People living with long-term, near-constant pain usually have one thing in common: they want to keep the hope that something, somewhere, will ease their suffering.
All too often hope is the one thing they can’t find.
Many people living with pain have repeatedly tried medication after medication – getting stuck in a cycle of expectation, followed by crushing disappointment when yet another medication doesn’t work.
In many cases, the medication can actually make things worse with side effects such as fatigue, brain fog, or weight gain.
This cycle can continue for decades. One woman whose case I reviewed had 560 clinic letters collected on her notes, many about the different doses and types of medication she had tried ? all to no avail.
Last month, a study of 10,000 people by scientists at the University Hospital of Northern Norway found that even light exercise can improve pain tolerance (File image)
In fact, every new piece of evidence unearthed in recent years through research into chronic pain (defined as pain that lasts 12 weeks or more) and its various treatments confirms just how disappointing medications are at treating it.
So last month’s news that a review by a group of leading British scientists had found little evidence for 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 effect on pain that is very different from the effect they have on mood.
Last year, some ten million prescriptions were issued in England for the antidepressant amitriptyline in the dose used for pain. But in May, the respected research institute Cochrane announced it could find “no reliable” evidence to support the use of antidepressants for chronic pain.
In addition, a 2015 Australian study found that acetaminophen also doesn’t work for chronic pain. And the same has been found for stronger drugs, including opioids (such as codeine, morphine and fentanyl) and gabapentin, an anticonvulsant for epilepsy often prescribed as a pain reliever at lower doses.
They’ve all been used for years for chronic pain – but when we examine them with contemporary rigor for evidence that they work, it’s just not there.
That’s 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).
We need to change this mindset that medication can cure anything – and to make exercise a viable option, even for older patients who may think it’s unfeasible
In fact, the list of medications that have good evidence to help most people with chronic pain has now dwindled to essentially nothing.
In general, pain relievers are designed to interrupt the signals that are sent – via nerves – from an injured part of your body to your brain. The idea is that this drug blocks most of the signals so the pain can’t “register” in the brain. Or the pain that is registered is minimized.
In the case of acute pain – short-term pain, for example after an injury or surgery – the severity is usually related to the size of the injury or wound.
But chronic pain is different. In some cases, there is no injury and there may not be an obvious trigger (although, let me be clear, the pain is very real).
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Even if there is an obvious injury or joint damage, for example from arthritis, this may have little relation to the severity of the pain. That’s because with chronic pain, other factors can make a huge difference.
For example, depression, sadness, fears about debt or family can all affect your brain chemistry, exacerbating feelings of pain.
This explains why a painkiller has, at best, only a limited effect on your perception of pain.
I was the clinical lead for the pain guidelines to be published in 2021 by NICE, the National Institute for Health and Care Excellence ? a body that researches the effectiveness of treatments on behalf of the NHS and makes recommendations on how to use them.
Our view was that while antidepressants may be worth prescribing, doctors should be mindful of the uncertainties surrounding their effectiveness.
That’s not to say they won’t work for anyone, but they’d rather not work than help. This also applies to virtually any medication used for chronic pain.
So what’s the answer?
In fact, there is one thing that NICE says has good evidence for treating chronic pain and should be recommended to all patients ? and that is exercise.
Last month, a study of 10,000 people by scientists at the University Hospital of Northern Norway, published in the journal PLOS One, found that even light exercise can improve pain tolerance.
Not only does it provide many health benefits, but for people with chronic pain, it has also been shown to improve their pain and their quality of life.
But it can sound indifferent when a doctor tells a patient who comes to him in agony to move more. Some doctors prescribe 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 medication can cure everything – and to make exercise a viable option, even for older patients who may think it’s unfeasible. In Gloucestershire, where I work, we are running a pilot project – a joint venture between the local health council and Active Gloucestershire – to formulate the best approach for chronic pain. As part of the program, exercise instructors organize group sessions for patients of all ages with chronic pain, no matter how much pain they are currently in and how immobile they are.
First, the instructors spend an hour with each participant, assessing all aspects of their lives and activity goals, before customizing exercises for the individual (for some this included light stretching, while for others regular stair climbing or frequent walks to the local shops).
The exercises are then done in a mixed skills group setting as this helps motivate people to work towards their goals. The evidence also suggests that advice is better received from an instructor who helps you help yourself, rather than a medical professional who “treats” you. The scheme is also cost-effective: a program of ten group sessions with an exercise instructor costs ?85 per patient, compared to an outpatient appointment with a consultant, which costs the NHS around ?200.
More importantly, the results are spectacular. We put over 100 patients through the programme, and the first results from a sample of them, published in the British Journal of General Practice in 2021, showed that while the goal was to improve their quality of life and function – some it did – for many it actually reduced their pain.
Other areas appear to be increasing access to similar schemes. We have to accept that there is no simple medical cure for chronic pain – and I don’t think there ever will be.
But there are ways to improve lives through more programmes, such as the one in Gloucestershire, and helping people access services to help with the issues that directly contribute to their pain – whether that be counseling or hands-on help in isolation, weight management or debt management. For example.
This will help people live fuller, happier lives more than any pills – and it won’t have any side effects.
- Dr. Cathy Stannard, former pain consultant and clinical lead of NICE’s chronic pain guidelines, is clinical leader for pain transformation in Gloucestershire.
As told to LUCY ELKINS
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