If your appointment is about a chronic painful problem, please read this leaflet while you wait to understand what you can expect
What is chronic pain?
As people live longer, but not necessarily healthier, lives, it is becoming more common to live with long-term, incurable conditions that cause significant pain. Examples of these conditions include arthritis, sciatica, fibromyalgia, chronic headaches and many more. Medical or surgical treatments may be available for these conditions, but not always, and you may be left with having to live with pain in the long term. It is known that at least 1 in 5 people in Scotland live with chronic pain, but the figure may be as high as 1 in 3.
Traditionally, if curative treatment wasn’t available, these conditions would be managed with prescribed painkillers. However, we now know that these medications are not always effective and can cause significant harm.
What medication is available?
It’s easy to think, if a painkiller you have been given hasn’t helped or has caused unacceptable side effects, that there is an alternative your GP will be able to prescribe which will be better. In reality, almost all painkillers you could be prescribed fall into one of these three categories:
Opiates
Examples include codeine/co-codamol, dihydrocodeine, tramadol, oxycodone and morphine. These are among the most commonly prescribed painkillers and they can be effective for many types of pain, although they are rarely prescribed for headaches or abdominal pain as they tend to make these worse. They are highly addictive – they belong to the same family of drugs as heroin and methadone. For this reason, national guidelines state that they should not be prescribed for longer than a week for anything other than cancer-related pain. This is why you’ll only be supplied with a week’s worth of these medications if you’ve been discharged from hospital even after a major operation. The risk of becoming addicted rises significantly if they are taken for longer than a week. There may be times when it’s appropriate to make an exception and continue opiates for slightly longer, but this should be an exception rather than the rule.
Common side effects include constipation, nausea and dizziness. If you experience unacceptable side effects with one type of opiates, you may well experience them with them all. They are sedating, meaning they increase your risk of falls and may affect your ability to drive. Strong opiates or high doses can suppress your breathing drive, which can be fatal. This could happen even at lower doses if you are also on other medications which cause similar effects. This is not just a theoretical risk – Scotland has by far the highest rate of opiate-related drug deaths in Europe, and 41% of those deaths last year were in people who were prescribed opiates. Over-prescribing of oxycodone (which is stronger than morphine) has led to an addictions crisis in the USA that claims tens of thousands of lives each year, mainly in communities not unlike Kirkcaldy.
Even aside from these risks, we now know that taking long term opiates just isn’t very effective. Studies have shown that only 1 in 3 patients taking long-term opiate painkillers actually gets any benefit from them, but every patient taking them is at risk of the harm they cause. Higher doses of opiates can actually make pain worse rather than better, an effect known as ‘opiate-induced hyperalgesia’. If you are already taking high doses of opiates and present with ongoing pain, a dose reduction will probably be suggested as this is likely to improve your pain.
NSAIDs (non-steroidal anti-inflammatory drugs)
Examples include naproxen, ibuprofen and diclofenac. They are good general painkillers and they can be particularly effective for musculoskeletal problems like back pain and arthritis as they also work by reducing inflammation. Unlike opiates, they are not sedating or addictive, so they can be taken for longer.
However, they still have some downsides. They can increase blood pressure and put you at higher risk of heart attacks and strokes. Diclofenac is particularly bad for this, hence why it is now rarely prescribed in its oral form. All NSAIDs can cause stomach upset, so you may be prescribed another tablet to take alongside them to protect the lining of your stomach.
NSAIDs are unfortunately not suitable for many patients. If you have stomach problems, kidney problems, heart problems, asthma or if you take blood thinners then they may be unsuitable for you. However, if you’re unsure, please ask. NSAIDs avoid many of the harms that opiates can cause and your doctor or nurse will be happy to discuss the risks and benefits with you before prescribing. If your pain is localised to one area, a topical preparation like ibuprofen gel may be suitable for you even if the tablets are not.
Neuropathic analgesics
These painkillers specifically target pain which arises from nerves, such as sciatica, diabetic neuropathy and shingles pain. They are less effective for other types of pain. Unlike opiates and NSAIDs, which can be used on an as-required basis, they generally have to be taken at a regular daily dose to get benefit from them. There are two main types of neuropathic painkillers:
Tricyclic antidepressants
Examples include amitriptyline, nortriptyline and imipramine. As the name suggests they were developed as antidepressants, but they are also effective in the treatment of neuropathic pain so if your doctor or nurse suggests this, please don’t think they’re suggesting that an antidepressant is what you actually need! They are not usually considered addictive, but they can have significant withdrawal effects if stopped suddenly so a gradual dose reduction is usually suggested. They are very toxic if taken in overdose, so it’s extremely important not to exceed the prescribed dose. They are usually taken once daily at night before bed as they have a sedative effect, so some of the risks of opiates like falls and breathing difficulties also apply here. This risk is heightened if you are on several medications which have a sedative effect. Common side effects include constipation, dizziness, dry mouth and eyes, difficulty passing urine and abnormal heart rhythms which can be very serious. If you have heart problems, prostate problems or are prescribed other medications which affect heart rhythm then they may not be suitable for you. A slightly different type of antidepressant called duloxetine is available which avoids some of these risks and can be particularly effective for diabetic neuropathy or fibromyalgia.
Gabapentinoids
Examples include gabapentin and pregabalin. They can be effective in the treatment of neuropathic pain. However, they are very addictive, meaning it can be difficult to stop using them even once your pain has improved. They also have a sedative effect, so the risks discussed above also apply to these. Common side effects include dizziness, drowsiness and headaches. If you are on other medications with a sedative effect then the risk of taking gabapentin or pregabalin will likely outweigh the benefit.
At higher doses they cause euphoria, especially pregabalin, which is widely used as a recreational drug. Pregabalin was implicated in 502 drug deaths in Scotland in 2020, 37% of all drug deaths that year. We know that a large amount of pregabalin being sold on the street was obtained on a legitimate prescription so we need to be very cautious with prescribing these and you may be asked to collect the prescription on a weekly or even daily basis. Pregabalin’s status as a controlled drug means it is illegal to possess it without a prescription or supply it to others, even for free. It is therefore a criminal offence to give pregabalin which has been prescribed for you to friends or family, even if you are genuinely trying to help them with pain. The same applies to some opiates. Some practices have a strict policy of never prescribing gabapentin or pregabalin due to their potential for recreational use. We don’t think a blanket ban like this is the way to go, but we do have to be very cautious and consider other options before prescribing.
And that’s about it! There are a few other painkillers available, such as nefopam, a new oral painkiller whose mechanism of action is not well understood, and Ralvo plasters, local anaesthetic patches which can help for some types of neuropathic pain, but almost all painkillers you could be prescribed are one of these three types. No painkiller is without risk, and we hope it’s easy to see how a combination of side-effects, medical contraindications and interactions with other medications could quickly rule out many options for an individual patient.
So if medication isn’t the answer, what can be done?
We appreciate that we as clinicians have a lot to learn here too. Our appointments are short and sending you out of the room with a prescription in hand is the easiest way of making you feel like your expectations have been met, and making us feel like we have done our job. However, it’s becoming increasingly clear that, for chronic pain, medication is rarely the answer.
We will always do our best to identify and treat an underlying cause for your pain, by arranging investigations and referring to the appropriate specialty where needed. However, there may come a time when there is no treatment available (such as for fibromyalgia), or where the risks of a treatment outweigh the potential benefits (such as a joint replacement for a frail elderly patient where the risk of the anaesthetic is likely to be very high). Rarely, there are times when a cause for someone’s pain is never identified despite extensive investigation. In all these scenarios, we need to change our focus to managing the pain in the long term.
For most musculoskeletal problems such as arthritis or back pain, physiotherapy is the best long-term management, and your doctor or nurse will be happy to discuss referring you for this. Physiotherapy will require some effort and commitment on your part, as the exercises you will be given may be difficult and sometimes painful to complete, but we know it is the best way to bring about long-term improvement in these conditions. Taking a painkiller before you go to physiotherapy may help you to engage with the exercises more easily, and we will be happy to discuss prescribing something for this purpose. We appreciate that the waiting list for physiotherapy is long, and the NHS Inform website has useful information on exercises you can do yourself at home while you wait.
For some conditions like arthritis and carpal tunnel syndrome, an injection of steroid into the joint can bring about improvement for several months at a time. We now have two clinicians in the practice who can carry out steroid injections. Some types of steroid injections such as those that need x-ray or ultrasound guidance will require a referral to the hospital.
Changing how we think about pain
Living with chronic pain is a relatively new problem that we haven’t really evolved to deal with yet. Problems like arthritis were relatively rare in the past, when few people lived to old age and even fewer were overweight. Historically, most painful problems like illnesses or injuries would be fatal fairly quickly unless you made a full recovery. Either way, the pain didn’t last for long! However, now that we are able to treat, but not always cure, lots of diseases, living with pain for a long time is much more common.
However, our bodies haven’t quite caught up with this yet. Pain is your body’s way of telling you that there is a problem that needs to be addressed. When you’ve been in pain for more than a few months, your body wonders why the problem hasn’t been addressed yet. It decides that the pain you’re in clearly isn’t bad enough to alert you to the problem, so your brain’s pain threshold is automatically lowered, making the pain feel worse. Obviously this is useless when the cause of the pain is an incurable chronic illness, and it explains why painkillers which seemed effective before now no longer work.
How we think about pain is closely tied to how we feel the pain itself. Feeling that a situation is hopeless, that the condition is never going to get better, can make the pain feel more severe. Similarly, mental health problems like depression and anxiety change the way we feel and perceive pain, making it seem worse. Conversely, when pain is associated with a positive experience, it seems much less severe. One example we see all the time is patients with tattoos who are scared of needles when they need to have blood taken or be given an injection. Getting the tattoo is much more painful, but because it’s part of something that they’ve chosen to do, that they’re excited about, the pain doesn’t seem so bad. Because the pain of getting blood taken is associated with fear, anxiety and illness, it feels much worse than it actually is. Another example is childbirth – obviously this is very painful at the time, but because the overall experience results in something so wonderful, women often don’t really remember the pain, until the next time!
These are extreme examples, but they demonstrate nicely how the way we think about a painful experience changes the way we feel the pain itself. This is a learned behaviour and, with some effort, we can learn to think differently about pain and therefore improve the pain itself. The most effective way of doing this is with cognitive behavioural therapy (CBT). A self-help CBT guide focused on chronic pain is available through the NHS Inform website. Pain-focused CBT with a professional psychologist is also available through the chronic pain clinic.
What can the pain clinic offer?
NHS Fife has a specialist chronic pain clinic based at Queen Margaret Hospital in Dunfermline. They are a large multidisciplinary team consisting of anaesthetists, pharmacists, physiotherapists, occupational therapists and psychologists. They generally only accept referrals for patients who have already had the appropriate investigations and no treatment for their underlying condition is being considered. For example, if you are struggling with knee pain but are on the waiting list for a knee replacement, the pain clinic are unlikely to be able to help. Their focus is on helping patients to live well with chronic pain in the long term.
Their anaesthetists and pharmacists can make changes to medication if that is what’s needed. However, most of their focus is on non-medication management. Their physiotherapists have special expertise in treating chronic painful conditions. Their occupational therapists can help you learn to overcome your pain in order to resume your usual activities and get back to work. Their psychologists can help you relearn how to think and feel about pain which can be hugely beneficial.
As you might imagine, there is a large demand for the services the pain clinic can offer, and not everyone referred to the clinic is best placed to receive the help they can give. They therefore need to be selective in the referrals they accept, and you will need to demonstrate understanding about the chronic nature of your pain and willingness to look past medication and focus on the other methods of learning to live with pain in the long term in order for the referral to be accepted. If you’re not sure if the pain clinic is right for you, their clinicians run educational sessions both in-person and online that you can attend free of charge without a referral. You need to book a place which can be done by searching ‘Sore? Know More!’ on the NHS Fife website or by calling 01383 674106. We would advise attending one of these sessions before approaching your GP to ask for a referral.