At clinic, I usually prescribe drugs that act on the cardiovascular system. When Jenny, a patient who had responded very well to treatment for a heart attack, quietly asked me to give her a prescription for tramadol, a strong opioid painkiller or analgesic, I politely refused. I explained that she was already taking a weaker opioid, codeine, and that I did not know enough about the causes of her pain. I spoke with her community cardiac rehabilitation nurse, who explained Jenny was on sick leave from work due to pain from arthritis and that she was a carer for her mother, who had advanced dementia. Jenny also had anxiety and depression, exacerbated by recent events.
Opioids have been used for at least four millennia. The Sumerians in the third millennium BC extracted opium from the seed capsules of the poppy referred to as “hul gil” (“plant of joy”). In contemporary medicine, opioids are commonly used in the treatment of acute pain, for example after surgery; for cancer patients; and, more controversially over the past two decades, for chronic non-cancer-related pain. While the focus on opioids is predominantly on their analgesic effects, they are often used for their anxiety-reducing or “anxiolytic” properties – which is one of the reasons why we give morphine to patients having heart attacks.
At medical school in the mid-Nineties, we were taught that patients in pain were woefully under-treated, and if pain was not controlled with “simple” non-opioid analgesics such as paracetamol, the next step would be to go up the World Health Organisation’s “pain ladder” and prescribe an opioid. The ladder was originally used for those with cancer but was then applied to all patients in pain. Medical students were erroneously taught that patients with severe and chronic pain were less likely to become addicted as the pain would somehow neutralise the euphoria of opioids.
Opioid prescribing has doubled over the past ten years, with 23.8 million prescriptions made in England in 2017. Opioids have many side effects such as addiction, constipation, hormonal disturbances, cardiovascular disease and, in some cases, increased pain.
Dr Jan Melichar is a psychiatrist specialising in the treatment of substance misuse. Five per cent of the patients he sees have a dependence on prescription opioids. “In addition to prescribing more, we are not stopping them early enough,” he says. He does not think that the scale of the problem in the UK is likely to match the depressing epidemic of opioid use and deaths in the US, which has less than 5 per cent of the world’s population but is responsible for 80 per cent of opioid use.
The NHS is a single-payer service, free at the point of care. There is access to pain management teams and it is unusual for patients to go “doctor shopping”. The US system is funded by insurers, government and patients, and over the past two decades doctors have been incentivised to prescribe opioids by drug companies and a liberal regulator. Once they stop prescribing many patients have to resort to illegal suppliers.
A 2018 UK study found that areas with the most poverty had the highest opioid prescription rates. An appreciation of a patient’s biological, psychological and social needs – the “bio-psycho-social model” of medicine – helps shift the focus from prescribing towards a more holistic approach. The British Pain Society recommends use of a pain team consisting of a doctor, psychologist, nurse and physiotherapist for patients on high doses of opioid analgesics. This multidisciplinary approach is a rare resource and many doctors prescribe opioids as there is little else they can do.
Jenny was referred to the local pain clinic, where she had counselling and a course of physiotherapy. Her GP contacted social services, who commissioned carers to help with her mother’s needs. Within six months, she was back at work and no longer needed tramadol.
Nishat Siddiqi is a cardiologist based in South Wales
This article appears in the 20 Mar 2019 issue of the New Statesman, State of emergency