I want you to close your eyes for a second. Imagine the most relaxing place you can possibly imagine. Take a few deep breaths and think about how it feels to be there, in that moment. Now, imagine that feeling is gone, forever. What would you do? How would you feel? What would you do to get back to this place?
OxyContin, a prescription opioid-based painkiller, was introduced into the market in 1996. Promoted as less addictive and non-habit forming than other prescription painkillers, it soon became the most popular opioid drug on the market in the USA. The maker of OxyContin (Purdue pharma – owned by the Sackler family) incentivised its sales force with huge bonuses for selling OxyContin to doctors who rarely treated chronic pain. Drug reps were instructed to downplay the risk of addiction and the potential for abuse. The way they did this was through pointing out that the FDA licensed it for Moderate Pain (previously opioids were only licensed for Severe pain) and the fact that they presented information using misleading charts and untrue information. They were also told to recommend OxyContin for a wide range of pain problems, including headaches, back pain, and arthritis as the primary drug, instead of drugs like paracetamol or anti-inflammatories like ibuprofen. Despite the growth of its use as a drug of abuse, Purdue pharma continued to push the drug as a valuable first-line painkiller.
Opioids
Our nervous system produces our own opioids to relieve physical and emotional pain, and to give ourselves a feeling of well-being – that’s why we have opioid receptors. However, we can’t very often give ourselves supra-physiological (more than our body is usually able to produce) levels of opioids for a prolonged period of time. What would happen if you found a way to do this – wait, we have designed drugs called opioids to do this – drugs derived from poppy seeds. Other opioids are codeine (found in co-codamol), dihydrocodeine, tramadol, morphine, diamorphine (heroin), buprenorphine, oxycodone (in oxycontin), fentanyl, and some others.
Are you shocked? Have you been on these medications? Have your family or friends been on these tablets or patches? If they didn’t have side effects, then I suppose we would just be very contented all the time and we wouldn’t have to do anything about it.
However, we know that opioids very quickly stop working (probably weeks, but maybe even days), our body builds tolerance and we need more drug to get the same effect, and eventually we get so used to having no pain, that suddenly any pain becomes an even worse pain (opiate hyperalgesia – feeling more pain). Overdoses of opioids lead to respiratory depression leading to stopping breathing, and so death. Reversal is with injecting a drug called naloxone which all of us doctors have used at some stage of our careers to bring someone with too much opioid in their system and so very drowsy and who has slowed breathing back to reality and to breathe again.
Is opioid use ever appropriate? Yes, in post-operative pain-relief and severe pain – say trauma-related, or cancer-related pain, or even end-of-life pain. I would hate to work without having morphine as part of my tool kit. Used appropriately, it is effective and valuable.
What can we learn?
The question is how can we improve our approach to prescribing? The lessons we learn from this article – don’t rely on drug companies and the ‘experts’ who work for drug companies who promote a drug that they are trying to sell. Question the research, and teach yourself to look carefully at data. Don’t believe everything you read and do your own research. My teachers used to tell me to look for outcome data – life or death. Does the drug make you live longer? If it doesn’t, there must be a good reason to use it. Would you believe it that there are very few drugs that make you live longer? More importantly, will drugs make you live shorter? In the case of Oxycontin and many opioids which can be abused, the answer is yes. All it takes is the widespread use of a drug. I remember being given samples of Tramacet (tramadol and paracetamol) for free and I remember feeling like I was flying when I took the first dose. Today, Tramadol is a controlled drug as it was prescribed and widely available and was abused and sold illicitly on the street. Perhaps we could learn different ways of approaching presribing – are there natural foods, or alternatives, or even just improving our lifestyle. The NICE guidance for pain talks about Exercise as the first line for pain-relief for Chronic pain and back pain, and Osteoarthritis. What about a better diet so we can sleep better, weigh less, and take the strain off our muscles and joints.
How can we approach pain better? Maybe the language we use matters? I would argue, everything we do matters. In our talk at the recorded Integrative Health Convention Virtual Event on 11 Feb 2022 (tickets available still), Dr Akhtar and myself will discuss how from the outset, how the approach to the patient, the format of our rooms, and the subliminal messages we give to our patients, make our approaches more conducive to avoiding the need for analgesia. In exchange for coming to help out at our recent vaccination drive, I taught the doctors a technique of painless injections. Up to that point, every one of their patients felt pain with injections. After that day, they found many patients reporting not having felt any pain and were in awe that such simple techniques worked. Come learn them at IHC Feb 2022.
Breathing techniques help with anxiety and how we feel. Correct movement helps with pain-relief and preventing injury. Our voice helps calm people and ourselves. Dealing with traumatic past events aids our ability to handle ongoing chronic pain. Lifestyle medicine integrates self-care approaches into medicine. All these techniques will be featured for you in our February conference.
Don’t you and the people you serve deserve better? Don’t be the victim of the next Drug Company.
