Roger Knaggs
Associate Professor in Clinical Pharmacy Practice, University of Nottingham
Supporting patients with chronic pain is complex and requires appropriate medicine along with support from multi-disciplinary teams.
When it comes to treating chronic pain, there is no magic pill. Great emphasis is placed on medicine, but this is just one part, albeit an important one, of the complex mix of considerations that need to be made when treating patients.
As doctors battle to get the appropriate prescriptions for their patients, Roger Knaggs, Associate Professor in Clinical Pharmacy Practice at the University of Nottingham, believes there needs to be greater understanding of the wider issues that are associated with chronic pain.
“While pain may be the presenting symptom, very often there is an awful lot underlying that,” he says. “Persistent pain medicines may help, but they are not necessarily the only solution.”
In cases of acute pain – which may last hours, days or weeks – there is a clear cut off point for medication. With chronic pain, time frames are much longer. Knaggs believes prescriptions should come with clearly defined and documented outcomes and expected time frames for benefit and assessment, so alternatives can be sought if the drugs are not effective.
We need to remember that any treatment for chronic pain has about a one-in-five to a one-in-ten success rate…
We should not deny medicine that we know works.
Are patients relying on opioids too much?
His comments come in light of the dramatic increase in the prescription of opioids in the last 10 years. A BBC study reported GPs prescribed 23.8m opioids in 2017, the equivalent of 2,700 packs an hour and around 10m more than in 2007.
The significant rise is one that Knaggs puts down to a number of different factors, including an ageing population, more patients seeking relief from pain and the changing attitudes toward the drugs. In the 80s and 90s, opioids were used primarily for trauma patients, those recovering from surgery and in end-of-life care, where time frames were clearly limited.
In the late 90s, opioids began to be prescribed indefinitely for conditions such as chronic back pain and arthritis. Now, with 15-20 years of experience and insight into the long-term impact of the drugs and their subsequent side effects, attitudes are shifting again.
Personalising opioid treatment
According to the BBC, only one in every 10 patients who are given opioids for chronic pain will have any benefit from treatment.
“This is probably about right,” says Knaggs. “But we need to remember that any treatment for chronic pain has about a one in five to one in ten success rate. The fact is thatthey [opioids] are making a significant difference to a number of people and we should not deny medicine that we know works.”
According to Knaggs, there has been around a small reduction in the number of opioids prescribed over the past two years. As we assess their place within treatment strategies, he believes that more needs to be done to understand who can benefit from them.
“We know that opioids can make a life changing difference to some people,” continues Knaggs. “We also know that if they provide only marginal benefits, then they are not right.”
Patients must come first to treat chronic pain
Above everything, Knaggs believes that it is essential for medical professionals to gain a better understanding of the individual needs of patients and how those needs change over time. “At a personal level, being closer to patients and other members of the primary care team has made a big difference,” he says.
As knowledge about the effectiveness of treatments grows, so attitudes toward drugs will continue to evolve, but medicine alone will never solve the complex biological, psychological and social issues that contribute to chronic pain. This a complex problem, that requires a multidisciplinary solution.
