When the drugs don’t work: medication alternatives

For 25 years, Sean Jennings took a cocktail of painkillers to manage his chronic pain, triggered by an infection following a routine hernia repair operation.

Despite higher and higher doses, the pain got worse, and he began suffering nasty side-effects, including severe constipation and sleep apnoea, and he’d wake up gasping for breath.

Eventually, Sean, 60, decided to take action, and with the help of a support group he came off the drugs over a period of six months, adopting mindfulness, meditation and exercise instead.

‘Coming off the drugs has transformed my life,’ says Sean, from Saltash in Cornwall. ‘I exercise daily – kayaking, lifting weights and doing resistance training – and I am able to play with my grandchildren.’

He is still in pain every day but can ‘dial it down’ using breathing and meditation techniques. ‘I am able to put it to the back of my mind and get on with my life. I feel better now than I did before the operation.’

It’s exactly the approach recently championed by the National Institute for Health and Care Excellence (NICE), the Government’s drug and treatment regulator. Under new guidelines released earlier this year, people like Sean who have ‘chronic primary pain’ – in other words, pain with no clear underlying cause, such as arthritis – should no longer be started on common painkillers, including paracetamol, non-steroidal anti-inflammatory drugs (ibuprofen or naproxen), benzodiazepines (tranquillisers Valium or Xanax) or opioids (codeine, tramadol and morphine).

Instead, they should try a range of other treatments: for example exercise programmes, psychological therapies (such as cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT)), acupuncture and antidepressants, says NICE.

Drug-free ways ease arthritis pain

Chronic or persistent pain is defined as pain that lasts for more than three months, and it is thought to affect around one third of adults in the UK, with older people most likely to be affected. In most cases, there is a direct cause for this pain – conditions such as osteoarthritis or ulcerative colitis. But for a smaller number of patients – between 1-6% of all adults – the pain has no direct cause, making it a complex condition and difficult to treat.

The pain might be the result of fibromyalgia, some types of headache, musculoskeletal pain, or complex regional pain syndrome. The new NICE guidelines, published in April, relate to these chronic primary pain patients and are born of concerns that there is ‘little or no evidence’ that common painkillers make a difference to the quality of life of people living with chronic pain.

Indeed, there can be unpleasant side-effects, including liver and kidney damage, and there is the risk of addiction. The opioid crisis in the United States is estimated to kill one person every 11 minutes and while the problem is not as bad in the UK, the overprescribing of opioids is a significant problem.

Although the number of prescriptions has fallen slightly, a 2019 report by Public Health England revealed 5.6 million people a year are prescribed opioids. Research shows that, at best, they might help one in ten patients.

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‘Based on the evidence, for most people it’s unlikely that any drug treatments for chronic primary pain, other than antidepressants, provide an adequate balance between any benefits they might provide and the risks associated with them,’ says Dr Paul Chrisp, director of the Centre for Guidelines at NICE.

So why don’t painkillers work? ‘The term “painkillers” is actually a misconception,’ says Professor Sam Ahmedzai, a pain specialist and council member of the British Pain Society. ‘There is no drug that kills pain apart from general anaesthetics. The drugs that we think of as painkillers – opioids, paracetamol, anti-inflammatory drugs – reduce the awareness and sensation of pain that the body feels, but they don’t get rid of it.

‘Chronic pain, a condition that tends to affect older people, is a very complicated issue and is associated with an oversensitive and over-responsive nervous system, which could be caused by many factors, including their physical, psychological and emotional health plus social factors.

‘Over the past ten years there has been increasing evidence that the traditional methods of treating pain – with so-called painkillers – are effective for acute pain, such as a week or so after surgery, but for chronic pain they don’t work as well as we thought they did.

Can the mind affect pain?

‘The longer you use painkillers, the less they work because the body builds up a tolerance to them and many people can become dependent.

‘Plus, these drugs all have side-effects. Opioids can cause constipation and problems with hormones and the immune system; non-steroidal anti-inflammatories can damage the stomach and kidneys; and paracetamol can damage the liver. It’s about balancing the benefits and risks.’

However, some are concerned that the pendulum may have swung too far in favour of non-drug treatments. GPs have warned that they simply don’t get enough consultation time with patients to discuss alternatives to their usual painkillers. Pilot programmes have trialled half-hour appointments, and even that wasn’t quite enough.

And anyway, GPs often don’t have access to alternative treatments such as acupuncture or talking therapies, or, even if they do, there are long waiting lists.

‘Access to these therapies recommended by NICE can be patchy at a community level across the country,’ points out Dr Martin Marshall, chair of the Royal College of General Practitioners. ‘This needs to be addressed urgently if these new guidelines are to make a genuine difference to the lives of our patients with primary chronic pain.’

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