Painkillers that could make chronic pain WORSE
Josie Cowan has learned to ration prescription painkillers to three tablets a day, keeping the rest of the box at her mother’s house, so she doesn’t give in to temptation. The 24-year-old barmaid has been taking high dose co-codamol pills for 12 years after initially being prescribed a four-week course by her GP for a back injury she suffered on a trampoline as a teenager.
each tablet contains 30mg of codeine — a strong, potentially addictive opioid from the same family of drugs as morphine.
Josie quickly became hooked. when her first prescription ran out, she was given another and within a few months, was craving the tablets before her next dose was due.
‘when i mentioned to the GP that i seemed to be needing them more frequently, he suggested i double the dose to two tablets four times a day from one tablet four times a day,’ says Josie. ‘He never mentioned they could be addictive. i was 13 at the time.’
By the age of 15, Josie, from Bolton, Greater Manchester, was taking the tablets every three hours, rather than every four — that means eight or sometimes more pills a day, most days.
‘My science teacher asked me why i kept having to leave class early to go to the school office — the reason was that i was craving my painkillers,’ she says.
‘i was addicted to the feeling of calm and euphoria or “high” they gave me. i’d feel really chilled out and my back pain wouldn’t bother me.
‘every so often i would try to come off them, but the pain always became unbearable and i needed to go back on them.’ Josie admits that, like an estimated three million Britons, she was hooked on painkillers.
she has since managed to reduce her intake but, worried about becoming hooked again, keeps her tablets at her mother’s house, rather than at the home she shares with her son, anthony, five: ‘it’s too much temptation to have the whole box on hand,’ she says.
over the years, experts have increasingly warned that opioid painkillers, such as the type Josie has been taking, are highly addictive — and yet prescriptions have soared.
The latest figures covering 2014 found there were 22.75 million prescriptions for the drugs, up from 10.70 million in 2005.
now experts are saying the drugs often don’t work for chronic pain and can even make it worse, and are concerned about the long-term health risks.
opioid painkillers — which i nclude codeine, co- codamol, dihydrocodeine, tramadol and fentanyl — are derived from the opium poppy. They work on the opioid receptors in the brain and spinal cord.
when opioid drugs attach to these receptors, they trigger chemical changes within nerve cells so they fire pain signals less often — reducing the perception of pain.
However, the downside is that as well as relieving pain, opioids can create a feeling of euphoria — this And is why they are addictive.
yet their use has risen dramatically. opioids were traditionally reserved for short-term use for severe pain after heart attacks, surgery or as palliative care for people dying of cancer.
But in the past ten years they have been increasingly prescribed long-term for back pain, arthritis, fibromyalgia and endometriosis.
as well as being addictive, sideeffects include constipation and drowsiness. opioids also affect the area of the brain responsible for respiration and some can depress the rate of breathing, sometimes leading to accidental death.
a new phenomenon has been identified, where use of opioids make the pain seem worse — a problem known as opioid-induced hyperalgesia.
‘opioids “up-regulate” the body’s pain system so natural painkilling chemicals, such as endorphins, become less sensitive and effective and make some people more sensitive to pain — so your pain gets worse,’ says Roger Knaggs, an associate professor of pharmacy at nottingham University and a council member of the British Pain society.
‘Patients affected by opioids in this way will often complain that the nature of their pain has changed or it has spread to other areas, but, in fact, this could be caused by their drugs.’
He also raises concerns about how safe it is to use the drugs in the long term, pointing out that studies have only been conducted on patients having them for a maximum of three months.
‘Most patients with long-term conditions, such as back pain and arthritis, will be taking them for longer,’ he says.
‘There are concerns that longterm use of opioids could affect sex hormone function and reduce levels of oestrogen and testosterone. Low testosterone can affect mood, cause anxiety, alter pain perception and affect bone strength.
‘ Low oestrogen can l ead to menopausal s y mptoms a nd increase the risk of the fragile bone condition osteoporosis.
‘There are also issues emerging about how opioids may affect the immune system — making people more prone to infections.’
even the lower dose 8mg codeine available to buy from pharmacies is not suitable for long-term use, he says, and carries a warning that it can become addictive after just three days’ use.
Furthermore, the drugs may not be effective for chronic pain.
‘a high percentage of prescriptions may not be appropriate, but we don’t know how many,’ he says. ‘Research has found opioid drugs are mostly not effective for long- term pain conditions — they simply don’t work.
‘The message needs to get out there to doctors who are prescribing them and patients who are asking for them that if you are on opioids and still in pain after a few months then it’s not that you need a higher dose — the drugs are not working for you and you need to think about other options.’
so why are GPs i ncreasingly writing out opioid prescriptions?
one problem is a lack of alternatives — GPs are being advised not to prescribe non- steroidal antiinflammatory drugs (nsaids), such as diclofenac, to some groups of patients because of concerns about a higher risk of gastric bleeding and heart attacks.
added to this are concerns about the long-term safety of paracetamol, which research has associated with an increased risk of gastric bleeding, cardiovascular disease and impaired kidney function.
another popular painkiller, coproxamol, was phased out between 2005 and 2007 after concerns about accidental overdose with alcohol.
‘They wonder what drugs they can give patients for long-term pain, for example, arthritis — it’s not easy,’ says dr Martin Johnson, a spokesman on pain management for the Royal College of GPs and co- chair of the opioid Painkiller dependence alliance.
The surge in opioid prescriptions is also driven by an ageing population with more people living longer with chronic pain conditions and problems with access to physiotherapy, says dr Johnson.
‘if patients are put on opioids it’s very important they are monitored and not put on repeat prescriptions — they shouldn’t be on them continuously. opioids should be reserved for treating flare-ups.’
He says GPs should also give advice to patients about exercise, physical therapies, giving up smoking and losing weight, which can all affect pain conditions as well as — and sometimes instead of — prescribing painkillers.
dr Tim Johnson, a consultant in pain medicine at salford Royal Foundation nHs Trust, says some newer opioid drugs are marketed aggressively t o GPs by t he pharmaceutical industry. opioids are only appropriate for about half the people who are prescribed them long term.
‘ There are some patients for whom l ong- term opioid use is appropriate — those with severe rheumatoid or osteoarthritis pain, for instance. Up to half of patients prescribed opioids may fall into this category,’ he says.
‘But there’s a question mark about why the other half are on long-term opioid prescriptions.
‘Presumably it’s because when they try to come off them they perceive their pain gets worse because opioid use has suppressed their body’s natural painkillers and they get trapped on the drugs.
‘This usually lasts only a few weeks, though, but still patients need help with tapering their dose so they can DR come off them gradually.’
KnaGGs stresses that opioids do have their place, but mainly as a short-term treatment for severe pain, such as post surgery, heart attack or end-of-life care.
‘There are some circumstances where they might be of benefit in l onger- t erm chronic pain conditions such as osteoarthritis — where the patient says they have improved their pain management greatly, for instance, and this has enabled them to move about more,’ he says.
‘But those patients should still be monitored closely. They should be started off on opioids on a trial basis on a low dose and regularly reviewed. and the dose should be intermittent, not continuous.’
For Josie, long-term opioid use has become the norm and she’s concerned about the potential long- term effects on her health.
apart from during her pregnancy (‘i just had to grit my teeth through the pain’), she’s remained on cocodamol. However, she has reduced her intake to three tablets a day after seeing a physiotherapist five years ago and learning exercises to strengthen her lower back.
‘i think doctors dole out these pills too freely,’ she says.
‘it’s quicker for them to write a prescription than to arrange physio or a referral to a pain management clinic.
‘i’m horrified when i think i was prescribed these drugs when i just a schoolgirl. i have a friend who is terminally ill with cancer and he is on the same dose as i was taking — it’s shocking.’