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GPs buried under trusts' workload dump

Potent analgesics destroy lives: we must stop prescribing them

Dr Des Spence

Deference to specialists and guidelines is killing patients. Their advice is often misleading and, as with all elitist rulings, can be riddled with conflicts of interest. It is time to speak the truth. And the truth is that expert advice on chronic non-malignant pain has been damaging.

In the 1980s, the pain community co-opted the WHO’s ‘analgesic pain ladder’ into non-cancer pain, although this was never its intended use.1 GPs were instructed that there was a simple remedy – ‘the painkiller’, in the form of opioids, gabapentinoids and duloxetine. As the bandwagon rolled on, GPs were accused of poor care for underdiagnosing or undertreating chronic pain. They were told these medications were effective and – especially in the case of opioids – had no ceiling. Most of all, GPs were told they were non-addictive.

Yet this was all based on shoddy evidence and flawed assumptions. The assertion these medications were non-addictive, for example, can be traced back to a single letter in 1980, which has since been widely cited.2

But more than this, the whole research area has been underpinned by the widely quoted definition that ‘pain is what the patients says it is’. But this ‘truth’ is purely opinion. I have searched extensively and found no scientific evidence to support this statement. Furthermore, it is biologically impossible. The self-reported prevalence of pain varies ten-fold3 between similar populations. If the statement had a scientific basis, prevalence should be the same in similar populations.

However, this definition has benefited Big Pharma, which peddled these highly psychoactive drugs that obviously ‘worked’ on grateful patients.4 Any attempt to challenge the experts was difficult, as you were denounced as uncaring and paternalistic.

Such an environment naturally led to stellar increases in prescribing worldwide. Today, prescribed drugs are the greatest public health threat in the US.5 In the UK the level of prescribing is a fifth of what it is in the US – something I believe is due to single doctor registration in the UK, and the efforts of GPs who have disputed these assertions.

But despite GPs’ efforts, these medications continue to poison UK patients, on a scale far larger than the benziodiazepine chaos of the 1970s and 1980s.

Now, we know better. The pain community is at long last trying to change,6 with calls to stop prescribing opioids in primary care.7 But GPs are still in line for blame, so we need to work together. We need an immediate moratorium on prescribing. Take these medications off repeat and review the patients. Also, write to pain clinics stating you will no longer initiate opioids and gabapentinoids, even if they recommend them. Let’s get this message out. These medications are destroying lives.

We need to ask tough questions too. So much money is poured into research on how to start these medications, but where is the research on how stop them or the resources to support dependent patients? And lastly, why does no one seem to care about the pain we’re causing?

Dr Des Spence is a GP in Maryhill, Glasgow

References

1. Ballantyne, JC. WHO analgesic ladder: a good concept gone astray. BMJ 2016; 352: i20

2. A 1980 Letter on the Risk of Opioid Addiction. N Engl J Med 2017; 376:2194-2195

3. Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being: a World Health Organization study in primary care. JAMA1998; 280: 147-151

4. Meir, B. In Guilty Plea, OxyContin Maker to Pay $600 Million. New York Times 10 May 2007 

5. Christensen J, Hernandez S. This is America on drugs: A visual guide. CNN  23 Jun 2017  

6. Bird, E. Opioids: GPs set to be central in reduction drive. Pulse 29 Jun 2017

7. Alderson, S. Dangerous Ideas: GPs should stop prescribing opioid medication except for palliative care. Br J Gen Pract 2017; 67 (660): 310 

 

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Readers' comments (13)

  • Hi Monty,
    This comes from the Scottish Government's Mental Health Strategy 2017-2027. It does not refer specifically to antipsychotics (but the view of a number of experts, who have looked at the evidence, is that antipsychotics are a major contributing factor to early death):

    Scottish Government: "It is unacceptable that people with severe and enduring mental illness may have their lives shortened by 15 to 20 years because of physical ill-health."

    https://beta.gov.scot/publications/mental-health-strategy-2017-2027/pages/7/

    aye Peter

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  • What about those who do have pain? Cancer Osteo and Rheumatoid arthritis all look painful to me. Maybe if I haven't seen a good double blind placebo controlled trial I should ignore my insticts and the pleading of my patients. Of course some patients exaggerate symptoms others don't.
    Low dose long acting morphine can be very benefical and I do use low dose buprenorphine patches in the elderly. It helps them to function and they are not strong. I wonder if Dr Spence prescribes anything in his practice.

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  • It is not so much that they are addictive, its that they do not work in the long term. Have you noticed that those with chronic pain are on chronic medication? The medications locks the patients into permanent pain, and give hyperathesia. It blocks the brain from phasing out the pain, a process that must happen in normal people who have avoided such meds. If we look at MRI of people complaining of nothing, their backs look just as terrible as those in agony.

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