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Transcript – Programme 54: Opioids, Memories and Prison Healthcare

Delv­ing into the issues sur­round­ing opi­oids and health­care with­in pris­ons and inves­ti­gat­ing the rela­tion­ship between mem­o­ry and pain

To lis­ten to this pro­gramme, please click here.

 Paul Evans talks to Dr Cathy Stan­nard, a Con­sul­tant in Pain Med­i­cine at Fren­chay Hos­pi­tal in Bris­tol, who out­lines the use and mis­use of opi­oids in chron­ic pain man­age­ment. She points out that whilst opi­oids are a use­ful anal­gesic for some peo­ple, they can have a detri­men­tal effect on oth­ers due to their strong side effects. She empha­sis­es the need for health­care pro­fes­sion­als to be aware of how to use opi­oids effec­tive­ly as a pain man­age­ment resource.

Paul also meets Dr Rajesh Munglani, a Con­sul­tant in Pain Med­i­cine in Cam­bridge, who has car­ried out research into the rela­tion­ship between pain and mem­o­ry. He describes chron­ic pain as a cir­cuit that can be trig­gered by seem­ing­ly small events or mem­o­ries and high­lights the impor­tance of con­text and mem­o­ries on pain. He explains that med­ical or psy­cho­log­i­cal inter­ven­tion is need­ed to dis­rupt the cir­cuit of pain.

Then Paul speaks to Dr Cathy Stan­nard and Dr Ian Brew, a prison GP, about health­care with­in pris­ons. Stan­nard reveals some prob­lems in this area, say­ing that some med­i­cines are a trad­able com­mod­i­ty in pris­ons and that often pris­on­ers’ accounts of pain are treat­ed with mis­trust. She reports that the sit­u­a­tion is improv­ing, as the health­care needs assess­ment that pris­on­ers receive when they arrive in prison now includes a sec­tion on pain, along­side the orig­i­nal sec­tions on sub­stance mis­use and psy­chi­atric dis­or­ders. Dr Ian Brew empha­sis­es that pris­on­ers deserve to receive the same qual­i­ty of health­care as those out­side of prison and says evi­dence sug­gests that good health­care, along­side oth­er reha­bil­i­ta­tion ini­tia­tives in pris­ons, can reduce the rate of re-offending.

Issues cov­ered in this pro­gramme include: Opi­oids, side effects, edu­cat­ing health pro­fes­sion­als, prison, pain mem­o­ry, psy­chol­o­gy, drug overuse, drug mis­use, dosage, over-pre­scrip­tion, under-pre­scrip­tion, trig­gers, sen­so­ry mem­o­ry, asso­ci­a­tions, ampu­ta­tion, phan­tom limb pain, neu­ro­path­ic pain, med­ical research, psy­chi­atric dis­or­der, men­tal health, con­fi­dence and self-esteem.

Paul Evans: Hel­lo. Wel­come to Air­ing Pain, a pro­gramme bought to you by Pain Con­cern, a UK based char­i­ty work­ing to help, sup­port and inform those of us who live with pain and health­care pro­fes­sion­als. This addi­tion has been sup­port­ed by a grant from the Scot­tish Government.

Opi­oids are drugs which either come from the opi­um pop­py plant or are chem­i­cal­ly relat­ed to those made from opi­um. Stronger opi­oid drugs include the likes of mor­phine and fen­tanyl. Their use, overuse or abuse still cre­ates con­fu­sion amongst patients and some health pro­fes­sion­als. Dr Cathy Stan­nard is a con­sul­tant in pain med­i­cine at Fren­chay Hos­pi­tal in Bris­tol. A lead­ing expert in the use of opi­oids, she was chair of con­sen­sus group and edi­tor of the British Pain Soci­ety guide­lines on Opi­oids for Per­sis­tent Pain: Good Prac­tice. In 2013 she gave a lec­ture to the soci­ety under the head­ing ‘When the cure is worse than the dis­ease: strate­gies for safe opi­oid prescribing’.

Dr Cathy Stan­nard: What is behind all that is that, par­tic­u­lar­ly in North Amer­i­ca, they have a huge prob­lem with mis­use of pre­scrip­tion drugs and I think that’s large­ly about dif­fer­ent choic­es that drug users make and the avail­abil­i­ty of pre­scrip­tion drugs is much eas­i­er, for exam­ple, in get­ting hold of hero­in in the States, so pre­scrip­tion drugs are com­mon­ly a drug of abuse.

Now, this had led to a great deal of pub­lic and pol­i­cy con­cern about the amount of pre­scrip­tion drugs I guess out there in the sys­tem. So what’s hap­pen­ing is that there’s been a great move to restrict clin­i­cians or to try and edu­cate clin­i­cians to very much focus on who and for how long they tar­get opi­oid med­i­cines for. Now the thing that’s a real pub­lic health prob­lem, and I’ve worked with col­leagues in the States,  and I think they are tack­ling it respon­si­bly – but I think what is a risk here is that we are con­cerned about what essen­tial­ly are drug mis­use prac­tices in the States and maybe let that influ­ence undu­ly our deci­sion to treat the patient that’s in front of us, who actu­al­ly might ben­e­fit from opi­oids. Now, I think how it gets com­pli­cat­ed is that as many peo­ple under­stand, chron­ic pain is real­ly dif­fi­cult to treat and what we end up doing most of the time is sup­port­ing peo­ple in their self-man­age­ment strate­gies to improve their qual­i­ty of life and all the var­i­ous things we offer patients in terms of med­ical inter­ven­tion are not very helpful.

So almost any sort of inter­ven­tion you think of, whether it’s a tablet or what­ev­er will help about a third of peo­ple. Now that means that even very strong med­i­cines like mor­phine are not going to help every­body: there are going to be more peo­ple that they don’t help than they do help. And there are quite a lot of side effects of the drug. And I guess that what I am try­ing to sup­port is the idea that we don’t put peo­ple on mor­phine-like drugs and because there is noth­ing else, leave them exposed to all the harms of those drugs. But that we assess peo­ple and if they are help­ing, if the drugs are help­ing to improve qual­i­ty of life, we sup­port them on stay­ing on them. But if they are not help­ing we take them off. And I think it’s just about try­ing to tar­get what is quite a strong class of med­ica­tion with quite a lot of side effects, just try­ing to tar­get it to peo­ple who are def­i­nite­ly get­ting the benefit.

Paul Evans: So is there or was there a dan­ger, that if the mor­phine is not work­ing now then just ‘up the dose and up the dose and just keep going’?

 Dr Cathy Stan­nard: No, and I think it is a very inter­est­ing point and I think that’s maybe where we’ve got­ten in a bit of mud­dle because the tra­di­tion­al teach­ing over decades ago for treat­ing patients with can­cer-relat­ed pain at the end of life, is if the cor­rect dose is enough. So, if the first dose doesn’t work, then dou­ble it, and dou­ble and dou­ble it. Now that would maybe work well for can­cer pain in the short term at the end of life, so this is not for can­cer pain with patients who have a long prog­no­sis. It might also work for very short term pain like post-oper­a­tive pain.

But I think that’s a real­ly impor­tant point because what we know from the lit­er­a­ture about dos­es for long term pain is that there comes a point at not a very high dose, where when you put the dose up you get more harms but you real­ly don’t get any more ben­e­fit. So there is a ratio­nale for start­ing some­body on a drug and then adjust­ing upwards a few times to get to a rea­son­able dose, but there comes a point when there’s not going to be a ben­e­fit in tak­ing the drug high­er and I think that part of the prob­lem is that peo­ple have bor­rowed from what we know about can­cer pain and felt that if a drug isn’t work­ing it’s because it’s not being giv­en in enough dose and the drug dose goes up and up and up and even­tu­al­ly the dose gets turned up to a lev­el that is just not help­ful to people’s qual­i­ty of life, because they can’t con­cen­trate, they can’t invoke self-man­age­ment strate­gies and they have oth­er side effects.

Paul Evans: I was speak­ing to some­body few weeks ago, who I sus­pect is in that sit­u­a­tion and he is des­per­ate­ly try­ing to reduce his dose to come off the drugs so that he could main­tain some qual­i­ty of life but bal­ance the pain along with it. Is that usual?

 Dr Cathy Stan­nard: I think that is and I talk a lot to pre­scrib­ing doc­tors about this, and actu­al­ly I think patients have a much bet­ter under­stand­ing. Because I can have a con­ver­sa­tion with the patients about this and they will get it imme­di­ate­ly and what I might say is that a patient might come to me and they would come to my ser­vice because they had pain that was impair­ing their qual­i­ty of life. If they come to me with pain and they are on a very high dose of an opi­oid med­ica­tion, I say to them well, it’s not work­ing because they’ve got pain. And I point out that if it’s not work­ing they might be bet­ter not tak­ing it.

So there are sort of two health states: you can have a cer­tain amount of pain and be on a lot of med­ica­tion or you could come off the med­ica­tion and be in the same amount of pain. And actu­al­ly, as soon I explain it like that, with­out excep­tion patients say, ‘when can I start? How can I come off?’ And I think that’s some­thing we all want to do as pre­scribers. If a patient is on a high dose and it’s not help­ing – and this doesn’t just apply to opi­oids, it applies to all the oth­er drugs that patients take to sup­port their pain man­age­ment – is to try bring­ing it off and see what hap­pens. And you might bring it off and find the pain’s a lot worse, in which case it has been help­ing more than you think. But then when your pain doesn’t get worse when you come off, it’s great ‘cause you stay off it and you are freed from all the side effects of that drugs which in them­selves can impair your qual­i­ty of life.

Paul Evans:  Dr Cathy Stan­nard and we will be hear­ing from her a lit­tle lat­er in this pro­gram. I’ll just remind you that whilst we at Pain Con­cern believe the infor­ma­tion and opin­ions on Air­ing Pain are accu­rate and sound, based on the best judge­ments avail­able, you should always con­sult your health pro­fes­sion­al on any mat­ter relat­ing to your health and well­be­ing. He or she is the only per­son who knows you and your cir­cum­stances and there­fore the appro­pri­ate action to take on your behalf.

Dr Rajesh Munglani is a con­sul­tant in Pain Med­i­cine in the Cam­bridge area. He was also a lec­tur­er in the Uni­ver­si­ty of Cam­bridge where he ran a lab­o­ra­to­ry look­ing at the mech­a­nisms of chron­ic pain. So straight to the heart of the mat­ter, what are they?

 Dr Rajesh Munglani: I actu­al­ly got into my research look­ing at mem­o­ry for­ma­tion and my ini­tial ques­tion of that many years ago was, can you remem­ber under anaes­the­sia. If you’re hav­ing an oper­a­tion, can you form mem­o­ries and what we showed is that in fact you can in cer­tain sit­u­a­tions form mem­o­ries despite the fact that you are not aware of what is going on. That is called implic­it mem­o­ry for­ma­tion. Now the inter­est­ing thing is that as soon as I start­ed doing the research I realised – and because my oth­er inter­est was pain – that pain is a mem­o­ry. And it is the same sort of thing, that if you, for exam­ple, have a real­ly nice meal at a hotel and you … the smell of the restau­rant you find that to re-expe­ri­ence that rather nice event, say, a few months lat­er all you need is one smell, the smell of the food, and that will re-evoke the whole atmosphere.

In the same way chron­ic pain is a mem­o­ry. It’s a cir­cuit that’s been set up and it doesn’t take much to keep it going. You don’t have to have the ini­tial trau­ma, say it was an acci­dent or an oper­a­tion. You can have just very light touch­es that set the whole thing off or a cer­tain move­ment or a cer­tain unpleas­ant expe­ri­ence that you expe­ri­ence emo­tion­al­ly, and it will set off the whole pain expe­ri­ence. If you say, ‘does that mean it is not real?’ The answer is ‘no’, it’s actu­al­ly very real because every­thing in our brain is relat­ed to mem­o­ry, that’s our iden­ti­ty. I don’t know if you remem­ber see­ing Blade Run­ner, and the guy realis­es that the robots all have mem­o­ries. And they don’t know they’re robots because the mem­o­ries have been implant­ed and then he has to think about his own and he’s sit­ting there play­ing the piano and look­ing at all the pho­tographs, and it is real­ly quite an impor­tant con­cept that what we are deal­ing with and what we are try­ing to dis­rupt if we need to is that cir­cuit. And there are a lot of dif­fer­ent ways of dis­rupt­ing that circuit.

Paul Evans: So, I could go to a con­cert and I could expe­ri­ence won­der­ful a vio­lin sym­pho­ny and there would be some­body cough­ing next to me, some­body smelly next to me and I could go home and lis­ten to the CD of that and I might have a com­plete­ly dif­fer­ent expe­ri­ence. Or per­haps when­ev­er I lis­ten to that music again I would have the smelly, noisy experience.

 Dr Rajesh Munglani: Absolute­ly. It’s been mod­i­fied and you can mod­i­fy it and that’s actu­al­ly a very inter­est­ing way that you may have lis­tened to that sym­pho­ny in the past and you had a real­ly nice attach­ment to it but then sub­se­quent­ly it is mod­i­fied. One of the ways of an unpleas­ant mem­o­ry being tack­led is through the psy­cho­log­i­cal approach­es, and what you attach to that mem­o­ry sub­se­quent­ly. And lots of dif­fer­ent tech­niques are called – and some psy­chol­o­gists will be able to talk about this in a bet­ter way than I – but, for exam­ple, refram­ing, and you put dif­fer­ent con­texts around and dif­fer­ent mean­ing to that mem­o­ry. And it’s very clever. I mean, it works for some peo­ple and doesn’t work at all for oth­ers. Oth­er peo­ple you have to just mod­i­fy with drugs, try­ing to get rid of the cir­cuit, and oth­er peo­ple of course…

What I do, I spend my time find­ing the trig­gers, like we talked about the smell that evokes the restau­rant. There are some­times in the body lit­tle trig­gers that set off the cen­tral pain state and they’re called periph­er­al trig­gers and the posh word is periph­er­al main­te­nance of cen­tral sen­si­ti­za­tion. Some­thing from the periph­ery feeds in, keep­ing the whole thing going. And so what we can do is – as well as work­ing on the cen­tral mem­o­ry and mod­i­fy­ing it through, say, psy­chol­o­gy, through drugs – you can do some­thing with a periph­er­al trig­ger. You can, for exam­ple, kill it off, numb it as I do some­times, Botox it, take away the mus­cle spasm, and we know that that is not the whole pain but that’s all you need, is to take down the evok­ing of that memory.

Paul Evans: Lots of peo­ple give the exam­ple – and you may have giv­en it as well  – that if I stamp on your toe and tell you ‘oh, by the way, some­body has stolen all your mon­ey and your bank has gone bust’, you will feel quite a lot of pain. But if I stamp on your toe and I say, ‘oh and you won the lot­tery too,’ the pain might not be so severe. So the pain isn’t finite; it’s every­thing else that feeds into it.

 Dr Rajesh Munglani: Absolute­ly, it’s a very, very impor­tant point, the con­text of suf­fer­ing is very impor­tant. If you have a mem­o­ry of a pain and it’s asso­ci­at­ed with, for exam­ple, deeds of val­our and you came out of it well. I mean, when I treat mil­i­tary guys, this is inter­est­ing – the way they stand up to cer­tain pains, because of the con­text of the pain meant there was mean­ing to what they did, mean­ing to the out­come. It doesn’t always work but this is – and it’s not meant to sound con­dem­na­to­ry to any­body else – but if you had that expe­ri­ence like hav­ing your leg blown off – I have seen peo­ple who, for exam­ple, had stepped on mines, had an ampu­ta­tion and still have severe phan­tom limb pain but they are now rid­ing hors­es, run­ning event com­pa­nies. They have got back to nor­mal life.

You see, oth­ers who have lost their leg in a road traf­fic acci­dent [have] deep anger at the drunk dri­ver involved who caused this to hap­pen and the focus for them very much becomes the court case, the anger at the dri­ver being allowed to go off with a rel­a­tive­ly lit­tle fine, which often hap­pens, and they have got the pain in the leg still. So you have this awful sit­u­a­tion of try­ing to help them move on from that expe­ri­ence and of course that is where refram­ing that whole expe­ri­ence, try­ing to get them to come to terms with the pain is part of the heal­ing process and let­ting them move on – and peo­ple do move on.

But some­times you get stuck, and you can get stuck phys­i­cal­ly because the pain is just too severe to deal with. Because one of the issues is, if the pain is that severe, your brain can­not move on, the stump is painful. Every time the stump hurts, it trig­gers a whole phan­tom limb expe­ri­ence, it trig­gers the mem­o­ry of the acci­dent and you can’t get them to move on and they can’t do it for them­selves. So this is where lots of inter­ven­tions – do you numb the end, do you kill off some nerves, do you put in a pump in their back? As well as help­ing them move on with say, the court case, the med­ical or legal process, all of that needs to end to help them move on with their lives. Oth­er­wise they are trapped. They are in a prison.

Paul Evans:  Dr Rajesh Munglani, well from the prison of the mind to the phys­i­cal prison of four walls, locks and keys. We heard Dr Cathy Stan­nard talk­ing ear­li­er about the issues sur­round­ing the use of opi­oids. At the same British Pain Soci­ety Annu­al Sci­en­tif­ic Meet­ing, she and Dr Ian Brew launched a Nation­al Guid­ance for pre­scrib­ing non-med­ical man­age­ment of chron­ic pain in secured environments.

 Dr Cathy Stan­nard: The new prison guide­lines are a project that I have been involved in. I’ve been inter­est­ed in it, actu­al­ly for the whole area for about a decade. And what has dri­ven me to want to do some­thing about this is hear­ing the sto­ries of patients who have got very gen­uine pain com­plaints but who are not believed in pris­ons and have their pain man­aged poor­ly. And I think chron­ic pain is a great vul­ner­a­bil­i­ty for some­body in a secure envi­ron­ment. Now one of the prob­lems around all this is that although there lots of strate­gies – I mean, we do not only use med­ica­tions in pain man­age­ment, med­ica­tions do play a part in pain man­age­ment – but the nature of the med­ica­tions that we use make them in essence a trad­able com­mod­i­ty with­in the prison set­ting where par­tic­u­lar­ly illic­it drugs are now much more dif­fi­cult to get hold of. So I think hith­er­to peo­ple who are work­ing in secure envi­ron­ment have been con­cerned about the overuse of the med­ica­tions because of the risk as well that that pos­es the patient in pain for being bul­lied or coerced and hav­ing their med­ica­tions being tak­en away. And I think that this has result­ed in peo­ple prob­a­bly under-prescribing.

And I think also that as with many health­care sys­tems there is not always a good under­stand­ing about man­age­ment of per­sis­tent pain. And so I think there is quite a learn­ing curve for peo­ple work­ing in secure envi­ron­ments to under­stand about per­sis­tent pain, to under­stand about the caus­es, what it is, how to diag­nose it, the effect it has on people’s lives. And what the piece of guid­ance is about – it’s just a sim­ple piece of guid­ance but a lot of it is about assess­ment and under­stand­ing patients’ pain and under­stand­ing the influ­ences on patients’ pain. And hav­ing made that assess­ment we then try to talk about appro­pri­ate evi­dence-based treat­ment pathways.

And real­ly what’s quite inter­est­ing about the project is it’s con­sid­ered a kind of  risky con­text in which to pro­vide pain man­age­ment ser­vices but I think it’s focused every­body very much on think­ing about qual­i­ty and about best prac­tice. And large­ly the sorts of rec­om­men­da­tions we make about pain man­age­ment in secure envi­ron­ments would real­ly very much stand up for pain man­age­ment in the community.

But I think one thing I would say that’s quite impor­tant, because there might be mis­un­der­stand­ing about this, is that some drugs for pain are more pop­u­lar as a com­mod­i­ty in prison than oth­ers. And what we have said in the guid­ance is if a patient is assessed as hav­ing pain, and if a less risky drug is more like­ly to help, giv­en that not all drugs help, we would always start with the less risky drug. It’s bet­ter for the patient, because they will not be bul­lied or coerced for their med­ica­tion. And we would be choos­ing that drug not just on the grounds of its trad­abil­i­ty but because we have it as the best bet for man­ag­ing pain. Now, if that doesn’t work we would then move down the list. The drugs down the list may be less good for man­ag­ing pain, but are also some­what more risky in that setting.

So actu­al­ly it’s turned out in a way I think quite well that the less risky drugs are the more effec­tive drugs. And what we hope is that… we had a lot of con­tacts from groups who have read this guid­ance who tell us very sad tales about peo­ple who had very poor treat­ment of pain in prison. But actu­al­ly I think that what is a good road test is when I plug in all those patients nar­ra­tives to this piece of guid­ance, in every case the patient would have had a much bet­ter deal if they had been man­aged accord­ing to this guidance.

And I think we have the pol­i­cy mak­ers behind us and one of the things that I think is very impor­tant is that on recep­tion into prison, patients are giv­en a needs assess­ment in rela­tion to their health, and a lot of that is often around sub­stance abuse and relat­ed dis­or­ders, psy­chi­atric dis­or­ders. But actu­al­ly now pain is going to be right there with­in the few min­utes of assess­ment and ask­ing pris­on­ers if they have pain and then assess­ing that, eval­u­at­ing it and mov­ing them on down through appro­pri­ate pain man­age­ment path­way. So I think it will take time, but I am very reas­sured. I have been going around the coun­try to do dif­fer­ent group­ings of prison health pro­fes­sion­als and com­mis­sion­ers of health ser­vices. And every­one is ter­ri­bly enthu­si­as­tic to take this up, real­ly keen, soak­ing it up like a sponge. And I think peo­ple real­ly want to change things and make things bet­ter. So,  I would real­ly hope  that the sort of bad sto­ries that we hear now will become much few­er and far between as this becomes much more embed­ded in reg­u­lar practice.

Paul Evans: One of Dr Cathy Stannard’s col­lab­o­ra­tors in those Nation­al Guid­ance for pre­scrib­ing and non-med­ical man­age­ment of chron­ic pain in secure envi­ron­ments was Dr Ian Brew. He is a GP who has been work­ing in pris­ons since 2001.

 Dr Ian Brew: We have spent the last 10 years main­stream­ing prison prac­tise so that pris­on­ers hope­ful­ly get pri­ma­ry care equiv­a­lent to that that they receive out­side, which cer­tain­ly wasn’t always the case . It’s a chal­leng­ing envi­ron­ment. There is lots of learn­ing to do along the way but it’s a fas­ci­nat­ing envi­ron­ment with a very vul­ner­a­ble group of patients who real­ly deserve the best health­care. And there is some evi­dence that good health­care can reduce reof­fend­ing rates by giv­ing some of the patients some self-esteem which they have long lacked.

Paul Evans: What are the main dif­fer­ences, then, between your com­mu­ni­ty and an out­side community?

 Dr Ian Brew: The com­mu­ni­ty is very sim­i­lar. The biggest dif­fer­ence is that 70% of our patients are drug users or drug depen­dant, and about 10% are alco­holic, and a very large con­cen­tra­tion of men­tal health prob­lems. It’s sad that up to 90% of the patients in prison have a diag­nos­able men­tal health prob­lem. So it’s sim­i­lar to an out­side com­mu­ni­ty, but more con­cen­trat­ed men­tal health prob­lems, I would say.

Paul Evans: In terms of chron­ic pain, how does that affect prisoners?

 Dr Ian Brew: Chron­ic pain is a big prob­lem for a lot of our patients. Their opi­oid abuse may make them more sus­cep­ti­ble to pain and may make them less able to cope with pain when it comes along. Some of the med­ica­tions that are used in chron­ic pain are very desir­able to drug users because of the oth­er effects that they get whether they’re seda­tion or eupho­ria or whether the drugs just make their pre­scribed opi­oids more effec­tive. So chron­ic pain is a prob­lem. But patients com­plain of chron­ic pain prob­a­bly some­times when they haven’t real­ly got pain. That’s part of their drug seek­ing behav­iour. So it’s a mix­ture of the two.

Paul Evans: How did you decide who is in the lat­ter group, rather than the real chron­ic pain user?

 Dr Ian Brew: Yes sure. Patients com­plain of nerve pain and nerve dam­age. If a gen­uine patient has nerve dam­age, there will be some evi­dence of a cause for that, whether it’s dia­betes, whether it is a neu­ro­log­i­cal prob­lem or whether there is some scar­ring from burns or surgery or injuries or what­ev­er. Patients who are drug seek­ing will tend to fab­ri­cate their symp­toms and they won’t be anatom­i­cal­ly log­i­cal. So in oth­er words, they might com­plain of pains affect­ing areas that aren’t sup­plied by the nerve that goes through dam­aged area, if that makes sense. So non-anatom­i­cal pain dis­tri­b­u­tion is one thing that would make us think that this is drug seek­ing and the oth­er is, patients who are gen­uine are grate­ful for the sug­ges­tions that their clin­i­cians give them. Patients who are drug seek­ing have one drug in mind. They usu­al­ly name it and they usu­al­ly argue if it’s not suggested.

Paul Evans: So if I were a drug abuser then and you offered me like some psy­cho­log­i­cal approach…

 Dr Ian Brew: My expe­ri­ence and that of my col­league is usu­al­ly that would usu­al­ly end in an argu­ment, that’s right, yes.

Paul Evans: So let’s con­cen­trate on the peo­ple with gen­uine chron­ic pain. How do you treat them?

 Dr Ian Brew: I would like to think that we treat them the same as I would treat such a patient out­side the prison walls. The changes that we make are not because of the impris­on­ment. It’s cru­cial to under­stand that patients are enti­tled to equiv­a­lent health care, that may not be iden­ti­cal but it’s equiv­a­lent to the care that they would receive out­side oth­er­wise. So, if some­body came to me with very good evi­dence of nerve dam­age caus­ing chron­ic pain then I would assess them by tak­ing their his­to­ry and lis­ten­ing to them, which can be help­ful in itself. I would exam­ine them look­ing for evi­dence to sup­port the diag­no­sis, and if nec­es­sary arrange tests that would help to con­firm that. Nerve con­duc­tion stud­ies is one exam­ple. They can show dam­age to nerves which will con­firm beyond doubt the pres­ence of neu­ro­path­ic or nerve-relat­ed pain. Then I am very hap­py to treat peo­ple as the nation­al guide­lines sug­gest. The NICE guide­lines from three or four years ago sug­gest some drug treat­ments, they sug­gest phys­i­cal treat­ments, and they sug­gest some psy­cho­log­i­cal treat­ments as well. And we would cer­tain­ly look to go down that route. I think some of the pro­grams that you have done pre­vi­ous­ly look as if they would be very help­ful to our patients so I am going to sug­gest that we give them access to those on CD. Unfor­tu­nate­ly most of our patients don’t have access to the internet.

Paul Evans: I am real­ly glad to hear that our pro­grams are use­ful. But for pris­on­ers there are cer­tain con­straints put on them that would make approach­es that would, say, be used on me, psy­cho­log­i­cal approach­es, vir­tu­al­ly impos­si­ble – fac­ing things like depres­sion and what my GP would tell me to do, what my pain man­age­ment peo­ple would tell me to do, involve the out­side world.

 Dr Ian Brew: Yes, it’s cer­tain­ly true to say that some aspects of psy­cho­log­i­cal approach­es may not be eas­i­ly avail­able to peo­ple in prison, but oth­ers will be. Cog­ni­tive behav­iour­al ther­a­py is already used for patients who suf­fer with anx­i­ety and through increas­ing access to psy­cho­log­i­cal ther­a­pies, or IAPT, pris­on­ers are able to access psy­cho­log­i­cal ther­a­pies much more than ever they were before. So whilst I take your point that there are some things pris­on­ers won’t be able to do there are a lot of oth­ers that they can and they have cer­tain­ly got very good access to gym­na­si­um facil­i­ties and phys­io­ther­a­py, far bet­ter than I have. So over­all the holis­tic approach is going to be use­ful for pris­on­ers, I think.

Paul Evans: What evi­dence is there that a healthy, pain-free pris­on­er will not go back to reoffend?

 Dr Ian Brew: Cer­tain­ly pris­on­er patients who come in for the first time or the first few times are very often very low in their self-esteem; they haven’t tak­en care of them­selves. These patients don’t access health care facil­i­ties read­i­ly out­side, maybe because of fear of author­i­ty fig­ures, maybe because of chaot­ic lifestyles, mean­ing appoint­ments gets missed.

Com­ing into prison is a real oppor­tu­ni­ty to take charge of patient’s health­care. They can take charge of it them­selves, take some per­son­al respon­si­bil­i­ty, and through see­ing their health improve in the prison set­ting, because they are access­ing health­care, they are eat­ing well, hope­ful­ly their ille­gal drug use is con­sid­er­ably reduced, and they are get­ting sup­port for any men­tal prob­lems that they have. And also the pris­ons these days are very good at help­ing with train­ing, with employ­ment skills, with hous­ing if peo­ple are on more than very short sen­tences. All of this will help to con­tribute to an increase in self-esteem.

I always say to the young men who come into prison, if you don’t have any self-respect, it’s very dif­fi­cult to respect oth­er peo­ple. And if you don’t respect oth­er peo­ple, you won’t respect their stuff. So these guys will per­ceive noth­ing wrong with steal­ing and dam­ag­ing them­selves. By giv­ing them some self-respect, they can devel­op respect­ful rela­tion­ships with oth­er peo­ple, and there is good evi­dence that that helps to reduce reof­fend­ing. So clear­ly send­ing some­one out health­i­er than he came in, whether it’s in terms of pain, drug use, men­tal health or all three, that’s got to help in the reha­bil­i­ta­tion of the offend­er and reduce reof­fend­ing for that individual.

Paul Evans: Dr Ian Brew. Now before we fin­ish this edi­tion of Air­ing Pain, I’ll remind you that you can down­load all edi­tions of Air­ing Pain from, CD copies are also avail­able direct from Pain Con­cern. Please do vis­it the web­site where you can find all sorts of essen­tial infor­ma­tion about pain man­age­ment, includ­ing details of Pain Mat­ters, our mag­a­zine that com­ple­ments and expands on issues cov­ered with Air­ing Pain. It’s now also avail­able as an enhanced dig­i­tal down­load. So please do check it out at the Pain Con­cern web­site. Once again, it’s And final­ly in talk­ing to Dr Ian Brew about those guide­lines for treat­ing pris­on­ers with chron­ic pain, I was inter­est­ed to know why a GP who could have opt­ed to work in a much more con­ven­tion­al, and pre­sum­ably less stress­ful envi­ron­ment, should have opt­ed for one with­in the walls of her majesty’s prisons.

 Dr Ian Brew: My Mum and dad often say, ‘What are you doing work­ing in a place like that, why don’t you get a prop­er job out in the sub­urbs some­where?’ And I just think that it’s so reward­ing, work­ing with this very vul­ner­a­ble group. A suc­cess for me is not see­ing the patient again, which is quite bizarre for a GP. Most GPs go into pri­ma­ry care because of the life­long rela­tion­ship, the ther­a­peu­tic rela­tion­ship they can build up with peo­ple. I enjoy the ther­a­peu­tic rela­tion­ship with vul­ner­a­ble peo­ple who can be helped to help them­selves, and when I see some­one out­side the prison who hasn’t been back for a few years, it makes the day worth­while. It’s real­ly great to see peo­ple who are doing well. We do get a bit of skewed view, because of course, the peo­ple we see are the ones who aren’t ready to end their offend­ing career. So we can some­times feel that we’re not doing much good. But as I say, one guy in the super­mar­ket – ‘Hel­lo Dr Brew, how are you doing? I haven’t seen you for years,’ I’ll say, just makes the whole thing worthwhile.


  • Dr Cathy Stan­nard, Con­sul­tant in Pain Med­i­cine at Fren­chay Hos­pi­tal in Bris­tol and Chair of the Con­sen­sus Group/Editor of the British Pain Society’s Guide­lines on Opi­oids for Per­sis­tent Pain: Good Practice
  • Dr Rajesh Munglani, Con­sul­tant in Pain Med­i­cine in Cam­bridge and a lec­tur­er in Anaes­the­sia and Pain Relief at the Uni­ver­si­ty of Cambridge
  • Dr Iain Brew, GP work­ing in prisons.


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