Addictions: Opioid Pain Management

I was recently drawn to an interesting and thought provoking tweet by a lady who publishes under the Twitter handle @CannacatL (see below).

The author’s bio says she suffers from Fibromyalgia, a debilitating condition (which I have empathy for), where her “only relief is found in cannabis and/or SR morphine” and, in addition to that, she is an “advocate for cannabis legalisation” – something that I happen to agree with, at least in part. However, conflating the ‘criminality’ aspects of drugs policy with any prescribing guidance for clinicians, actually serves to add confusion to those two separate issues, in my opinion.

Individual Expectations

The ‘Cat Lady’ – a “past health-care professional” – understandably has some personal concerns around the proposed Draft Guidelines from NICE. That guidance relates to the clinical management of chronic pain and the clue is in the word… guidance, despite the fact ‘guidance’ usually underpins practice.

Indeed, her loud statement – “AGAINST THE NEW PROPOSED NICE GUIDELINES” – probably illustrates her obvious angst. Her concerns (and/or any anger) were clearly the foundations of her subsequent change.org petition to the Government (see here).

On her petition page she highlights the scale of what many see as a common problem – people suffering from ‘chronic pain’ and not receiving sufficient pain relief. She backed the claim by citing comments from the charity Action On Pain (2020) who highlight recent surveys to suggest; “around 1 in 7 (14.2%) of the UK population are suffering from chronic pain” and from those “affected” [by chronic pain], around 1 in 4 (25%) receive no medication to alleviate that pain.

Chronic pain is often difficult to treat and can have a significant impact on individuals and their families and carers. Estimates suggest that chronic pain may affect between one-third and one-half of the population, although it is not known what proportion of people meeting the criteria for chronic pain either need or wish to have treatment (nice.org.uk)

Cat Lady tweeted again, to highlight a comments from Zachary Kellerman (a “Psychotherapist & Mental Health Expert by Experience”), who reportedly said; “NICE can go **** themselves, shown themselves to be such a backward organisation, more and more since Brexit, pandering to American ideals.”

Clearly another strong opinion however, I suspect there might be some additional (political) beliefs at play here. Certainly ones that are probably based upon more than purely clinical interests and considerations.

I am also struggling with the “American ideals” aspect of this particular comment. Especially as ‘American ideals’ have (arguably) driven society’s painful (pun intended) but apparent over reliance upon pharmaceutical solutions, within almost every clinical intervention. All of which has probably come from that commercially orientated cure-all ethos, prevalent amongst the marketing activities of Big-Pharma, whilst gratefully and understandably soaked up by those who believe in the ‘quick-fix’ of ‘magic’ potions.

Disparity of Opinions

The disparity of opinions and polarity of expectations, between patients and clinicians are a common factor, in many aspects of our health-care provision. Patients and clinicians, similar to service-users and practitioners in addiction services,  often butt heads when it comes to NICE Guidelines, the NHS position and the perceived efficacy of any clinical process. And all that before you even start to consider the so-called ‘postcode lottery’ of chronic pain management delivery. The opinions and expectations of both the Cat Lady and Kellerman, should probably be expected.

I’m not in the habit of formulating opinions based upon anyone’s past lived-experiences or behaviours however; I will assume from Kellerman’s Twitter and LinkedIn profiles that he draws upon some first-hand knowledge and importantly, his own personal experiences around mental-health care issues and treatment. His connections with the Lincoln Trauma Centre are probably also relevant.

I suspect that Kellerman’s opinions are based in the poor levels of prescribed alternatives to medication, in his area. That or perhaps he is attempting to attract additional clients, for those services he is now involved with, but are sadly unavailable from (or via) the NHS.

Postcode Lottery Health Care

I am partly in tune with at least some of of Kellerman’s opinion. At least where he (and the Cat Lady) bemoan the lack luster ‘postcode lottery’ for ‘alternatives’ to the pharmaceutical management of pain. Something that is reflective of many other aspects of health care provision and delivery in the UK. Indeed, the Royal College of General Practitioners (RCGP) also highlighted similar issues and concerns recently;

‘Patchy’ access to chronic pain management therapies must be addressed if new NICE guidelines are to make a difference… (rcgp.org.uk)

The RCGP press release went on to point out that “GPs and our teams are aware that prescribing pain medication to patients comes with risks, including addiction.” No shit Sherlock would be an appropriate retort here!

Opioid Prescription: Realities & Risks

All flippancy aside, I have known many cases where prescribed medications was apparently the preferred option. But, perhaps too many Doctors, in too many cases, are basing their decisions to medicate from a perspective of convenience?

Yes, the GP is often responding to the demands of their patient however; is that demand reasonable, appropriate and in any case, will it be clinically effective – within an appropriate and safe timescale – and if so, who should make that decision… patient or doctor? This is a common issue when it comes to developing and agreeing treatment plans.

Despite the welcome comments from the RCGP, about the expected ‘robust’ decision making procedures, within all clinical process and “subsequent medication reviews” – sometimes the situation almost dictates a vastly different response. One where in reality, that decision making is flakey, rather than ‘robust’. All of which can be due to financial / political impacts and pressures within that decision making process. And the availability of appropriate alternatives, which are often not available and in many cases.

Paul Chrisp, director of the Centre for Guidelines at NICE, was quoted as saying; “What this draft guideline highlights is the fundamental importance of good communication” when it comes to care provision. 

Commonly used treatments for chronic pain can do more harm than good and should not be used, says NICE in draft guidance (nice.org.uk)

I don’t believe anyone should or would want to disagree with that fact. Effective communication, as part of the therapeutic relationship between client and clinician, is a fundamental and important factor in all health care provision.

Chrisp was correct, the two-way conversations between clinician and patient are critical for the efficacy of any health care intervention. But again, it can also be something that is sadly lacking. Given the pressures of [politically] contrived time constraints, which often dictate the length of the consultation process. This issue might get challenged by the media from time to time, when ‘news’ is in short supply however; it is clearly evident, and probably far more widespread than the periodic headline tends to infer.

As with almost all health-care provision today, perceptions about delivery of process and, to perhaps a lesser degree, the expectations about subsequent efficacy, usually revolve around personal experiences, and any mutual-understanding between patient and clinician.

However, that process is (or should be) all about matching clinical interventions to the specific needs/expectations of individual patients. This is one of those areas where (sometimes) the process suffers from contrived protocols and procedural broad-brush methodology. Rather than being agreed solely upon and around the specific clinical needs of the individual. These experiences of care, for people with chronic pain, will be no different (in general) to any other clinical interventions. 

NICE have acknowledged that “many treatments are ineffective or not well tolerated” and so, it is “important to get an understanding of how pain is affecting a person’s life” because; “knowing what is important to the person is the first step in developing an effective care plan.” This is something that is confirmed by research (see below).

I have seen that many of the underlying causal factors in people’s addictions are; (1) societal inherent belief in the powers of the ‘magic-pill’ – the cure-all for any and all pain, regardless of the ‘pain’ being physical or psychological and (2), that past over reliance upon purely pharmaceutical solutions, by so many clinicians. That said and to be realistic, is it really fair for society to expect doctors can or will fix all our social maladies?

Society’s over reliance upon drugs finds roots in political/financial incentives, and government guidance. As well as the common ‘sweeteners’ which are provided by Big-Pharma.

OK, there are undoubted ethical factors to be considered here however; even if we only consider the time constraints and workflow demands, in a declining and underfunded workforce, those factors also create a reliance upon expediency of process. Something that would be farcical to ignore, and puerile to suggest or expect those issues don’t exist.

Irrespective of any personal or organisational drivers, research has shown; “There is currently no evidence in treating chronic noncancer pain with opioids” – at least not from a long-term (>1 year) perspective. Where, opioid therapy abounds, there are significant risks, including opioid overdose and death… “in 2013 alone, millions abused opioids or became dependent” [on those drugs]. Is this something that we really want to perpetuate ad infinitum?

I can however partly agree with the RCGP observation; “most patients in pain do not want to take medication long-term, and GPs do not want this either, but sometimes medication has been the only thing that brings relief.” Again unfortunately, I have seen so many examples where this is not the case, especially amongst more ‘senior’ physicians (GPs) who still base their current practice on tried and tested’ methods now based in debunked theory, that drove and developed past protocols and guidance. 

The Key Clinical Messages

  1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain.
  2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation).
  3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit: tapering or stopping high dose opioids needs careful planning and collaboration.
  4. If a patient has pain that remains severe despite opioid treatment it means they are not working and should be stopped, even if no other treatment is available.
  5. Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detailed assessment of the many emotional influences on their pain experience is essential.

Source: The Faculty of Pain Medicine at the Royal College of Anaesthetists (RCoA) accessed 22-09-2020 https://fpm.ac.uk/opioids-aware

Summary

Irrespective of any personal desires or appropriate work ethics, amongst most clinicians; their service delivery is unfortunately constrained by external factors, which are often mostly beyond their control. Doctors but in particular General Practitioners, are sometimes unable to deliver the best of service. They are often resigned to doing what they can, due to insufficient and/or limited resources.

That said, the patient should still be able to expect the absolute best and moist efficient clinical interventions and treatment that are available. To be fair, I suspect that probably is the case, and in most scenarios.

All I would ask of Doctors, before they offer that next batch of ‘addictive’ medication is; please, please always think twice before prescribing more drugs. Ask yourself… is that pill actually the best way to cure this particular problem? If not, how can I help to provide an appropriate alternative?

Notes & References:

Note: Clinicians in Primary care are often the first caretakers when patients present with chronic pain issues. Current literature for those care providers is limited. Additionally, much of the existing literature is very broad and large in scope and size. The Evaluation and Management of Chronic Pain for Primary Care – A Pocket Guide for the Primary Care Provider was published in 2020 to mitigate against that issue..

Reference: Hall B.H. (2020) Management of Chronic Pain: Medication. In: Huang Hall, MD, PhD B. (eds) Evaluation and Management of Chronic Pain for Primary Care. Springer, Cham. https://doi.org/10.1007/978-3-030-47117-0_6

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