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Transcript — Programme 123: Opioids and Chronic Pain

Rethink­ing long-term pain management

To lis­ten to this pro­gramme, please click here.

This edi­tion of Air­ing Pain has been sup­port­ed with a grant from Kyowa Kirin donat­ed for this purpose. 

The opi­oid cri­sis reached its peak in the Unit­ed States in 2017, where addic­tion and over­pre­scrip­tion have led to 218,000 deaths from pre­scrip­tion over­dos­es between the years of 1999 and 2017. The side effects of opi­oids can affect the day-to-day activ­i­ties of peo­ple man­ag­ing long-term or chron­ic pain, yet soci­ety as a whole has yet to ful­ly eval­u­ate the rela­tion­ship between opi­oids and addic­tion.  

In this edi­tion of Air­ing Pain, pro­duc­er Paul Evans talks to two lead­ing pain spe­cial­ists. First off, Paul Evans meets with Dr Srini­vasa Raja, who dis­cuss­es opi­oids effects on the body’s opi­oid recep­tors and how the human body process­es pain. Dr Cathy Stan­nard then talks about the increase of opi­oid pre­scrip­tions in the UK and how the opi­oid cri­sis in the Unit­ed King­dom devel­oped. 

In the sec­ond half of the pro­gramme, Paul speaks with Louise Trew­ern, a chron­ic pain patient and patient advo­cate, about opi­oids’ detri­men­tal effect on her qual­i­ty of life and how she was able to tran­si­tion towards more effec­tive meth­ods of chron­ic pain man­age­ment. 

Final­ly, Paul sits down with Dr Jim Hud­dy, a GP in Corn­wall, who explains how the med­ical com­mu­ni­ty is re-eval­u­at­ing the rela­tion­ship between opi­oids and chron­ic pain. 

Issues cov­ered in this pro­gramme include: Can­cer, chemother­a­py, exer­cise, fibromyal­gia, med­ica­tion, neu­ro­path­ic pain, opi­oids, painkillers, phys­io­ther­a­py, pre­scrip­tion for pain, psy­chol­o­gy, side effects and dosage.

Paul Evans: This is Air­ing Pain, a pro­gramme brought to you by Pain Con­cern, the UK char­i­ty pro­vid­ing infor­ma­tion and sup­port for those of us liv­ing with pain and for those who care for us. I’m Paul Evans and this edi­tion of Air­ing Pain has been sup­port­ed with a grant from Kyowa Kirin.

Louise Trew­ern: Hyper­al­ge­sia was one of my biggest prob­lems. I could­n’t have den­tal treat­ment prop­er­ly. I had to have mul­ti­ple injec­tions because they could­n’t numb me. It was grad­u­al­ly, over a peri­od of months, sug­gest­ed to me that the dose I was on was not help­ing me, it was mak­ing me worse, and that a lot of the symp­toms I was suf­fer­ing [from] was as a result of my opi­oid use.

Evans: In this edi­tion of Air­ing Pain, I want to look at the use of opi­oid med­ica­tion for the man­age­ment of chron­ic pain. The so-called opi­oid cri­sis or opi­oid epi­dem­ic in Amer­i­ca came to a head in 2017 when, con­trary to the reas­sur­ances of phar­ma­ceu­ti­cal man­u­fac­tur­ers that patients were less like­ly to become addict­ed and an aggres­sive mar­ket­ing cam­paign, addic­tion, over­dose and death rates soared.

Before we delve into how this affect­ed peo­ple with chron­ic pain in the UK, I want to try and come to grips with some of the sci­ence behind the drugs and how they work. Now opi­ates are nat­u­ral­ly derived from the opi­um pop­py plant. They include mor­phine, codeine, hero­in, and oth­ers, and have been used for med­i­c­i­nal and recre­ation­al pur­pos­es since pre­his­toric times. Opi­oids, on the oth­er hand, which include tra­madol, methadone, pethi­dine, fen­tanyl, and oth­ers, was orig­i­nal­ly coined to denote syn­thet­i­cal­ly sourced opi­ate-like med­i­cines, but con­fus­ing­ly to me any­way, the term opi­oids is now used to also include the nat­u­ral­ly-derived opi­ates. So, for the sake of clar­i­ty, an opi­oid is a com­pound that acts on opi­oid recep­tors in the body. So, what’s an opi­oid recep­tor? Pro­fes­sor Srini­vasa Raja of Johns Hop­kins School of Med­i­cine, Bal­ti­more, in the Unit­ed States is inter­na­tion­al­ly recog­nised for his research into neu­ro­path­ic pain.

Srini­vasa Raja: One of the sci­en­tists and neu­ro­sci­en­tists, Solomon Sny­der, worked on this in the 60s, and he asked what now looks like a very straight­for­ward and sim­ple ques­tion. He knew and most of us, physi­cians or health­care providers, know that drugs such as mor­phine work well in treat­ing pain, par­tic­u­lar­ly things like pain after surgery. So, the ques­tion he said [asked] is: ‘There must be some­thing in the body that should be the site where these drugs are work­ing’. And he found these recep­tors called opi­oid recep­tors, and he found that they were present in mul­ti­ple areas not only in the brain, but [also] in the spinal cord and oth­er sites. You know, one of the ques­tions is ‘What is the role of these recep­tors?’. Are they there only for drugs giv­en by physi­cians to work in the human ner­vous sys­tem? So, you know, the ques­tion he asked is: ‘What is the role of these recep­tors in the body?’. And he came to the under­stand­ing that there are endoge­nous pain con­trol mech­a­nisms, that the body has a way to con­trol pain. And, often, the good exam­ple giv­en is ath­letes who are in the mid­dle of a game – a World Cup – and, you know, can be injured but con­tin­ue to play and don’t per­ceive the pain till the end of the game when they find some­thing that they hurt them­selves. There was a good exam­ple of a US gym­nast who did her last jump with a frac­tured ankle. It was­n’t found until after that. So, I think that the body, espe­cial­ly at times of stress, releas­es endor­phins or these endoge­nous opi­oid pep­tides, which then work on these recep­tors to con­trol pain. So, I think it’s a pro­tec­tive mech­a­nism that for­tu­nate­ly most of us have.

Evans: It’s fair­ly com­mon for top class ath­letes and foot­ball play­ers, rug­by play­ers, who­ev­er to go through what they call the pain bar­ri­er. Why are they more capa­ble of doing that than say, the man or woman in the street?

Raja: Wow, that’s a chal­leng­ing ques­tion. And I think the answer to that is com­plex in the sense that the pain expe­ri­ence is a very per­son­al thing and, giv­en the same injury, dif­fer­ent indi­vid­u­als per­ceive the pain dif­fer­ent­ly in terms of inten­si­ty and emo­tion­al aspects of it. I think [that] as far as the ath­letes [are con­cerned], there may be two rea­sons. One, there may be a bit of train­ing, you know, pri­or expe­ri­ences, say­ing that this injury usu­al­ly lasts for a few days, I’ll be bet­ter and, you know, I need to move on. They go through these repeat­ed injuries, maybe there is a bit of adap­ta­tion to that injury. So, they don’t expe­ri­ence the pain in the same way. The oth­er aspect is, it’s inter­est­ing how peo­ple talk about moti­va­tion and the result of the pain and how you react to the pain may have some impli­ca­tions for an ath­lete. You know, if he exhibits pain, he may be pulled out of the game and maybe he does­n’t want to do that. Sim­i­lar­ly, we noticed that giv­en sim­i­lar injuries in a devel­op­ing world, peo­ple move on because what that means to them is loss of their day’s work, you know, if they don’t go to work, they don’t get paid.

Evans: They don’t have the option of giv­ing up.

Raja: Exact­ly. They don’t have the option. They may be expe­ri­enc­ing the pain, but how they react to that pain expe­ri­ence may be very different.

Evans: Now, there are peo­ple who don’t expe­ri­ence pain. Is there a rela­tion­ship between that and the opi­oid receptors?

Raja: The most com­mon type of absence of pain or that group of patients that have been well stud­ied is not nec­es­sar­i­ly from opi­oid recep­tors, but more so from a spe­cif­ic sodi­um chan­nel that sig­nals pain. But there are muta­tions of the opi­oid recep­tor that have been observed and report­ed in humans. The impli­ca­tions there have been that how these patients may respond to opi­oid med­ica­tions may be dif­fer­ent, and their pain expe­ri­ence after things like surgery may also be different.

Evans: We’ve just had an inter­est­ing case in the news recent­ly of a woman who can’t expe­ri­ence pain. She only knows when her hand is on the hot plate of the cook­er because she can smell it burn­ing, but also, she expe­ri­ences no anxiety.

Raja: That’s an inter­est­ing obser­va­tion. And it tells us that these recep­tor sys­tems in the ner­vous sys­tem are often not hav­ing a sin­gle role. They often have mul­ti­ple roles and they are mul­ti­ple sites. And this is the chal­leng­ing part of basic sci­ence and the trans­la­tion of basic sci­ence to clin­i­cal new drug devel­op­ment. A very good exam­ple of that: there was a lot of work done on what’s now known as the chilli pep­per or hot pep­per recep­tor – the TRPV chan­nels. These chan­nels are well char­ac­terised and drugs were effec­tive – antag­o­nists or drugs that block these recep­tors are very effec­tive in ani­mal mod­els of pain – so much so that it did go all the way up to clin­i­cal tri­als. What was observed in these clin­i­cal tri­als was that these ani­mals devel­oped hyper­ther­mia or increase in body tem­per­a­ture. And this was total­ly unan­tic­i­pat­ed from the ear­li­er stud­ies in exper­i­men­tal ani­mals. Sub­se­quent stud­ies found that not only do these TRPV‑1 recep­tors or chan­nels are involved in pain sig­nalling, but they’re also involved in ther­mal reg­u­la­tion or reg­u­la­tion of body tem­per­a­ture. So, when you block these recep­tors, you do have effects on pain, but you also have an unde­sired effect on body temperature.

Evans: Pro­fes­sor Srini­vasa Raja of Johns Hop­kins School of Med­i­cine, Bal­ti­more, in the Unit­ed States. With the Amer­i­can opi­oid cri­sis com­ing to a head in 2017, The Times news­pa­per warned that ‘the UK is hurtling towards a US style cri­sis’ where super strength painkillers have killed more than 91,000 peo­ple in the past two years. Now, to be clear, NHS guid­ance says that opi­oids are very good anal­gesics for acute pain and pain at the end of life, but there’s lit­tle evi­dence that they’re help­ful for long-term pain. Despite this, they were wide­ly pre­scribed for long-term or chron­ic pain. Opi­oid pre­scrib­ing more than dou­bled in the peri­od 1998 to 2018. Dr Cathy Stan­nard is a lead­ing pain med­i­cine spe­cial­ist now work­ing with the NHS Glouces­ter­shire Clin­i­cal Com­mis­sion­ing Group. She is an inter­na­tion­al­ly-recog­nised expert on aspects of pain man­age­ment and opi­oid ther­a­py in particular.

Cathy Stan­nard: It is a fact that pain and pain pre­scrib­ing has this almost unique posi­tion where peo­ple are left on med­i­cines even if they still have pain. So, if we treat some­body for blood pres­sure, and they come back and their blood pres­sure is still high, we do some­thing else. If some­body is in pain, and they come back and the pain med­i­cines aren’t work­ing, we either put up the dose or just leave patients on it. And it’s very under­stand­able that patients, who are tak­ing med­i­cines but not observ­ing much in the way of pain relief, would make the not unre­al­is­tic assump­tion that if they reduce their med­i­cines the pain would be worse. We know that’s not the case. And often peo­ple can feel bet­ter and more alert and shed side effects when they’re sup­port­ed to come off med­i­cines. But if you’re in a very short, pres­sured med­i­cines use review, if you’re not report­ing active adverse side effects, it’s our expe­ri­ence that nobody will have had a con­ver­sa­tion as to pre­cise­ly how well those med­i­cines are doing what they say on the tin. And, actu­al­ly, that’s where the results are often dis­ap­point­ing. So, it’s not some­thing that can be resolved with a super­fi­cial, you know, what’s this med­i­cine doing? What are the side effects? It is much more com­plex about the way that the med­i­cines are work­ing for that patient.

Evans: The way these things are com­mu­ni­cat­ed to patients is often inter­pret­ed in com­plete­ly the wrong way. The opi­oids are being tak­en away from me. I’m now a drug addict. I’m crim­i­nalised. Maybe the press is at fault, maybe we’re at fault. How do you com­mu­ni­cate these things? The prob­lems the patients are feeling?

Stan­nard: I think that’s real­ly impor­tant. And there’s been a huge fren­zy of vari­able qual­i­ty report­ing, par­tic­u­lar­ly around the opi­oid issues at the moment. And there’s an undoubt­ed pub­lic health dis­as­ter of bib­li­cal pro­por­tions in the Unit­ed States, ini­ti­at­ed by peo­ple tak­ing opi­oid med­i­cines for pain and now mov­ing on to var­i­ous illic­it sub­stances. I think there are lots of pro­tec­tive fac­tors about our own health­care sys­tem in the UK and I think it’s unhelp­ful to make quick deci­sions on the basis of what we see at a Unit­ed States pop­u­la­tion lev­el. I think it is impor­tant to com­mu­ni­cate, with peo­ple using these med­i­cines, what we’re try­ing to achieve. And the most impor­tant mes­sage to get across is that we do not want to expose peo­ple to the harms of med­i­cines that aren’t working,

Evans: How to get it over, you know, this isn’t doing you any good, you will be bet­ter, tak­ing few­er drugs.

Stan­nard: It’s not that easy and nobody finds it easy to have that con­ver­sa­tion. I think it’s about bring­ing peo­ple to that real­i­sa­tion them­selves. So, when I assess a patient, I will spend maybe half an hour talk­ing about the patient, what life is like for that patient liv­ing with their pain, what lim­i­ta­tions that pain brings. Then we get onto the med­i­cines’ his­to­ry. And you know, they may be on sev­er­al med­i­cines and I kind of will say to the patient: ‘You said how dif­fi­cult your pain is and you’re tak­ing these med­i­cines, do you think the med­i­cines are mak­ing much dif­fer­ence?’ And there is a dawn­ing real­i­sa­tion that it’s just like tak­ing Smar­ties – is some­thing that we com­mon­ly hear. We know that patients are fear­ful of reduc­ing because of course, if your pain is bad and you’re on med­i­cines, what if it’s worse? It’s very dif­fi­cult and it depends on the individual’s per­cep­tions and so on. But we do have evi­dence from a huge num­ber of patient reports that, freed from the many bur­dens and side effects, peo­ple feel much more alert, able to engage with their fam­i­lies and engage them­selves in strate­gies which help man­age their pain. So, we know that most of the med­i­cines that we pre­scribed for pain which actu­al­ly stop the way that nerves talk to oth­er nerves do have side effects which make peo­ple sleepy, sedat­ed, gid­dy and so on. And all those things make it very dif­fi­cult to start try­ing to man­age peo­ple’s lives to try and mit­i­gate the effects of long-term pain. It is more about the bal­ance of ben­e­fits and harms and it’s more about get­ting peo­ple to reflect how well they think the med­i­cines are sup­port­ing them, which is often that they’re not.

Evans: Dr Cathy Stan­nard. Louise Trew­ern has lived with pain for most of her adult life. She was pre­scribed opi­oids for over twelve years and was the first inpa­tient at New­ton Abbot Hos­pi­tal in Devon to come off them.

Trew­ern: The day before I went into hos­pi­tal, I had clocked up some­thing like twen­ty-five steps on my pedome­ter, prob­a­bly that was from the bed to my chair, the chair to the bath­room and then back to bed. And I was touch­ing twen­ty-five stones in weight, and my life was pret­ty non-exis­tent by this point. I’d been on opi­oids for over twelve years – high dose. And it was sug­gest­ed over a peri­od of time that I need­ed to come off this med­ica­tion because, in actu­al fact, it was­n’t help­ing me.

Evans: How was it put to you that you should stop?

Trew­ern: It was grad­u­al­ly, over a peri­od of months, sug­gest­ed to me that the dose I was on was not help­ing me, it was mak­ing me worse. And a lot of the symp­toms I was suf­fer­ing was as a result of my opi­oid use. And I def­i­nite­ly – hyper­al­ge­sia was one of my biggest prob­lems. I could­n’t have den­tal treat­ment prop­er­ly. I had to have mul­ti­ple injec­tions because it could­n’t numb me. I could­n’t have the cats walk over my legs, because the pain was intense. And then I suf­fered a cou­ple of quite severe med­ical episodes, which meant I was an emer­gency   admis­sion to hos­pi­tal, which met the cri­te­ria to have me in and get me off these opi­oids. My ini­tial week in hos­pi­tal was where I came— they halved my dose overnight and the doc­tor said to me that, in the morn­ing, your pain will not be any worse, I can guar­an­tee that and I had to put my trust in him and it was true. It was­n’t worse. Since then, we’re talk­ing two years now, I’ve lost sev­en stones in weight. I know walk up to five miles a day. I still live with pain on a dai­ly basis, but I deal with it with­out med­ica­tion apart from per­haps a cou­ple of paracetamol.

Evans: Louise Trew­ern. Jim Hud­dy is a GP. He is Corn­wall Clin­i­cal Com­mis­sion­ing Group Clin­i­cal Lead for Chron­ic Pain.

Hud­dy: Corn­wall has always been a heavy pre­scriber of opi­oid anal­gesics for pain and that is not a good thing because we know that the high­er lev­els of opi­oids in a pop­u­la­tion, then that is asso­ci­at­ed with, well to cut a long sto­ry short, high­er lev­els of mis­ery. So, we real­ly want­ed to bring that lev­el down. A lot of peo­ple talk about reduc­ing dos­es and it is real­ly impor­tant to put out there that there are some peo­ple who are on the right dose for them and we real­ly don’t want to be tak­ing away drugs that work for peo­ple, but what we think from the med­ical side is that the vast pro­por­tion of peo­ple with chron­ic pain who are on opi­oid med­ica­tions, those med­ica­tions prob­a­bly aren’t work­ing very well. And, more impor­tant­ly, if they were on a much low­er dose or pos­si­bly even off the drugs, then not only would they feel bet­ter but their lives would get bet­ter. So, that’s why there is a big empha­sis on this. It’s not pure­ly a mon­ey-sav­ing exer­cise although it does save a lot of mon­ey which we can then sort of put into oth­er direc­tions which is quite excit­ing, but it real­ly, hon­est­ly, and sci­ence does back this up, but a lot of the time peo­ple don’t feel any worse or a lot of peo­ple talk about get­ting their lives back, and that’s par­tic­u­lar­ly if they are on very high dos­es. The Fac­ul­ty of Pain Med­i­cine have put out what I describe as a ‘nation­al speed lim­it of dose’ and that is 120mg of mor­phine and over this dose the sci­ence is clear that this is going to be more dam­ag­ing than good for you. So, that group of patients who might be on 200, 500, maybe even up to 1000mg of mor­phine per day are very like­ly to be more harmed than ben­e­fit­ed by that. But the prob­lem with those drugs is that they have effects on the mind and the body that make the mind and body need their dos­es each day. And the idea of reduc­ing or stop­ping the drug is so scary for patients that, very often, they don’t believe that that’s in their best inter­est. So, it’s a very inter­est­ing and chal­leng­ing con­sul­ta­tion, where some­times the doc­tor and the patient have very oppos­ing views, but we have got some expert patients that are help­ing us and, actu­al­ly, we’ve got a video from NHS Eng­land that’s about to be released of one of our patients called Sean, and there’s a lit­tle bit of me on this video, that tells Sean’s sto­ry. It’s only a three- or four-minute lit­tle bite that could be watched in con­sul­ta­tions and Sean’s absolute­ly engag­ing with explain­ing his sort of epiphany of life could be bet­ter with­out these strong drugs. And now he’s not on the strong drugs and he’s back on his jet-ski. It’s a great sto­ry. And that’s why we believe a lot of peo­ple out there would have bet­ter lives if they’re depre­scribed their medication.

Evans: It’s a conun­drum, isn’t it? The fact that peo­ple are on these high­er dos­es of opi­oids pre­scribed by their doc­tors. Did that last one work? No, have a bit more, have a bit more again, have a bit more again. So, doc­tor has said this is good for me. And now doctor’s say­ing it’s not good for me?

Hud­dy: Yes.

Evans: How do you square that circle?

Hud­dy: Yes. Well, the way I explain it to patients is that, you know, med­ical and med­ical under­stand­ing, med­ical beliefs are an ever-chang­ing field and for var­i­ous rea­sons, which aren’t very sort of whole­some or par­tic­u­lar­ly nice. I think over the last ten, twen­ty, thir­ty years pain spe­cial­ists were led to believe by drug com­pa­nies that if you give high enough dos­es of opi­oid med­ica­tions, you will get peo­ple pain free, and it’s their right to be pain free. And this was when I was at med­ical school in the mid-90s. This is what was taught to us the WHO anal­gesic lad­der, you keep going up the lad­der until you get some­one pain free. And we all believed that that was the way to go. We now don’t believe that. We now kind of know from the sci­ence that the data that that was based on was flawed, let’s put it polite­ly. And, more recent­ly, we’re get­ting research that is show­ing that, just as you described, when you start these med­ica­tions very often there is a, there’s a tem­po­rary ben­e­fit that then wears off. So, then, you have a dose increase and there’s a tem­po­rary ben­e­fit which then wears off and, just as you described, peo­ple get on high­er and high­er dos­es and some­times some very, very high dos­es. Now what’s real­ly tricky is that when you do the reverse process, the reverse process hap­pens. So, when you drop the dose, their pain gets worse for a bit, and then it goes back to the base­line, and then you drop the dose again, and the pain gets worse. So, we are embark­ing on a treat­ment sched­ule which might, you know, go on for six, nine or twelve months. It has to be done slow­ly and the patient has to realise that, you know, there is a bit of a storm com­ing, this isn’t going to be an easy ride. But the ben­e­fits at the end of it, if you talk to the patients who’ve done it, are worth that pain. But for a doc­tor to be sug­gest­ing a man­age­ment approach for the next few months that’s going to be painful for you is quite a tricky one. That’s not what we’re trained to do. And it is a com­plex and quite chal­leng­ing con­sul­ta­tion that I cer­tain­ly haven’t mas­tered. I’m, you know, try­ing to per­fect it and some patients are more up for it than oth­ers, but they do have to believe and we do believe that hav­ing alter­na­tives to make things eas­i­er dur­ing this process is a real­ly impor­tant part, which is why we’re empha­sis­ing alter­na­tives to pills at the moment.

Evans: That’s GP Jim Hud­dy. Louise Trew­ern, hav­ing been the first inpa­tient to come off opi­oids at New­ton Abbot Hos­pi­tal in Devon, is now work­ing with a doc­tor to help her to help oth­ers reduce or give up their opi­oid use for the man­age­ment of their chron­ic pain.

Trew­ern: I am work­ing with the doc­tors that helped me come off the opi­oids and back twelve months after that because I need­ed that long to recov­er as it were. I’ve been work­ing with them, and it’s a mul­ti­dis­ci­pli­nary group, on a com­mit­tee called the Ratio­nal Use of Opi­oids. So, I’m help­ing the team make patient leaflets and videos for the web­site, this is in Tor­bay, for prop­er use of opi­oids, which will hope­ful­ly help those that don’t seek help and those that do, inpa­tient and out­pa­tient leaflets. So, because the things I expe­ri­enced, both before and after, are not all in the jour­nals, they’re not, it’s not all writ­ten down. Some things they’ve heard about, but they did­n’t know for sure that it was hap­pen­ing. And it’s not just me. There’re sev­er­al patients now in Tor­bay that they’ve helped since and it’s just that I was the first inpa­tient that they did this with. So where­by cer­tain things they thought would hap­pen, they’re now going to put this in a warn­ing in the leaflet. You know, if you come off opi­oids too quick­ly, this could hap­pen. And we’ve been told this hap­pens and not nec­es­sar­i­ly to every­body but it, it can hap­pen, just so that peo­ple are aware of the dan­gers. You can’t just stop these drugs, but not every­body knows this. So, they’re tak­ing my expe­ri­ence plus, putting it togeth­er with the med­ical side and phys­i­cal ther­a­py. All the dif­fer­ent areas are com­ing togeth­er to make these leaflets that will be cir­cu­lat­ed in GP surg­eries and on the web­site. And so yeah, it is work­ing. And I’m sure with Tor­bay, it’s not just in this with opi­oids, it’s with oth­er things as well. And so yeah, it’s hope­ful that, that will con­tin­ue and it needs to be coun­try­wide, I think.

Evans: So rather than like the leaflets we get in all our packs of med­i­cines and tablets, they list all the every­thing that could hap­pen to you and more. These are com­ing from your voice. This is, this has hap­pened to me. And this is what can hap­pen after.

Trew­ern: That’s it and one of the key things that we’ve gone out of our way to make sure of is that, between the team, the lan­guage is what can be under­stood by the per­son tak­ing those opioids.

Evans: Louise Trew­ern and there is infor­ma­tion on the use and with­draw­al of opi­oid med­ica­tion at Tor­bay and South Devon NHS Trust Pain Ser­vices web­site. I just entered the words ‘Devon’, ‘pain’ and ‘ser­vice’ into my search engine to get me there. In neigh­bour­ing Corn­wall, where Jim Hud­dy is a GP, the over­pre­scrib­ing of opi­oids has come down by 18% in three years.

Hud­dy: An 18% reduc­tion is a much big­ger reduc­tion than most of the CCGs in the UK and we assume that a large part of that is because of the work that we’ve done.

Evans: So, what has brought that down?

Hud­dy: Some of this is assump­tion and some of this is hope. But we also think that some of it is log­i­cal, that a lot of our work has been based around GP edu­ca­tion, and GP edu­ca­tion that the way to deal with some­one who’s got chron­ic pain is not to just reach straight for the pre­scrip­tion pad, which is our ten­den­cy as doc­tors because that’s kind of how we’re trained. We decid­ed to write some infor­ma­tion for patients and write infor­ma­tion for doc­tors, and we did that, and it was all bril­liant, and we pub­lished it on one of our web­sites, and no one read it because it was long-wind­ed and every­one’s busy. At that point, we thought, okay, we need to rethink this. So, we decid­ed to move in a direc­tion of video edu­ca­tion. So, we’ve now made three videos, main­ly for pre­scribers, real­ly, we’re going to move on from that in time. But the videos that we’ve got, one is about sort of safe opi­oid pre­scrib­ing, one is about safe depre­scrib­ing of opi­oids. It’s quite a sort of chunky thing. It’s about half hour of like me nar­rat­ing a Pow­er­Point pre­sen­ta­tion about iden­ti­fy­ing what patients might be right for depre­scrib­ing and how to engage them and how to do it safe­ly and how to sup­port them dur­ing it and also con­sul­ta­tion skills and prac­tice-based strate­gies. How to make your­self more robust against patients that might be quite keen on con­tin­u­ing their dos­es, let’s say. Then the third video that we’ve done more recent­ly is enti­tled ‘If I don’t pre­scribe, what do I do?’, which starts intro­duc­ing ideas of how to talk about self-man­age­ment as a strat­e­gy for chron­ic pain, mov­ing away from pills and tools, the alter­na­tives. We split up the rest of the video into twelve mini-sec­tions because if you suf­fer from chron­ic pain, Frances Cole’s work has sug­gest­ed to us that there are twelve con­se­quences of chron­ic pain, you’re very like­ly to be suf­fer­ing from one or maybe all of them – things like phys­i­cal inac­tiv­i­ty, social iso­la­tion, sleep­less­ness, emo­tion­al prob­lems, rela­tion­ship prob­lems, work-relat­ed prob­lems, and there are twelve of these things. So, we’ve split up the rest of the video just going through each of those one by one and giv­ing the doc­tors ideas of what can be done and, more cru­cial­ly, on our web­site, we’ve got writ­ten infor­ma­tion for patients which is in elec­tron­ic for­mat. It’s kind of crude because our web­site is kind of crude and basic, and that’s some­thing that we want to work on. We slight­ly sort of grandiose­ly called it ‘Chron­ic Pain – The Answers’ and it goes through each of these twelve con­se­quences of pain and gives the read­er just things that we’ve cob­bled togeth­er from online stuff and Corn­wall-based stuff of what would be rel­e­vant to sleep for exam­ple, or to emo­tion­al stuff or ‘boom and bust’ stuff, the stuff that you, you know all about, but try­ing to bring it all togeth­er into one place.

Evans: Jim Hud­dy, Corn­wall Clin­i­cal Com­mis­sion­ing Group Clin­i­cal Lead for Chron­ic Pain. Now the web­site address for those resources is a bit of a mouth­ful. So, I sug­gest you put ‘opi­oid pre­scrib­ing for chron­ic pain Corn­wall’ into your search engine. It’s well worth a vis­it. As always, I’ll just remind you that, whilst we in Pain Con­cern believe the infor­ma­tion and opin­ions on Air­ing Pain are accu­rate and sound, based on the best judg­ments avail­able, you should always con­sult your health pro­fes­sion­al on any mat­ter relat­ing to your health and well-being. He or she is the only per­son who knows you and your cir­cum­stances and there­fore the appro­pri­ate action to take on your behalf. You can find all the resources to sup­port the man­age­ment of chron­ic pain includ­ing details of our helpline, videos, leaflets, all edi­tions of Air­ing Pain and Pain Mat­ters mag­a­zine at Now, last words of this edi­tion of Air­ing Pain to Louise Trew­ern about her jour­ney with opioids,

Trew­ern: I’m choos­ing not to be upset about it, because I think the doc­tors at the time that pre­scribed it were work­ing with the infor­ma­tion they had at the time. Now, of course, we know that long-term use of opi­oids does­n’t help chron­ic pain con­di­tions at all. And so, I’m try­ing to get the mes­sage out there that there are oth­er ways of cop­ing with your pain oth­er than just tak­ing painkillers.


  • Dr Srini­vasa Raja, Pro­fes­sor of Anaes­the­si­ol­o­gy and Crit­i­cal Care Med­i­cine and Neu­rol­o­gy at the Johns Hop­kins Uni­ver­si­ty School of Med­i­cine, Mary­land, USA  
  • Dr Cathy Stan­nard, Con­sul­tant in Pain Med­i­cine and Pain Trans­for­ma­tion Pro­gramme Clin­i­cal Lead for NHS Glouces­ter­shire Clin­i­cal Com­mis­sion­ing Group 
  • Louise Trew­ern, Vice Chair of the Patient Voice Com­mit­tee at the British Pain Soci­ety 
  • Dr Jim Hud­dy, Corn­wall GP and Clin­i­cal Lead for Chron­ic Pain at NHS Ker­now Clin­i­cal Com­mis­sion­ing Group. 

More infor­ma­tion:

With thanks to:

  • The British Pain Soci­ety (BPS), who facil­i­tat­ed the inter­views at their Annu­al Sci­en­tif­ic Meet­ing in 2019 —
  • The Inter­na­tion­al Asso­ci­a­tion for the Study of Pain (IASP)

Tran­scrip­tion by Nathalie Johnstone