How a pill for period pain could turn you into an addict

It’s available over the counter for everyday ailments, but many don’t realise the hidden risks of codeine

Despite the physically demanding eight-hour shifts as a builder, Jim Morrison would always have the energy to play with his three children when he got home.

But now not yet 50, Jim barely has the energy to move, struggles to recall key facts in his life and feels almost permanently drowsy.

His deteriorating health isn’t due to a disease — but to the painkillers he was prescribed by his surgeon.

ten years ago, Jim, injured his left wrist during an accident at work. six years ago when repeated operations failed to end the constant pain, he was prescribed morphine, in the form of liquid and a patch. three years ago, dogged by their side-effects, he tried to come off them, but became so ill he had to start taking them again.

As Jim says bleakly: ‘i have been poisoned by the drugs that were supposed to help me. And i’m still in pain: i’m not living, i’m surviving.’

the drugs in question are opioid painkillers, a group of medications that includes codeine, tramadol, fentanyl, morphine and dihydrocodeine.

For short-term acute pain, opioids can be effective. But the bitter truth is that many taking them longer term are gaining no benefit — yet are being exposed to the risk of side- effects, addiction and even death, as opioids can slow breathing.

Dependency on prescription pills such as opioids has reached epidemic proportions in the UK, and Good Health has campaigned for proper support for the countless thousands of patients who’ve become addicted to these drugs through no fault of their own.

With fears that the UK might follow the pattern of the U.s., where more than two million people are hooked on opioids and over 100 die every day as a result, there are moves to reduce the number of opioid prescriptions issued here.

Yetstill tens of millions are being written each year — with 23.8 million opioid prescriptions in england alone in 2017 (although this is an improvement on the 23.9 million the year before, it’s still far more than the 13.4 million of ten years ago).

Dr Cathy price, a consultant in pain medicine at University Hospital southampton says most patients arriving at her pain clinic have been on at least one opioid.

‘Virtually anyone who arrives at the pain clinic will have been tried on at least one.

‘the typical scenario is a middle aged person who’s had spinal pain for a while. they’ve been on tramadol and dihydrocodeine — neither is working and they have problems as a result, as the drugs in effect sedate them. But when you take them off the opioids they experience problems, too.’

Dig a bit deeper into the figures and another worrying trend emerges. While prescriptions for some opioids, such as certain strength fentanyl patches, have halved over the past ten years, those for some forms of codeine such as 30mg tablets have risen.

Furthermore, co- codamol — a combination of codeine and paracetamol — is now one of the most commonly prescribed items in this country — more than 15 million prescriptions are written for it annually, but it’s not included in the statistics for opioid prescriptions as it contains paracetamol.

But codeine, which is regarded as a ‘weaker’ opioid, is far from a safe option — according to the Office of National statistics the number of codeine-related deaths in england and Wales have risen, from 92 in 2010 to 156 in 2017, while deaths from other opioids have fallen. indeed people given ‘weaker’ opioids such as codeine were more likely to develop an addiction, according to a recent study by Dr Blair smith, a pain consultant and national clinical pain lead in scotland, published in the British Journal of Anaesthesia.

‘the results did surprise me,’ he told Good Health. ‘the best explanation is that they don’t do anything so patients get prescribed higher and higher doses.’

there is a perception that codeine is the safer option because an 8mg version (with paracetamol or ibuprofen) is available over the counter. But Dr smith says codeine ‘can be just as bad for side-effects as other opioids when taken at high doses’.

it’s often where people start on the opioid ladder, suggests Dr Cathy stannard, a pain consultant at NHs Gloucestershire CCG, who is also chair of Opioids Aware, an online resource. ‘there’s a group of people who might start taking co-codamol for period pain or headaches who get hooked.

‘these are often intelligent people and they end up going from chemist to chemist for more or even buy online. ’

However she has mixed views about banning the sale of opioids altogether. ‘For some the overthe-counter version will help, and you don’t want people going to their Gp for everything,’ she says.

‘But it is easy to avail yourself of more than is good for you.’

Opioid painkillers were originally used to treat acute pain, a broken leg, for example, or given to those with terminal cancer.

But increasingly they’ve been prescribed to those living with chronic pain — defined as pain lasting longer than three months. that means people with, say, arthritis, back pain or fibromyalgia are taking daily doses of drugs that should only be used for days or weeks. indeed around 90 per cent of the prescriptions written for opioids are issued to those in chronic pain, says Dr stannard.

But as Jim’s experience highlights, even the strongest opioids rarely help with long-term pain. ‘At best one in ten gets some benefit from taking them,’ says Roger Knaggs, an associate professor of clinical practice at the University of Nottingham.

Opioids are little better than a placebo for chronic pain but had more side-effects such as vomiting, according to a review of 96 trials by McMaster University in Canada last year. the researchers said even applying ice to a painful area could be more helpful.

‘there is a small number of people for whom these drugs work well and for whom they can be life transforming,’ says Dr stannard.

‘those are people who take them at a low dose intermittently — for something like a bad arthritis flare-up. But by and large opioids don’t work for long-term pain but nor does any pain medication.’

And as Good Health has reported recently, opioids might even make chronic pain worse — possibly by making cells which transmit pain signals to the brain, more sensitive to pain.

Around 80 per cent of people who take opioids will experience one or more side-effects, such as dizziness, sickness and constipation, says Roger Knaggs.

‘the drowsiness they can cause can mean people struggle to work, maintain relationships or function as normal human beings,’ adds Dr price, who is also medical director of the charity pain Concern.

‘For elderly patients the dizziness raises the risk of falls and we see one patient a week who has kidney damage as a result of taking opioids.’

And that’s not all. Opioids work by attaching to opioid receptors found in cells dotted through the body. there are a large number of opioid receptors in the hypothalamus, the area in the brain that controls the production of oestrogen and testosterone.

‘When people take particularly large doses of opioids for long periods it switches off these processes so the levels of these hormones can reduce, leading to irregular periods and a lack of sex drive,’ says Roger Knaggs.

experts believe the key to getting opioid prescribing down is to overhaul the way that long-term pain is treated. the role that biological factors play is fairly small, he explains.

‘the influence of other factors such as mood and anxiety, which very often co- exist with chronic pain, can have a greater role.’

that means psychological interventions and even exercise can help more than painkillers.

Profesor Helen stokes-Lampard, chair of the Royal College of Gps, says the challenge for doctors is to help patients with pain to have the best possible quality of life ‘ and for some patients opioid-based drugs provide relief —sometimes they are the only things that do,’ she says.

One initiative led by Warwick University called i-Wotch, is assessing the effect of giving patients access to a nurse to teach them pain coping strategies and stress management techniques as well as ways to keep active.

For many such as Jim any solution is welcome. He would like to bin his medication but previously when he stopped it abruptly, he became ill. ‘i started vomiting violently and i had to take the morphine to stop it,’ says Jim, 49, from the Vale of Glamorgan.

With the help of his doctor, he’s tapering his dose and hopes to come off within a year.

‘i want to be the old me, even if that means living with the pain.’