Letter to my patient #4 by Dr Lars Williams

Dr. Lars Williams is consultant anaesthetist and pain specialist working for NHS Greater Glasgow & Clyde Pain Service, as well as the Scottish National Pain Management Service. In this article, originally published in Pain Matters 87, Dr. Williams explores the complexities of using opioids for chronic pain management, reflecting on the evolving understanding of their benefits and risks.

Finding a way through the opioid conundrum
When I started working in pain medicine 20 years ago, opioids (morphine-family drugs) were still being promoted in the UK as an effective solution to chronic pain, which everyone agreed was shamefully undertreated. Since then, clinical and societal experience has been that long-term opioids do more harm than good for most people who take them. The limited research supporting opioids has been picked apart and found to be wanting, leading to strong recommendations in UK guidelines that opioids should not be used at all for chronic pain, simply because they don’t work. As a person struggling with chronic pain, you may well feel frustrated by this seemingly abrupt shift from one extreme position to the other, more so if the narrative of opioids = bad doesn’t reflect your own experience.
Research findings vs individual experience
Research studies tell us how a population, on average, will respond to any intervention. These are studies of probability: they give us a sense of how likely any particular response is, but they can’t predict whether you as an individual will have that response. Some responses, such as changes in blood pressure, are easy for healthcare practitioners to measure objectively. But there is no objective measure of pain. Pain is a subjective experience and this is a problem when it comes to research, because studies of probability are less reliable when they are based on outcomes that can’t be objectively measured.

Although research can guide us as to whether or not a drug is likely to help, it is your experience of the drug that really matters. And your subjective experience is all anyone has to go on when it comes to pain. Your GP can easily see whether or not your blood pressure medication is working, but only you can say how effective your pain medication is. A key part of self-management of chronic pain is taking a step back and getting a clear-sighted view of what your pain medication is actually doing to you. How much is it helping? Does it reduce your pain, and by how much? Does it improve your sleep, or allow you to walk further? Conversely, how much harm is it doing to you? Do you get side effects? Do your family say that you seem withdrawn? Does it stop you doing things you want to do (for example driving, or going to the pub)? The first step towards a sustainable approach to opioids is getting this clear view of what these drugs are doing for (or to) you. If they are causing you more harm than good then you should stop taking them – slowly, of course, to avoid withdrawal symptoms. Unlike medication for high blood pressure, you don’t have to take pain medication. Your underlying condition won’t get worse if you stop (it might even get better). This realisation can be empowering.
Using opioids sustainably
Population studies suggest that a small proportion of people (maybe 10%) will continue to benefit from opioids in the long term. But for most people, any benefit wears off, or side effects begin to outweigh the benefits, after a few months. By conducting an honest appraisal of your medication you should have a clear idea which group you belong to. If your opioids are no longer helping, or they are causing you more harm than good, you have two options. You could slowly reduce them with the aim of coming off them completely, or you could continue to take them, just not every day.
Rethinking Opioid Use: From Daily Dosing to As-Needed Treatment
Received wisdom used to be that constant pain is best treated by round-the-clock opioids. But this goes against what we now understand about tolerance to opioids. A common sense approach would be to use opioids only for short periods, perhaps to treat a difficult flare up of pain, or to support an activity which you know will be painful. If you are not taking opioids every day then your morphine receptors are more likely to remain sensitive to the effects of opioids, and you are less likely to develop the side effects we talked about in the last column. There is a small amount of research evidence to support this common sense approach – a 2011 Canadian study showed that people taking opioids only when required took much lower doses and had fewer associated problems compared to people taking opioids regularly for the same problem.
Making Changes Safely

So, we can be guided by population research and by clinical experience, but ultimately this is about finding an approach that works best for you. Take some time for a frank and honest reflection on what the medication you take does for you. Ask your family or friends what they have noticed – the insight of those around us can be invaluable. If you want to change, reduce or stop, then see your GP or the prescribing pharmacist attached to your GP practice, so that they can support you to make any change in a safe and controlled way. If you want to find out more, the NHS GG&C pain service website has links to some resources you may find helpful.
© Lars Williams. First published 4 December 2024. All rights reserved.
What matters to you?
Lars would love to hear what readers think so please do contact him at editorial@painconcern.org.uk.