20 November 2014

The increasing use of powerful drugs to manage chronic pain is leading to long-term harm.  Should we keep taking the tablets? 
from an article by Anjana Ahuja

In the Victorian age, legions of women relied on a medicine known as 'Mother's quietness' to soothe the pain of their infants.  The reason it worked was that its chief ingredient was laudanum - an extract of opium in alcohol- and its popularity meant that even babies ran the risk of overdosing on remedies bought with ease from chemists and street hawkers.
British laws regulating drug preparation, sales and labelling have been around since 1868 but we remain in thrall to the growing armoury of drugs that promise to take away our pain.  A report from the American Academy of Neurology unvails the extent of this modern intoxication: it says that, in the treatment of chromic pain unrelated to cancer, painkillers are, on balance, causing more harm than good.
The rampant use of powerful medicines, mainly opioids (a class of drugs, including morphine and oxycodone, that have similar pain-reducing effects to opium), is responsible for an epidemic of addiction and overdoes that is costing lives.  

The figures from the US are frightening: in 2007 alone, there were almost 12,000 deaths from unintentional overdose of opioid painkillers, more than the number of heroin and cocaine overdose casualties combined.
The American health-care system is particularly conducive to such abuse: privately funded patients can roam unchecked from doctor to doctor, collecting prescriptions as they go.  In Britain where patients can register with only one GP, massing a stockpile of painkillers is harder to achieve.
But while UK data on opioid overuse may not be precise, we should not dismiss it as an issue of public concern as apparently there has been a large increase in opioid prescribing of the order of 400% in the past ten years.  Other European countries have found similar trends, so this increase isn't restricted to the U~S.
That is why the British Pain Society, a professional body that aims to advance the understanding and management of pain, together with the Royal College, is revising and updating its opioid prescribing guidelines.  
According to the BPS, nearly 10 million Britons suffer pain on an almost daily basis, and work-related back pain alone results in five million working days lost every year.
One factor contributing to the riding prescription rate might be our ageing population, who are increasingly going to their doctors complaining of chronic conditions - that is, those that last longer than 12 weeks - such as osteoarthritis and nerve pain.
Around 2000 there were several trials that suggestion opioids might have some benefits in these types of pain.  It has taken a little while, but those findings have finally filtered through to everyday clinical practice.  Certainly, the pharmaceutical industry has been very proactive in promoting these medicines to health-care professionals.  As a result those new medications were taken up enthusiastically by patients and doctors alike.
But apparently there are problems with these trials.  First of all, the amount of pain relief provided is no better than that provided by alternatives, such an anti-epileptics and antidepressants such as amitriptyline.
Secondly, the trials were largely limited to 12 - 16 weeks, but once drugs go into everyday clinical practice, patients can end up taking them for much longer.  So we've now got patients possibly taking these drugs for many years on the basis of limited evidence.
Not only are the drugs of questionable long-term benefit, but evidence is coming to light that opioids may cause long-term harm by affecting the regions of the brain that produce sex hormones (oestrogen in women and testosterone in men).
In particular, the extended use of opioids appears to disrupt the production of testosterone.  A generation of older men may be on the verge of discovering that, even if their chronic pain is dulled by prescribed opioids, they are now plagued by sexual dysfunction, wasting muscles, thinning bones and low mood.
Over-the-counter (OTC) preparations are also implicated because many of them contain the opioid codeine.  For example, Nurofen Plus is a blend of codeine and ibuprofen, while co-codamol contains paracetamol and codeine.  Solpadeine is another well-known  brand of so-called compound analgesic (a mix of two or more drugs).
In 2009, on the strength of evidence showing that 30,000 patients were addicted to OTC medicines, tough new regulations came into effect.
Packets could not contain more than 32 tablets and had to carry prominent messages warning of the danger of addiction.  Patients are now urged not to take them for more than three days.
The charity Action on Addiction has recognised that some people do show the hallmarks of addition to OTC medicines: withdrawal symptoms if the tablets are stopped; being furtive about taking them; visiting multiple pharmacies to circumvent the limit on tablets; exceeding the stated dose; continuing to take tablets when the pain subsides, sometimes to cope with anxiety.
In fact someimes people resort to painkillers when they should be seeking help for depression or anxiety.  The difficulty is that prolonged pain casts a shadow in which depression can fester; the two conditions become dangerously entwined, and a desperate patient may come to believe that the mental agony, as well as the physical discomfort, can be numbed with painkillers.
Pain, derivated from the Latin poena meaning penalty, is a universal hnuman experience and we have always sought to address it.  Since 1000BC, some Peruvian communities have practised trepanning, believing that perforating the skull relieves pressure.  The Ainu, a hunter-gathered community is Sakhalin, Japan, categorise their headaches as 'bear', 'deer' or 'woodpecker', likening the discomfort to the heavy steps of a bear, the lighter skips of a deer, or the repeated pounding of a woodpecker on a tree trunk.
Opium is perhaps the oldest remedy; opium poppies were cultivated by the ancient Egyptians and Assyrians, amongst others.  The Chinese and Indians, too, have  a long history of opiate use.  Edwardian and Victorian Britons eagerly embraced the exotic therapies imported from the far-flung corners of the Empire. 
According to the Royal Pharmaceutical Society, 19th-century consumers were taking morphine for morning sickness, sniffing cocaine to banish catarrh, and ingesting heroin for bronchitis.  Opium-derived therapies were repackaged and marketed under such alluring names as Brathwaite’s Genuine Black Drop, Dr Bow’s Liniment and Mrs Winslow’s Soothing Syrup. These profitable elixirs spurred the birth of today’s global pharmaceutical industry.
That same industry has somehow lulled us into thinking that our lives can, and must, the pain-free.  This may be the case for short periods of acute pain, such as a headache or a sprained muscle, which can indeed usually be lessened with a pill.  I reserve particular praise for the epidural, which transformed my experience of childbirth.
But chronic pain is an altogether trickier customer.  There is no thing as a universal prescription for relief.   Our experience with acute pain, such as muscular pain or a headache, is that we take tablets and the pain goes away.  We think that we can do exactly the same for persistent pain.  In fact, trials suggest that, for chronic pain, if you manage to get a 30 – 50% reduction, you’re doing reasonably well.

Some pain management techniques include exercise, meditation, relaxation, hypnosis, pets, massage, heat or cold applied to the relevant spot, Tens machines and breathing techniques.  I'm not sure that alcohol helps, although I subscribe that dark chocolate does! 

See also:
Pain is also subjective: http://www.spine-health.com/conditions/chronic-pain/chronic-pain-coping-techniques-pain-management
Tens: http://www.mumsnet.com/Talk/childbirth/a916646-Tell-me-about-Tens-machine-any-good

Book: http://www.amazon.com/When-Painkillers-Become-Dangerous-Prescription/dp/159285107X

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