Social deprivation adds to chronic pain. So swapping opiates for talking therapy won't be the silver bullet

It is not just patients that will need to be weaned off these powerful drugs but also the doctors prescribing them

Ian Hamilton
Monday 03 August 2020 15:45
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Most of us are lucky enough not to experience pain for any length of time, but even that short-lived experience is enough to know how all-consuming pain can be. Millions of people in the UK suffer with chronic pain, defined as pain that lasts for three months or more. So, long awaited guidance on this topic from the National Institute for Health and Care Excellence (NICE) has been eagerly anticipated by doctors and patients alike.

But for the estimated one in four adults affected, this new guidance will make for uncomfortable reading. NICE is suggesting that the strong pain killers like opioids used in the treatment of chronic pain should not be prescribed for new patients and reviewed for existing patients. Unlike many other health problems pain is subjective and notoriously difficult to assess. Add into the mix the fear of dependency on pain killers and the associated stigma of dependency and you have a toxic mix of factors.

In theory, new guidance on how to manage chronic pain should be welcome to both patients and doctors but that would ignore how entrenched some patient and professional behaviour is. It is not just patients that will need to be weaned off these powerful drugs but also the doctors prescribing them. The guidance also assumes doctors have the capacity to provide extended appointments which would allow time for these challenging conversations to take place, and time is something we know GPs are not blessed with currently.

Drugs like opiates are effective in masking short-term pain but don’t provide long-term treatment, as tolerance develops and the risk of dependency increases. This new guidance will require a significant change in practice, something we know can take a long time to happen. The unwritten rule of not altering another doctors’ prescribing regime will also need reforming. There are many intelligent, compassionate and well-informed doctors and politicians, but the practice of medicine is no more about logic and evidence than politics is about truth and honesty. The reality is quite different.

Due to recent research we now know something many have suspected for some time: opioids are not just prescribed for pain. The strong correlation between social deprivation and elevated levels of prescribing painkillers point that out clearly. Doctors know that they can’t prescribe jobs, housing or hope, but in addition to relieving physical pain, opioids can numb the impact of deprivation. Without any hope of changing some patient’s social circumstances, the prescription pad is all many doctors have. NICE in some ways acknowledges this by suggesting anti-depressants should be an option instead of opioids. This strategy doesn’t address the cause of the problem, only the symptom.

Employment, decent housing and hope are all protective health factors, and far more powerful than any prescription drug, but it looks like they’ll be harder to secure than they’ve ever been due to recent political and economic turmoil.

It will be a tough sell to persuade both doctors and patients that talking therapies or exercise instead of drugs are the best treatment, irrespective of the evidence. The assumption appears to be that patients will have the time, belief and motivation to adopt these non-pharmaceutical treatments. Higher socio-economic status provides individuals with these components, whereas lower socio-economic status often means you don’t have the time, confidence or positive experience of making change that will be necessary to take even the first step in embracing this radically alternative treatment.

Guidance, like pain, doesn’t exist in a vacuum. It might be desirable to avoid prescribing opioids for chronic pain, and understanding the context in which suffering and cures operate in is not an added extra – it is fundamental. But however well-intentioned this guidance is, unless people have the hope of earning a living, affordable shelter and something to look forward to, this guidance provides no real hope.

Ian Hamilton is associate professor of addiction at the University of York

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