The opioid crisis and chronic pain: three things to bear in mind

You only have to put the words "opioid crisis" into a search engine these days to find tales of terror, addiction and death. "NHS accused of fuelling rise in opioid addiction," "Can the UK curb the looming crisis," these headlines are frightening and would have you believe that every person who even looks at a fentanyl patch will be addicted to heroin before the week is out. Understandably, this has important implications for people who take opioids to manage chronic pain.  There are lots of things we can do about this situation, but here are three of the things that I think are important, based on my work in chronic pain services as a clinical psychologist.

Accept what people tell us about opioids
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The research suggests that, for chronic pain, opioid medication is ineffective for many people (that link, whilst being slightly sensationalist, gives a good overview of where this issue started and how). That research is borne out by the vast majority of the people I see in clinic. Opioids also have some serious side effects including nausea, constipation, hormonal changes, and potential shortening of life span - although the reporting of that last side-effect can also be quite sensationalist. From the perspective of the medical doctors I work with, I completely understand their reluctance to prescribe opioid medication. They want to help the people who come to see them, and the main way they are trained to do that is to give medication, or injections, to try to relieve pain. But chronic pain is complex, and for lots of people that doesn't completely remove their pain - and, for lots of people, it doesn't help at all or makes their pain worse. Having escalated doses of medication over years without realising the issues, it makes sense to me that when faced with the reality of some people having very serious side effects they would want to be more cautious about prescribing in future. Additionally, I routinely work with people who are taking four or five times the maximum recommended dose of opioid medication, who are still struggling with pain. For those people, that medication just isn't working well enough, and continuing to escalate the dose isn't the answer.

Accept what people tell us about opioids!

The people I work with who have chronic pain are very rarely "addicted" to opioids - there is a difference between being addicted and being dependent on a medication to function. Being physically dependent on medication usually means that as a person tries to cut it down they get some nasty side-effects - with chronic pain, that can include sudden increases in pain. But generally, people don't want to be on high doses of medication - they take it because it helps. Or, they take it because they just don't know what else to do.
By the time I meet someone with chronic pain, they may have had their pain for decades. The only help they might have been offered is medication, and vague advice about "learning to live with it." And they've received that advice against the backdrop of a society that tells people that if you have pain, take a painkiller and it will go away. Even the word "painkiller" implies that they are completely and wholly effective for killing pain and that pain is something that nobody has to live with. In acute pain, that might be true. But in chronic pain, it's a whole different ball game.
If the only option you're given is to take medication then you'll keep taking it, even if it doesn't work. I've lost count of the number of times I've had a conversation that goes something like:

"I take [x opioid medication], I have done for years"
"Does it help?"
"Not really...the pain's still there, I just care about it a bit less. I don't really think the meds are doing anything"
"So why do you still take them?"
"...Because there's nothing else"

We have to do better for people than just offering them medication and sending them away again, knowing full well that it won't take the pain away completely. People come to doctors to get help and they don't necessarily know the dangers of the medication that their doctor might prescribe. Then, once we've ratcheted up the dose and made them dependent, we say they're addicted and take the medication away suddenly. Or, worse - people come for help and we offer them medication. They come back still wanting help, and we change their medication. Then they come back and ask for medication, and suddenly we decide they're "opioid seeking." We need to recognise that in this regard, the reactions people give us are in response to our model of management.

Offer people appropriate medication, and alternatives to medication

Ultimately, what we need is a balance between appropriate prescribing and alternatives to medication for chronic pain. Chronic pain is a condition that requires ongoing management, and we need to be mindful of this fact when thinking about medications, but we also need to recognise that for some people, opioids really do make a significant difference to their function. And as far as I'm concerned, being able to do some of the things you want to do when you have pain, some of the things that make up a life in spite of pain, is the most important thing. People need access to high-quality pain management services comprised of a range of rehabilitation options (psychology, physiotherapy, occupational therapy, nursing and yes, medical intervention when needed) to help them to live well with their pain condition, rather than being too spaced out on opioids to do the things they want to, or constantly terrified that the medication that maintains their function will be taken away. At the end of the day, we need to make pain management work for everyone.

Let me know what you think about the "opioid crisis" in the comments. If you have questions about pain management in general, I'm happy to answer them via email or via the comments section.

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