Chronic pain: prescribe mental health support as well as drugs, say experts

People with chronic pain should be prescribed social interventions such as mental health support instead of just opioid painkillers, experts have said.

About 28 million adults in the UK live with pain that has lasted three months or more, according to recent research. But tackling such pain is challenging, with few effective treatments on offer.

“For long-term pain there are no medical treatments that work really well – that is a harsh fact,” said Dr Cathy Stannard, clinical lead for guidelines on chronic pain from the National Institute for Health and Care Excellence.

“Long-term pain is distressing and disabling, it is dreadful to live with, but medical treatments do not work to treat it.”

GP prescriptions in England for opioids – drugs such as morphine and oxycodone – doubled in the 10 years to 2017, to 23.8m. Although more recent data shows a slight dip, the British Pharmacological Society says strength of prescriptions is rising. Unlike the US, the UK has not seen a sharp rise in deaths linked to prescription opioids, but concerns remain around addiction and side effects.

While opioids are known to work for short-term pain, it is thought as few as one in 10 patients with chronic pain not linked to cancer may benefit from such drugs. Between 2017 and 2018, 5.6 million adults in England were taking opioids, with 540,000 having been taking them for at least three years.

Now Stannard says it is time to rethink how chronic pain is handled, noting that when asked to rate their pain on a scale of one to 10, with 10 akin to torture, many patients rate their pain at 12.

“That does not mean they are lying – what it means is they very, very much want help … The pain score is an articulation of distress,” she said.

Stannard said that not all relief comes in the form of medication. “Maybe we can’t change the pain, but we can do various things like we can improve mobility, we can improve sleep, we can improve social isolation, we can provide housing support, we can provide financial advice,” said Stannard, adding that such approaches can reduce reported pain.

“Our problem is that we treat pain as a medical thing, like hypertension, and what we use are drugs that interact with the pain pathway, and in fact we neglect the fact that pain is about so much more than that,” she added.

Although opioids fail to help 90% of those with chronic pain, Stannard says they should still be tried at least for an initial period of a few weeks to see if they work, and with patients made aware that they have only a small chance of helping. “The reason we don’t throw them out altogether is that for some people they are life-changing,” she said.

But pain management needs more than drugs, she said.

“We know now there is a very close relationship between, for example, adverse childhood experience and adult chronic pain,” she said, adding that she had also seen cases where intense pain had been linked to grief.

“It doesn’t mean that pain is any less real if there are profound emotional contributors,” Stannard said. But, she added, “if we had very easy open access to mental health support, we would prescribe much less.”

Stannard said that opioids are overprescribed in the UK but the extent is unknown and the reasons are complex, stressing GPs are not simply “doling out drugs”. As well as a lack of access to mental health services, she said, doctors can feel pressured to prescribe opioids even though they expect them to bring little benefit, because of the distress and desperation of the patient in front of them.

“If I see someone who says: ‘So, you are going to leave me in pain then,’ that is an existential threat to my identity as a healthcare professional,” said Stannard. “If somebody comes into a clinic being distressed, it is very difficult to say you are not going to help.”


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