to no benefit for patients.

There is next to no evidence to support the use of opioids in chronic pain. It is estimated that for every 10 patients who are given opioids for chronic pain, probably only one will have any benefit from treatment. Good news for this particular patient but the other nine patients are taking a medication which is ineffective and may also cause a myriad of unwanted side-effects including nausea, constipation, lowered libido, falls and difficulties breathing – they can even make the experience of pain worse. To put it simply, a bad situation is made a lot worse.

Well-intentioned doctors prescribe opioids to try to ease their patient’s distress. If the starting dose doesn’t work, the temptation is to increase it even though the evidence tells us that this will not be helpful; if opioids don’t help in the first couple of weeks they are unlikely to help in the longer term. If these prescriptions are not reviewed in a timely manner, the patient can become dependent. In trying to solve one problem, you’ve created another.

We know that many patients who have chronic pain also face other challenges: childhood adversity, poverty, domestic violence, mental illness. For such patients, opioids can become a way to numb themselves from the harsh reality of life, even though their pain persists.

Doctors will often recognise that the opioids have become a problem and advise reducing the dose carefully, in order to minimise the discomfort of withdrawal. But many patients are very resistant to this, believing that the opioids are the only way that their lives can be manageable and that doctors do not understand or believe their suffering.

Doctors describe being physically or legally threatened by patients who insist that under no circumstances should their opioids be reduced. They are faced with a choice of continuing to prescribe a medication they know is ineffective and harmful, or insisting on a reduction the patient says will cause them enormous hardship.

So what’s the answer? Although we don’t have painkillers that are highly effective for the treatment of chronic pain, there is still a lot that can be done to help. Primarily, we need to help patients develop a thorough understanding of the causes and consequences of their pain – this in itself can be a very powerful and empowering intervention.

In liaison psychiatry, we conduct a biopsychosocial assessment to explore the patient’s health and life circumstances as a whole. Where we find factors for which effective interventions are available, this is where treatment can then be focused: for example insomnia, inactivity, anxiety, depression, malnutrition, poor housing, obesity and stress.

All of this takes time. I don’t envy GPs who have to do the bulk of this work in the space of 10-minute appointments – it’s no surprise that whipping out a prescription pad happens so frequently. Pain specialists can play an important role, but the numbers involved mean a vast majority of patients will never get to see one.

As is often the case, patients who have complex health needs fall between the cracks of services which are designed with policy in mind rather than pathology: primary v secondary care, mental v physical. We need to find ways to work together more collaboratively as it’s clear that complex problems demand comprehensive solutions.

With many millions of people in the UK thought to be affected by chronic pain, it’s easy to feel overwhelmed by the scale of the problem. But herein also lies the key to transformation. We need to educate our population in order to adjust expectations of what can and can’t be achieved by health professionals, and to highlight just how much power people can have over their own experience of pain.

• Mariam Alexander is an NHS consultant liaison psychiatrist