0310 GMT August 22, 2019
“Some days even just lifting the brush to my head was too painful,” said the former care home assistant from Paisley in Scotland, dailymail.co.uk wrote.
“It was all over my body but worse in the back of my neck and shoulders. I put it down to heavy lifting in my job. But no matter how careful I was, my whole life came to revolve around this constant agony.”
The GP referred Amanda, then in her early 30s, to a rheumatologist who diagnosed fibromyalgia, a chronic condition that causes muscle pain and fatigue, for which painkillers are the main treatment.
Around eight million people in the UK live with chronic pain, where symptoms persist for longer than three months.
The problem for Amanda — and many others — is that the diagnosis of chronic pain often leads to a separate set of problems entirely due to the painkilling medication they are prescribed.
This leaves thousands dependent on the drugs through no fault of their own.
A growing concern is that many more people are now being prescribed opioid painkillers, which have their own unique set of problems — as Amanda discovered.
After her diagnosis, Amanda’s GP suggested she move on to prescription painkillers rather than rely on paracetamol, as she had until then. But within months she was taking a cocktail of medications, including the opioid tramadol, in doses her doctor continued to increase every couple of months until she was swallowing 16 pills daily.
Until recently, chronic pain was often dismissed as psychological because it often has no obvious physiological cause, with doctors telling patients “it’s all in your head”.
That approach is being consigned to history.
In the last two years, scientists have used technology known as fMRI (functional magnetic resonance imaging) to provide images of chronic pain patterns in the brain — and shown that it does have a biological basis, and is the result of a dysfunctional signaling system.
“fMRI scans on people with back pain show that for the first ten to 15 weeks, the same part of the brain that is involved in the immediate response to an injury — the sensory brain regions — are involved,” said pain management expert Professor Jane Ballantyne.
“But as the pain continues, that pattern changes. After a year, it’s clear that chronic pain is experienced in the emotional part of the brain.”
Chronic pain increases activity in the brain areas that can amplify pain signals, adds Irene Tracey, a professor of pain research at the University of Oxford.
“This mechanism is like a tap, and in chronic pain patients it’s turned all the way up and jammed there permanently.’
Her most recent study, published in October 2018 in the journal Arthritis and Rheumatology, showed that central sensitization syndrome (as the changes caused by chronic pain are known) can also amplify long-term pain where there is an identifiable cause, such as osteoarthritis.
The study showed those affected experience more severe arthritic knee pain both before and after joint replacement surgery.
“We know that the pain button can also be turned down, even blocking pain signals completely, for instance when the brain is distracted by the euphoria of crossing the finish line of a marathon”, said Tracey.
The hope is that the combination of this new understanding, together with pain management, can bring relief to chronic pain sufferers, she said.
It’s a story being repeated across the country. In 2017, GPs prescribed 23.8 million opioid painkillers, the equivalent of 2,700 items every hour, according to the Office for National Statistics. This is ten million more than in 2007.
Nearly half of these patients are prescribed opioids in bulk: Four out of ten patients with chronic musculoskeletal pain, for instance, take three or more opioids simultaneously, typically codeine plus tramadol and morphine, according to a 2018 study in the journal BMJ Open.
Opioids are known to be highly addictive. However the belief has been that this is not the case when patients are in genuine pain; that it’s safe to prescribe increasing doses to treat it.
Yet this belief is mistaken, say experts, and lies at the heart of the epidemic of opioid addiction currently causing turmoil in the US, where two million Americans are now addicts, with 115 deaths a day from opioid overdose.
Now a leading expert is warning the UK could face its own version of the devastating US problem.
Professor Jane Ballantyne, a pain management expert, was one of the first clinicians, back in 2003, to warn of the ‘societal catastrophe’ now facing the US.
Since then, she has warned persistently of the health risks of so-called ‘open-ended dose escalation’, where, as in Amanda’s case, doctors continue to increase the dose of powerful opioids in patients with continuing symptoms.
It’s the result, she said, of an entirely unproven belief, that ‘the existence of pain protects against addiction’. In other words, as long as a patient is feeling pain, they cannot develop an addiction to drugs that are otherwise highly addictive.
It’s a view that persists despite evidence from ‘countless studies’, said Professor Ballantyne, which show that addiction occurs in people who take prescription opioids for pain in exactly the same way as it occurs in those who use opioids recreationally.
Ballantyne, who trained at the Royal Free Hospital in London and is now a professor of anesthesia and pain management at the University of Washington in the US, has not made herself popular with her message.
In 2015, she caused outrage among fellow pain specialists by insisting that ‘reducing pain intensity should not be the goal of doctors who treat chronic pain’ because chronic pain causes changes in the brain that mean painkillers won’t work.
Instead, the role of doctors ‘should be to help patients accept their pain and move on with their lives’, she argued in a paper in the prestigious New England Journal of Medicine.
Fellow clinicians called for her resignation for ‘the insult to doctors and patients’.
But she stayed on to see her worst predictions come true in the US, with ‘an epidemic of prescription-opioid abuse, overdoses and deaths with no demonstrable reduction in the burden of chronic pain’, as she told Good Health. And she is now worried that despite a different healthcare system, the UK is seeing a similar trend in prescribing.
“The UK system, with GPs as gatekeepers of healthcare, should protect against overuse of opioids in a way that isn’t true of the US, where widespread advertising to patients raises awareness of opioids, and people can go from one doctor to another to get extra supplies,” she said.
“Despite these safeguards, I hear from colleagues in the UK that the NHS could now be facing the same kind of problems.”
This is borne out by the figures — with ten million more prescriptions for opioid-based painkillers handed to patients by GPs in 2017 compared to 2007.
It’s a warning call that needs to be heeded as new research highlights a further sting in the opioid tail: Used long term, they can actually make pain worse.