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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)

  • Quick question - interesting to see duloxetine mentioned amongst gabapentinoids and opioids - is there similar scope for misuse/abuse? In my albeit limited experience, it seems relatively effective and well tolerated for true neuropathy - would be interested to know if it's got a bad rep. V. useful article and references, especially as someone who works with a similar demographic in Glasgow - thanks.

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  • You do get the odd reports of people snorting duloxetine, but I think the evidence that it may give you a high is quite limited.

    Interesting article - very reminiscent of Illich's position in Medical Nemesis (Chapter 3 - The Killing of Pain; for those interested):

    "Medical civilization, however, tends to turn pain into a technical matter and thereby deprives suffering of its inherent personal meaning. People unlearn the acceptance of suffering as an inevitable part of their conscious coping with reality and learn to interpret every ache as an indicator of their need for padding or pampering. Traditional cultures confront pain, impairment, and death by interpreting them as challenges soliciting a response from the individual under stress; medical civilization turns them into demands made by individuals on the economy, into problems that can be managed or produced out of existence."

    Whilst lot's of points to agree with in the article, it still doesn't address the problem of what to do with patients in pain. I'm not sure quoting Illich to them will quite cut it.

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  • Banning GP initiation and removing strong opiates and gabapentinoids from pain management guidelines would help. Pain Clinics would see a surge in referrals, but would not be able to simply discharge back to GP on pregabalin and buprenorphine patches as they currently do. Naturally many patients will keep returning demanding stronger drugs, but at least we can hold up the guidelines, meekly smile and suggest weight loss and exercise, then wait for the complaints to roll in.

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  • Vinci Ho

    We need better understanding of chronic pain which in itself, I believe, is a syndrome by default and does not necessarily require a traceable pathology . It is a hydbrid of physical , emotional and social disturbances all in one.
    Painkillers are merely 'feeding' the monster of chronic pain and it gets hungrier and hungrier. I suppose medication-induced headache is at least , one well known ,proven entity.
    Can we really differentiate between physical and emotional pain? I suppose one example of the former is called myocardial infarction and that of the latter is called 'it's heartache, nothing but a heartache(remember the song?)'.
    Sting's immaculate lyrics in King of Pain is always inspiring to me :

    ''There's a little black spot on the sun today
    That's my soul up there.
    It's the same old thing as yesterday
    That's my soul up there.
    There's a black hat caught in a high tree top
    That's my soul up there.
    There's a flag pole rag and the wind won't stop
    That's my soul up there.

    I have stood here before inside the pouring rain
    With the world turning circles running 'round my brain.
    I guess I'm always hoping that you'll end this reign,
    But it's my destiny to be the king of pain...

    There's a fossil that's trapped in a high cliff wall
    That's my soul up there.
    There's a dead salmon frozen in a waterfall
    That's my soul up there.
    There's a blue whale beached by a springtime's ebb
    That's my soul up there.
    There's a butterfly trapped in a spider's web
    That's my soul up there.''

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  • Last month or so, Des, it was anti-depressant. I mean, I totally agree with you. Pharma has a magical formula, create a demand, most GPs are just open script pads and people just love taking pills.

    In the long run we're all dead, as JK Galbraith said.

    The next two articles about antihypertensives and amoxil write themselves...

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  • Just because they are hospital specialists doesnt mean they can prescribe better than GPs

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  • tell people they can be addictive and its up to them

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  • Yes medicine has made a big mistake here but GPs are left to pick up the pieces. The greatest problem in my daily practice is the demand for oramorph which has been started in secondary care for non-specific abdominal pains. Weaning them is impossible. Inpatient pain management is needed and would be cost effective in my humble opinion but no one is interested.

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  • I am a specialist but my passion is for generalism. Hence Hole Ousia webpage where I endeavour to show that knowledge and experience are not simply divided into distinct categories.

    I so welcome Des Spence. We need such forthright and plain speaking.


    I agree that "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."

    Those taking antipsychotics die 15-20 years younger than those who do not.

    Valproate babies.

    The Gabapentinoids.

    Mesh implants.

    Potential for dependence and withdrawal syndromes with SSRIs.

    And there will be many more examples than these current issues of concern.

    Many years on from advocating a Sunshine Act for Scotland (which has public support) and all the Scottish Government can say is that they are "scoping options".

    Meantime, earlier this summer, I did a peaceful protest outside the Royal College of Psychiatrists International Congress. Marketing should have NO place in science. That is what I was saying. My specialist colleagues looked worried for me and expressed concern for my wellbeing!

    Specialists can lack in insight just like any other!

    As said, I aspire to be a generalist.

    Peter Gordon.

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  • Hi Peter. I too think antipsychotics are not a force for good...could you please kindly supply a reference for the "die 15 years younger" quotation for my collection. Thanks

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