The problem with the problem of opioids

Over the last few weekdays, the Evening Standard has been running an investigation series on – according to the title on the 15th of March – the “Opioid Timebomb.” The articles are accompanied by an opinion piece by Dr Cathy Stannard, and two profile pieces on people who have experienced opioid addiction, with a third written by a woman who tried “alternative medicine.” The articles started with “The Growing Problem” so I have started there – but the ordering on the website edition is different.

The Growing Problem article definitely tends towards the sensational, and it focuses heavily on the “cost to the taxpayers” of opioid prescriptions – and it is only in one of the two profiles that the reader hears the voice of a person living with chronic pain.

The front page (of the paper edition) screamed about 23.8 million prescriptions written per year – which is a big number, especially once you express it as “one for every two adults.” However, it isn’t until the third page that you get the figure that those 23.8 million prescriptions are spread between 3.1 million people. But what the article doesn’t say is: how many of those prescriptions are for long-term use, how many are for short-term, and how many are for people with cancer or receiving other end-of-life palliative care. The figure of the 80% rise in prescriptions similarly doesn’t say if the rise is in long-term, short-term, or palliative care, which is crucial when we consider that treatment for pain in palliative care has changed to support more generous prescription and use of pain relief for the dying. The article does go on to say that 90% of the 23.8 million prescriptions are for chronic pain, but there is no source for this figure.

However – those 21.4 million prescriptions for chronic pain in a year isn’t actually unrealistic if you consider that most long-term prescriptions need to be repeated every couple of months, and there are an estimated 28 million adults living with chronic pain in the UK (according to a BMJ article). If all of these 21.4 million prescriptions are long-term, that’s more like 3.56 million  people with long-term opioid use (assuming one prescription lasts 2 months, so 6 prescriptions per year). Which is … a much smaller figure. And indeed, buried in the depths of the article, there is a figure of 3.1 million people on repeated prescriptions for opioids.

I’m not questioning the numbers themselves – they actually sound fairly reasonable to me – but questioning the use of the numbers to present the “opioid timebomb” does cast it in a sensationalist light – because “11% of people with chronic pain are on long-term opioids” sounds less urgent, as does “4% of the UK population receiving treatment for chronic pain, and it may not be working for them anyway.”

The article also assumes that 90% of long-term opioid use doesn’t work. This figure is sourced from a 2013 BMJ article by Moore, Derry, Eccleston and Kalso. Incidentally, the Standard article quotes that article as being titled “Expect analgesic failure” – when the title is actually “Expect analgesic failure; pursue analgesic success,” which isn’t quite so snappy sounding. The article doesn’t state that 90% of all long-term opioids are useless. It states that tapentadol and oxycodone were not effective in reducing chronic low back pain more than 50% (which is counted as failure in some clinical trials). This might be consistent with other opioids for chronic low back pain – but this isn’t the same thing as 90% of all prescribed opioids were wasted, which is what the Standard article implies instead. This returns to the same issue as above – the misuse of figures. There’s a big difference between failure for 90% of all long-term use, and failure 90% of long-term use of two of several possible opioids. Then, in casting that 90% figure in terms of “taxpayer money” (“£210 million … went on pills that did not work”) the article doesn’t frame it in terms of ineffective treatment, but on people with chronic pain as a burden.

This, for me, is the real problem with these articles. Chronic pain is hard to treat effectively, and harder still to live with. People living with chronic pain are already cast as failures – there is a tendency to blame individuals for their ill health and disabilities – and casting them as a burden is just more ableism. I’ve no doubt the Standard would cast any long-term treatment for chronic pain in terms of ‘taxpayer cost’ without considering the impact of doing so.

The article also calls for improving regulation around warning of addiction risk – I can get behind that to some degree, but just like casting the cost of medication in terms of taxpayers, it isn’t a neutral action, as it makes it easier to blame people for thier illnesses (just like we blame smokers and fat people for their cancer). It also isn’t about how prescriptions work – people rely on their GPs to prescribe medication that is appropriate despite the possible risks. And it’s worth noting that both Dr Cathy Stannard (who wrote an op-ed and was quoted extensively in the piece) as well as addiction charities agree that in reality of moving from prescription to addiction is relatively rare – and there systems in place already within the NHS which prevent a lot of the issues with the US system.

The impact of changing how opioid prescribing works is already a massive concern to disabled people – the US is exploring limiting how much a person can access on prescription (the National Committee for Quality Assurance is considering a limit of 120 milligrams of morphine equivalent daily over a three-month period), but this is a blunt instrument approach; it won’t do much of anything to help either addicted people or people with chronic pain. It doesn’t do much in terms of ensuring people with chronic pain get access to alternatives – which is the other side of the coin.

When we consider limiting access to painkillers, what else do we offer? Opioids – and other non-opioid painkillers – don’t stop pain effectively, but it isn’t about stopping chronic pain completely (we don’t understand chronic pain enough to do so) – it is about managing chronic pain in ways that support people to live fulfilling lives with chronic pain. And that’s hard to do, because it’s expensive – probably more expensive than £210 million per year.

 

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