We have a prescription drug problem. In September, Public Health England (PHE) published a report highlighting the alarming rise over the past decade in prescriptions for powerful opiate painkillers, antidepressants, and anti-anxiety medications. We are following America, where these potentially addictive prescription drugs have overtaken heroin as a cause of death through overdose. PHE has exhorted doctors to be more circumspect about initiating and continuing treatment with these agents. If only it were that simple.
We’re familiar with acute pain, caused by a broken bone, or an operation. This responds well to standard analgesic drugs, and as damaged tissues repair themselves, the pain gradually fades. Far more challenging is chronic pain.
“Chronic” is used to denote long-lasting or persistent pain. There may be damaged tissues that cannot repair, so pain signals never abate. Joint arthritis is a good example; the most common form, osteoarthritis, is age-related, so is ever more prevalent as our life expectancy increases. Conditions such as diabetes can affect nerve fibres, causing them to fire erroneous pain signals; we are in the midst of a type 2 diabetes epidemic. And chronic pain can arise even when tissues are apparently healthy: fibromyalgia is a common example.
In these instances, the central pain processing pathways in the brain and spinal cord have become overreactive: other innocuous types of sensory information are experienced as pain. A crucial feature of this aberrant pain processing is that standard analgesic drugs provide limited or no relief.
Unsurprisingly, people with chronic pain consult their doctors repeatedly. As we struggle to control their pain, patients frequently become frustrated and develop depression and anxiety. Their experience of pain is compounded by psychological ill-health. And instinct tells us that when in pain we should avoid activity, so muscles weaken and symptoms worsen. Chronic pain patients can become trapped in a downward spiral of disability and despair.
Fortunately, intensive input from multidisciplinary teams of physiotherapists, psychologists and occupational therapists helps people break the cycle, improve symptoms and cope better with those that remain. But such services are expensive and, not being perceived as “saving lives”, they have suffered repeated cuts. Ten years ago I could get physiotherapy appointments in weeks; now people wait months before being seen and are discharged with a leaflet. Joint replacement surgery – the most effective treatment for severe arthritis – has been subject to progressive covert rationing by cash-strapped clinical commissioning groups.
The only things left for many patients are drugs. Some antidepressants and anxiolytics provide a dual benefit, improving patients’ mental health while damping down hypersensitivity in central pain processing pathways. And although not brilliant, standard analgesics do have some effect. It can be tempting to push doses higher, chasing elusive relief until dose becomes overdose with fatal results.
Alongside bodily pain, we are seeing an epidemic of emotional distress. The PHE report notes prescriptions for depression and anxiety drugs closely mirror rates of socio-economic deprivation. Services are swamped, and therapy is largely ineffective where life circumstances are a primary cause. Poverty and insecurity have been stoked by the same austerity that is undermining the NHS’s ability to cope.
Funding to restore services is urgently needed, and our society needs radically different government policies to address poverty and inequality. Until those things happen, the drugs will continue to flow.
This article appears in the 02 Oct 2019 issue of the New Statesman, The Brexit revolutionaries