Management of Chronic Pain

Unfortunately, the medicines we currently have to relieve pain have their shortcomings. From paracetamol to aspirin, gabapentin to opioids, they all have their adverse effect and, in reality, most don’t work very well at all. Pain medicines are not like antibiotics which can cure 80-90 per cent of all infections. The effects of pain medicines are very varied, and can affect people in very different ways.

This is why we will be looking at new drugs and therapies that may be able to treat pain more effectively and safely in the future, at the upcoming Pharmacological Management of Chronic Pain conference at the RSM.

When it comes to paracetamol, there is evidence that it may not be very helpful for arthritis pain in the long-term, so you may be better off taking a non-steroidal anti-inflammatory like naproxen or ibuprofen. However, NSAIDS also carry risks, and may affect the cardiovascular system, stomach, kidneys, and so on.

While strong opioids such as morphine can be useful for short-term pain on a time-limited basis, loss of benefit occurs when used over longer periods, and the risk of opioid dependency or addiction is a very real problem. While we are not at the same stage here as in the U.S. where there has been widespread dependency, and many deaths, arising from the over-availability of opioids, here in the U.K we could be on the same curve, and should all be careful not to get into the same position .

The morphine-like drug, Oxycontin, for example, was said by one pharmaceutical company to relieve pain without causing addiction, when taken in this slow-release form. Doctors were told that patients wouldn’t get addicted because there wouldn’t be peaks and troughs of drug level in the body when oxycodone was taken in this way. But we were badly advised by the pharma companies, and several lawsuits are current in the U.S.

Through tireless work by high-profile pain specialists such as Jane Ballantyne in the U.S., and Cathy Stannard and others in the U.K., we know that oxycontin and other opioids should be used with great caution for long term pain. Beneficial effects can begin to wear off as early as after six week’s use, when the body’s natural mechanism begins to down-regulate opioid receptors in the sensory nervous system. Worse, than this, over the same period of time, the body gets used to the drug’s presence, and suffers opioid withdrawal symptoms if a dose is missed out. Patients can mistake these withdrawal symptoms for pain and insist on continuing the opioid. Opioid withdrawal symptoms include acute anxiety, sweating, abdominal cramps and diarrhoea, and are just the same as going ‘cold turkey after heroin’. So, many people keep taking medically-prescribed opioids for years, suffering side effects, and without benefit, just because they haven’t been helped, or allowed themselves to be helped, by going through a properly-controlled ‘weaning’ program, which can reduce and stop the opioid, while avoiding withdrawal symptoms.

As well as more effective medications to treat pain, what we really need to do is have a better system for following-up patients who are started on opioids in hospitals or pain clinics , so we can help people off opioids when they are no longer needed, or are not helping. We just don’t have the staff or the capacity to do this properly in the NHS. This means that many people slip through the net. And that’s a shame because we know that opioid and other medications can be weaned comfortably and successfully, and that people can often feel so much better, as a result . They may feel so much more like their ’old selves’ again after medication reduction, re-energised, thinking more clearly, and enjoying life again, once the burden of medication has been removed.

Moving on to other aspects of managing long-term pain, we now know that people in chronic pain develop permanent neurological changes in their nerves, spinal cord and the parts of the brain that process pain. The number of nerve cells and connections between the nerves in the sensory pathways actually increases when someone is in pain for a long time.
That’s why it’s really important that patients don’t get kept waiting for months on end to see a pain management specialist, which is all too much the case at the moment. Perhaps this results from cash and resource shortages in today’s health services, but delay is not cost-effective in terms of money, or human suffering. If someone is left waiting in chronic pain, their chance of finding a solution is reduced markedly.

People in severe pain really need to see a pain physician before their chronic pain can become wired into the system and other secondary changes can take place. Moreover, the healthcare system must then allow the doctor to treat patients promptly and effectively, allocating them sufficient treatment resources to do so.  If we do see and treat people in time, issues like shingles pain, sciatica, and so on can be settled more quickly, before pain becomes ‘wired in’ for ever.

Pain management techniques like exercise, physiotherapy, psychology and mindfulness can also be important , and can be extremely helpful to those in long-term pain, and may often do patients more good than pain medications. But, as we approach the year 2020, there is, no doubt, a clear need for us to develop pain medications that are more effective and less burdensome than those currently available for us to offer to our patients.

Dr Anthony Ordman is a pain management consultant based at London’s Wellington Hospital, and is involved in the organisation of the upcoming conference on New Developments in the Pharmacological Management of Chronic Pain to be held at the Royal Society of Medicine on the 24th January, 2020.