Summer 2010 - The British Pain Society

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PROFESSIONAL PERSPECTIVES A painful truth? Dr Des Spence General Practitioner and BMJ Columnist The work of doctors is to relieve suffering. All of us, bar a few rogue elements, work to the best of our abilities, earnest, well intentioned and continually striving to do the right thing for our patients. When I recently criticized the wider pain management community in relation to the use of strong opioids in the BMJ, it was neither intended to be disrespectful or offend. My motivation was to reflect on changes in practice that I had observed over the last decade, in the use of opioids and opiates, particularly in the wider community. As a General Practitioner I am one of the “canaries in the coalmine” of care, and have anecdotally witnessed increasing problems with prescribed opioids; from dependence and drug seeking behaviour, to the diversion of prescriptions into the black market. Anxiety, by myself and many colleagues, is also now expressed by the creep of strong opioids into non-malignant pain syndromes which too many seem often poorly defined diagnostically and of contentious and uncertain aetiology. Recently the promotion of opioids in the elderly for early osteoarthritis (OA) has also caused concern. This condition (OA) is notoriously intermittent and the wholesale introduction of potent medications, on the back of any guideline, may lead to problems in a vulnerable group. Opiate prescribing trends report a 70% increase since 2003 with the trajectory relentlessly upwards. Indeed some countries have experienced a 5 fold increase in 2 decades. [1] Such a rapid change in potent opioid use cannot be explained by changes in pathology but only by changing clinical practice. Concern has also been raised about the power and lobbying of pharmaceutical companies (“Big Pharma”). It is now recognized unequivocally, that worldwide these companies have close educational and financial links with many leading medical organisations, and pain specialists and medical charities are not excluded. My point was to challenge these changes, especially on behalf of general practitioners who are responsible for the vast majority of prescriptions, so that we might avoid the evolving disaster of the US experience of opiates and chronic pain management. Background There is an argument that pain has been under treated for decades. Anecdotally this is certainly true and many doctors were ignorant in the use of strong opioids and consequently weary of their use. Both palliative care and pain communities have been actively involved in improving this situation. This success, coupled with some limited research evidence, informally led to the more widespread use of opiates in non malignant pain syndromes. Over the last few decades NSAIDs fell from favour as a mainstay for chronic painful disorders, due to a strong research base showing significant and occasionally lethal side effects. Initial research suggested that when opioids were used therapeutically they were not associated with significant side effects nor addiction. Furthermore short small studies suggested opioids improved the quality of life of sufferers .It seemed logical that opioids should be more widely used. The acceptance of opioids first started in the pain clinic but soon became common clinical practice in the community, following education and promotion by pharmaceutical companies. Superficially this seemed like enlightened medicine. Figure 1 34 PAI N N E W S S U M M E R 2010
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Summer 2010 - The British Pain Society

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