Chronic pain – acute pain that lasts for longer than three months – affects around one in five people in Europe. The increase in use of strong morphine-type drugs (opioids) for the treatment of chronic pain is an area of much concern, particularly in North America.
Termed an “opioid epidemic”, most developed countries have seen a major increase in opioid prescribing over the last decade or so. Our latest research assesses how good the evidence is that opioids can help chronic pain effectively, balanced against any harms they can cause.
Chronic pain very often doesn’t get better, so people can be prescribed opioids for a long time – years, or even decades. Is there evidence that opioids continue to work well to reduce chronic pain and improve quality of life? The majority of clinical trials only study opioid use for three months, so we don’t really know much about their effectiveness over the longer term.
One of the few studies that has looked at how effective opioids are after 12 months, found that people who took opioid painkillers were not any more active than those on other types of painkillers.
There is also evidence that long-term use of opioids may be harmful. This is likely to be dose-related as risks increase at higher doses. Known harms include increased risks of:
Addiction and misuse: this can affect anyone who is prescribed opioids for pain. Prescribers and patients need to be aware of, and minimise, the risk from the beginning.
Overdose and death: deaths from prescription opioids are increasing dramatically in the US for example.
Interfering with the endocrine system: changes in hormone levels that can impact on sexual function and fertility.
Heart problems: heart attack risk is more than doubled in people taking long-term opioids.
Being in a road traffic accident: the risk is higher among drivers taking even relatively low doses of opioids.
Worsening pain or “opioid-induced hyperalgesia”: when long-term use makes pain worse. This is often difficult to recognise.
Opioid tolerance: when the body becomes used to opioids and requires a bigger dose to get the same painkilling effect.
Adverse effects on the immune system: people taking opioids eventually become more prone to infections.
Should we use opioids for chronic pain?
Yes, when appropriate – but with caution. The Scottish Intercollegiate Guideline Network (SIGN) publishes high-quality evidence-based management guidelines. SIGN 136 was the first comprehensive guideline on the management of chronic pain, published in 2013.
As a result of new evidence, SIGN 136 has specifically reviewed the section on opioid use and updated recommendations have recently been published. New research since 2013 has been critically reviewed to ensure that the new recommendations are based on the best available evidence. Some of the key points in the new advice include the following:
Opioids should be used for as short a time as possible, in carefully selected people with chronic pain. This should happen when other treatments haven’t worked to manage the pain and where the benefits outweigh the risks of the serious harms listed above.
Before starting treatment, the person with chronic pain and the prescriber should agree what the treatment aims are. These might include reduced pain, increased activity and/or better quality of life. If this doesn’t happen then there should be an agreed action plan to reduce and stop opioids.
There should be ongoing, regular review by a member of the primary healthcare team, especially if the daily dose is equivalent to more than 50mg of morphine. Review should be frequent in the early stages, and at least annually, after treatment is established. If problems arise – such as opioids no longer providing good pain relief, increasing the dose provides no sustained pain relief or then there is evidence of addiction – then more frequent review will be needed and consideration given to reducing/stopping treatment.
We should always use the lowest effective dose. Higher doses (equivalent to more than 90mg/day of morphine) should only be prescribed alongside review by a pain specialist.
These recommendations are consistent with those of The International Association for the Study of Pain (IASP). The organisation emphasises that the use of other approaches, including behavioural therapies and increasing physical activity to improve quality of life, is preferred.
Where do we go from here?
Current evidence indicates that widespread, long-term opioid prescribing for chronic pain is likely to cause more harm than benefit in society. But some individuals with chronic pain do benefit. They should continue to be prescribed opioids, with the recommended caution, careful monitoring and review, and use of proven non-pharmacological therapies. Some people may also need support to reduce and stop long-term opioids, where the harms outweigh the benefits.
There is an urgent need for research to understand how to manage chronic pain better, including the safe use of and withdrawal from opioids. In tandem we need national policies, based on best available evidence and approaches to educate healthcare professionals and patients. This is likely to require investment in the short term, but it may be a small price to pay for the longer term benefits and probable cost savings of improving chronic pain management, which is the leading cause of disability globally.
Exploring Other Treatment Options
There are a number of proven, non-pharmaceutical options to help manage chronic pain conditions. These not only help to avoid the unwanted side-effects of medication, but some can also help to manage the psychological effects of chronic pain – such as low mood and anxiety – which often accompany the living restrictions which the pain causes.
To explore these treatment options, visit our main website here
About the authors and source material:
The authors of this article are Lesley Colvin, who is Deputy Head of Division – Population Health & Genomics & Chair in Pain Medicine, University of Dundee; and Blair H. Smith, who isProfessor of Population Health Science, University of Dundee
This article was first published in the online academic discussion journal, The Conversation on August 29, 2019 and is reproduced here under CCL copyright provisions. The original article, which includes active links to all references, may be found here
Alpha-Stim AID benefits people with Moderate to Severe Generalised Anxiety Disorder
(video clip courtesy of SkyNews)
The first clinical results of a major NHS study on how Cranial Electrotherapy Stimulation (CES) provided by the Alpha-Stim AID medical device have been released.
The study, lead byRichard Morriss, Professor of Psychiatry and Community Mental Health at the University of Nottingham, shows that the wearable device can help patients with anxiety disorders.
Conducted under the auspices of The National Institute for Health Research, Professor Moriss and his associate’s research found that patients with moderate to severe generalised anxiety disorders, who had already tried basic psychological therapies unsuccessfully, were able to show remarkable improvements in thier condition.
A total of 161 patients took part in the trial, and each patient’s results were measured for 24 weeks. The treatment procedure involved 60-minute self-directed Alpha-Stim AID CES treatment sessions undertaken at the participant’s home, on a daily basis for 6 weeks for all participants. Following 6 weeks of Alpha-Stim AID CES treatment, participants had the option to receive a further 6 weeks of treatment and were then measured at 24 weeks after a minimum period of 12 weeks without treatment to see if the changes seen during the active treatment weeks had been maintained. The study started in October last year with the final patient measurements due to be taken in December of this year.
CES is already widely used in the US, particularly by the American armed forces, to help those suffering with PTSD. The results of Professor Morriss’s trial will hopefully help give many thousand more patients the chance to try this unique drug-free treatment that can be easily and safely used at home.
One in four people in the UK will experience a mental health problem in any given year  and the Improving Access to Psychological Therapies programme (IAPT) was introduced by the NHS in 2008 to help facilitate better access to treatment for patients throughout England suffering from anxiety and depression. Over 900,000 patients now use IAPT services each year.
The Alpha-Stim AID device works on the same electrical pathways that naturally occur in the brain and stimulates the nerve cells in the brain stem, the control centre of the brain. 98 percent of the synaptic communication in the brain is electrical rather than chemical and the treatment encourages the production of alpha-waves in the brain. It also stimulates the brain cells to trigger a reaction to produce Serotonin. Anti-depressant drugs (SSRI’s) do the same, but cranial electrotherapy stimulation does this without any lasting side-effects. Its positive effects are also cumulative, suggesting that the Alpha-Stim may bring about a permanent positive change in our neurological make-up.
The Alpha-Stim AID is available from Peak Health Online, your authorised dealer serving the UK & Europe. To explore more, visit our main websitehere
About study lead, Professor Richard Morriss
Professor Richard Morriss is a Consultant in General Adult and Community Psychiatry with Nottinghamshire Healthcare NHS Trust and Professor of Psychiatry and Community Mental Health at the University of Nottingham. He trained in psychiatry in Leeds, Johns Hopkins Hospital in Baltimore United States, Oxford and Manchester. He has a MD from University of Leeds.
Professor Morriss has clinical interests in mood disorders, somatization and primary care psychiatry. His research interests are in the management of bipolar affective disorder, depression and medically unexplained symptoms in primary and secondary care settings.
He was also a member of the NICE Guideline Development Group (GDG) for Bipolar Disorder and is currently a member of the NICE mental health panel.