People who live with long-term, near-constant pain tend to have one thing in common: they want to hold onto hope that something, somewhere, will ease their pain.
But too often, hope is the one thing they can’t find.
Many people living with pain have been repeatedly tried drug after drug and have been stuck in a cycle of expectations followed by crushing disappointment when another drug fails to deliver.
In many cases, the drug can even make things worse due to side effects such as fatigue, brain fog, or weight gain.
This cycle can go on for decades. One woman whose case I reviewed had accumulated 560 clinical letters on her notes, many on the various doses and types of drugs she had been tried to no avail.
In fact, every new piece of research evidence unearthed in recent years about chronic pain (defined as pain that lasts 12 weeks or more) and its various treatments confirms just how disappointing the drugs to treat it are.
So last month’s news that a review by a group of leading British scientists had found little evidence to support the use of antidepressants to treat chronic pain should surprise no one. Antidepressants have been prescribed for chronic pain for decades, in the belief that they have a distinct action on pain quite different from the effect they have on mood.
About ten million prescriptions were issued in England last year for the antidepressant amitriptyline at doses used for pain. But in May, respected research body Cochrane announced it had found “no reliable evidence” to support the use of antidepressants for chronic pain.
Also, in 2015, an Australian study found that acetaminophen doesn’t work for chronic pain either. And the same has been seen for stronger drugs including opioids (such as codeine, morphine and fentanyl) and gabapentin, an anticonvulsant for epilepsy that in lower doses is commonly prescribed as a pain reliever.
All have been used for years for chronic pain, but if we examine them with contemporary rigor to prove that they work, it’s simply not there.
Which is bad news for the 15 million people in the UK of all ages and backgrounds who live with chronic pain caused by everything from arthritis to fibromyalgia (which causes pain throughout the body).
In fact, the list of medications that have good evidence that will help most people with chronic pain has dwindled to virtually nothing.
In general, pain medications are designed to interrupt signals sent through nerves from an injured part of the body to the brain. The idea is that this drug blocks most signals, so pain can’t “register” in the brain. Or the pain it registers is minimized.
In the case of acute pain pain of short duration, for example following an injury or an operation, the severity is usually related to the size of the lesion or wound.
But chronic pain is different. In some cases, there is no injury at all and there may not be an obvious trigger (although, mind you, the pain is very real).
Even if there is an obvious injury or joint damage, say from arthritis, this may have little bearing on the severity of the pain. That’s because with chronic pain, other factors can make a huge difference.
For example, depression, grief, anxieties about debt or family can affect your brain chemistry, exacerbating pain sensations.
This explains why a pain reliever will have, at best, only a limited benefit on your perception of pain.
I was the clinical lead on pain guidelines published in 2021 by NICE, the National Institute for Health and Care Excellence, a body that reviews the effectiveness of treatments on behalf of the NHS and makes recommendations on their use.
Our view was that although antidepressants may be worth prescribing, clinicians need to consider the uncertainties surrounding their efficacy.
That’s not to say they won’t work for anyone, but they’re more likely to not work than help. This also applies to almost all medications used for chronic pain.
So what’s the answer?
Indeed there is one thing that according to NICE has good evidence for the treatment of chronic pain and should be recommended to all patients and that is exercise.
Last month, a study of 10,000 people by scientists at University Hospital of Northern Norway, published in the journal PLOS One, found that even light exercise can improve pain tolerance.
Not only does it offer many health benefits, but it also appears to improve the pain and quality of life of people with chronic pain.
But it may seem indifferent if a doctor tells a patient who comes to them in agony to start exercising more. Some doctors report prescribing painkillers to desperate patients because they don’t want to seem unsympathetic, even though they know it probably won’t help much. But we need to change this mindset that drugs can cure everyone and make exercise a viable option even for older patients who may feel it’s unfeasible. In Gloucestershire, where I work, we are running a pilot project, a joint venture between the local health authority and Active Gloucestershire, to formulate the best approach to chronic pain. As part of the program, exercise instructors are conducting group sessions for patients of all ages with chronic pain, however much pain they are currently in, and however immobile they may be.
First, the instructors spend an hour with each participant, assessing all aspects of their life and activity goals, before tailoring the exercises to the individual (for some this involved light stretching, while for others it was regular climbing stairs or taking frequent walks to the local shops).
The exercises are then performed in a mixed ability group setting, as this helps to motivate people to work towards their goals. Evidence also suggests that advice is best received from a trainer who is helping you help yourself, rather than from a medical professional who “treats” you. The scheme is also affordable: a program of ten group sessions with an exercise instructor costs £85 per patient, compared with an outpatient appointment with a consultant, which costs the NHS around £200.
More importantly, the results have been spectacular. We have referred more than 100 patients to the program and the first results from a sample of these, published in the British Journal of General Practice in 2021, showed that although the aim was to improve quality of life and function, which it did for many even actually reduced their pain.
Other areas look set to increase access to similar schemes. We have to accept that there is no direct medical cure for chronic pain and I don’t think there ever will be.
But there are ways to improve lives through more programs like the one in Gloucestershire and by helping people access services to help with the issues directly contributing to their pain, whether it’s counseling or hands-on help with isolation, weight management or debt management, for example.
This will help people lead fuller and happier lives more than any pill and will have no side effects.
- Dr Cathy Stannard, a former pain consultant and clinical lead for chronic pain guidelines at NICE, is clinical lead for pain transformation in Gloucestershire.
As told to LUCY ELKINS
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