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Chronic Pain Is Being Undertreated PDF Print Email

Chronic pain is being undertreated


It has been reported that a large number of patients with cancer and other debilitating conditions aren’t being given strong enough pain relief.  It is thought that doctors are reluctant to prescribe strong opioids, like morphine, due to patients’ concerns over addiction. It is also thought patients may wrongly assume that they are nearer the end of their life, as there is a misconception that opioids are only given during the final stages of terminal disease.


The National Institute for Health and Clinical Excellence (NICE),has issued new medical guidelines on the safe and effective prescribing of strong pain-relieving drugs for people living with and dying from a terminal condition, known as palliative care. The guidelines are designed to help healthcare professionals prescribe doses that improve both pain levels and quality of life. They also address side effects such as drowsiness and misconceptions about becoming addicted to opioid medication.


Pain is a common fear for people with an advanced or progressive disease but it can be largely controlled with the correct medication. This includes opioids, which, while susceptible to side effects like any other drug, are effective when prescribed appropriately.


Opioid drugs such as morphine provide some of the strongest pain relief available, but they also present the potential for certain side effects, such as a risk of extreme drowsiness and nausea. Due to their power they are usually prescribed to people suffering extreme pain, such as advanced cancer, but prescribing too low a dose or avoiding the use of opioids altogether can leave patients struggling with their pain. Equally, prescribing too large a dose can make a person too drowsy and weak, diminishing their quality of life.


This new clinical guidance sets out advice on the safe and effective prescribing of strong opioids for relieving pain in adults with advanced and progressive disease, often referred to as palliative care. The guidelines aim to improve pain management and patient safety but does not include care during the last days of life, otherwise known as end-of-life care. The guidelines have been issued by the National Institute of Health and Clinical Excellence (NICE), which sets out the guidance and standards for treating specific conditions and disease within the NHS in England and Wales.
The guidance looks specifically at five pain-relieving opioids (morphine, diamorphine [heroin], buprenorphine, fentanyl and oxycodone) and provides advice on offering pain relief and the key considerations that need to be addressed when deciding  doses. It also provides advice on the management of some side effects associated with taking these medications, including nausea, constipation and drowsiness.


The guidelines further recommend that doctors discuss any concerns that patients and their families may have about side effects, addiction, tolerance and concerns that treatment with strong opioids signals that a patient is entering the final stages of their life.


Palliative Care


Palliative care is a specific type of care provided for patients living with and dying from a terminal condition. The aim is to help the person live as well as possible and avoid suffering wherever possible. The aim is to improve quality of life for patients and their families by providing care that addresses the patient’s individual needs physically, emotionally, spiritually, socially and culturally.


Palliative care is provided by a range of health professionals, including GPs and specialist palliative care doctors and nurses. It can be provided in the home, a hospice, a hospital or a care home. End-of-life considered part of palliative care.


Chronic pain is common in advanced and progressive disease, and up to two thirds of people with cancer experience pain that requires a strong opioid. For patients experiencing strong pain, opioids are often prescribed. Opioid drugs come from either the opium poppy or are artificially produced. Strong opioids, such as morphine, are painkillers that act on the central nervous system to relieve severe pain. There is no standard dose of a strong opioid and the amount needed to ease the pain varies from person to person. Being offered strong opioids can happen at different stages in the course of a disease and it doesn’t necessarily mean a person is close the end of their life. However, there is concern that patients might perceive the use of opioids in this way, and become distressed.


Evidence suggests that despite increased availability of strong opioids in the UK, pain resulting from advanced disease often goes untreated. NICE reports that “misinterpretations and misunderstanding have surrounded the use of strong opioids for decades and these are only slowly being resolved”. They add that “until recently, prescribing advice has been varied and sometimes conflicting”.


Professor Mike Bennett, a professor of palliative medicine at the University of Leeds, said on this issue, “Almost half of patients with advanced cancer are under-treated for their pain, largely because clinicians are reluctant to use strong opioids.”


The NICE guidelines say that when offering treatment with strong opioids as pain relief to a patient, the patient should be asked about concerns such as addiction. Studies show that addiction is a common fear, but it is very rare for people in pain to become addicted to opioids in the same way that recreational heroin users might.


Patients that receive opioids are monitored carefully for any side effects, including the rare problem of addiction, to ensure their medication provides them the greatest relief possible without diminishing their quality of life.


People with concerns about the side effects of opioids and addiction can discuss these with their GP or treating doctor.
If you are concerned for yourself, or a family member, for instance in a care home; about medication and treatment for chronic pain you can discuss this with your pharmacist too, who can advise you on the best way to approach the doctor and what to discuss.