By Clive Lindley-Jones | September 22, 2016 12:28 pm
Riga, Prince, Pain and where we are going wrong.
In August I had an interesting and stimulating week examining and lecturing at an international medical conference with clinicians from 18 other countries in Riga, Latvia. I came back with several new clinical pearls to learn and apply over time. I finally retired from an international examining board that I had been on for many years, and while I will be sad not to be working with my multi disciplined colleagues from around the world, I will not miss the pressure of work that comes with such pro bono roles.
It was salutary on visiting a Baltic State, to remember that Latvia, which had been an independent state by 1918, then underwent the unimaginable hardships of first the brutal invasion by the Soviet Union in 1940, only to then suffer under the Nazis from '41-44, to be liberated by the same Stalinist Soviet regime that they had endured three years earlier and then have to suffer loss of statehood until their final freedom in 1992. This much longed-for freedom in turn, required a difficult and stressful roller coaster ride into the joys and sorrows of the faster moving and sometimes also ruthless world of winner-takes-all modern capitalism. That they have come out of it all so well is a credit to their endurance and fortitude. From that brief history of a nation's pain let us turn to the subject of chronic pain.
A few months ago the musician Prince died by an accidental overdose of the powerful opioid drug fentanyl. This is 100 times as strong as morphine. As Gary Franklin, a researcher at the University of Washington said in Scientific American recently,
“In a way, Prince is a poster child for what can happen with chronic use—and increasing doses—of these very powerful drugs.”
No one likes pain. I know, both as a human, subject to pain myself and as a health professional working in pain relief for decades. Throughout history each culture has struggled to battle the horrors of unstoppable pain employing all sorts of methods. We in our advanced, science soaked society have often thought we had moved on from those old painful days of yore. And so we had. No one who has used modern dentistry or undergone safe modern childbirth would say we should go back to the good old days. And yet, in recent years, we seem to have taken a few missed steps in our over focus on chemical solutions and overlooked other powerful avenues to pain relief, particularly chronic pain relief and resolution.
This month I want to look at the kind of chronic pain we endure from musculoskeletal pain, arthritis, fibromyalgia, headaches rather than the kind of chronic pain associated with cancer and end of life care.
Chronic pain is continuous, long-term pain of more than 12 weeks or after the time that healing would have been thought to have occurred in pain after trauma or surgery. According to the British Pain Society up to 28 million Britons are living with chronic pain, new estimates suggest. Problems such as low back pain or osteoarthritis effect between 35% and 51% of British adults, according to a new study.
Chronic pain is complex, multi factorial and needs to be approached in several ways at once. If we have taken some miss-steps in recent decades we can now see more clearly some better ways forward to approach chronic pain with greater understanding and more awareness of some of the pitfalls that have become more apparent, particularly where opioids are concerned. Too often where the USA goes, the rest of the world follows. Sadly this seems to be, in part, true of the opioid epidemic. The Centers for Disease Control and Prevention estimated that as many as 259 million painkiller prescriptions were written in 2012 alone, with the U.S. responsible for 99% of global sales for hydrocodone, a semi-synthetic opioid synthesized from codeine and 81% of the world's consumer market for oxycodone, a synthetic analgesic drug which is similar to morphine in its effects.
According to Modern Health Care;
"In 1996, pharmaceutical firm Purdue Pharma launched a campaign informing patients and doctors that a new, safe drug was available to combat pain that was not the result of cancer, surgery or trauma. This pill could relieve chronic back pain caused by daily physical demands. And it was safe because it would slowly release its narcotic ingredients, making it unlikely to become addictive, it said. The drug caused a cultural shift in the way physicians treated pain and how Americans viewed it".
It was this change in prescribing practices that would lead to our public health crisis, said Dr. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing.
As so often in these drug industry stories you can almost write the rest yourself. Two decades later, many advanced countries face record mortality rates associated with drug overdoses, including those related to heroin, an option many addicts turn to as a cheaper and more accessible alternative to painkillers. You will not be surprised to learn that the drug company had been economical with the truth and a huge row-back is underway as millions, particularly Americans, find themselves addicted to opioids or worse, like Prince, dead from over use. While things are not quite as bad here in the UK a similar pattern is emerging. As the British Faculty of Pain Medicine say in their recent Opioids Aware advice for clinicians and patients, "Opioids are very good analgesics for acute pain a the end of life but there is little evidence that they are useful for long-term pain".
In America where the opioid crisis has reached alarming proportions The Center for Disease Control and Prevention, in its 2016 guidelines for prescribing opioids, notes that non-pharmacologic therapies are preferred for treating chronic pain. Again from the other side of the pond, Modern Health Care , in their recent piece entitled
"Opioid crisis renews interest in osteopathic manipulation therapy"
report on the rediscovery of old tried and tested methods of pain relief that have been used in both Europe and America for over 100 hundred years.
“Rather than going through a standard physical examination, we will actually put our hands on the patient to feel if there are any asymmetries or restrictions in the tissues,” said Dr. Jim Bailey, an assistant professor of rehabilitative medicine at the Rowan University School of Osteopathic Medicine in New Jersey. “If we find them we can use various techniques to correct that.”
Most of the scientific research into Osteopathic Manipulative Therapy (OMT), as it is known in America, over the years involved small patient samples, so positive results were easily dismissed and providers like the NHS or insurers often refused to recommend or reimburse for the procedure. But that is changing; in the UK The National Institute for Clinical Excellence (NICE) has been recommending forms of manual therapy such as Osteopathy for back pain for some years now. A report on July 16, 2016 , stated;
"A fairly large randomized, controlled trial of over 400 patients that appeared earlier this year in the Journal of the American Osteopathic Association found six OMT sessions were associated with “significant and clinically relevant measures for recovery from chronic lower back pain.” This came on the heels of a 2014 meta-analysis—led by a German researcher who has worked with the respected Cochrane Collaboration—that found OMT helped reduce pain and improved function in both acute and chronic pain patients.
So despite our long running love affair with out-of-the-bottle 'magic bullet' chemical solutions, non-invasive, safe, and effective alternatives that address and resolves the source of pain are increasingly being taken seriously by governments slowly following many chronic pain sufferers who have known this for a long time. While opioids and NSAID's have their place, they are not the full answer and have too big a risk and are actually not that effective. Conservative, non-drug methods should be used much more extensively first.
What we consider as conservative methods needs to and is, slowly changing. As the recent 'Doctor in the House' programme on the BBC 1 showed, careful functional and structural examination and treatment can often, as on the TV programme, turn a chronic 20-pill-a-day pain habit around in as little as 30 days.
Pain, we have to remember, while seemingly so tied up with the area of the body that it is coming from, needs to be seen as a brain-based problem. To tackle it we need an integrated strategy that recognises this and addresses the issue structurally, psychologically, nutritionally, linguistically, energetically and, only as a last resort, chemically, and then with greater caution. In a recent article in Practical Pain Management it was cogently argued that;
"Osteopathic tenets and principles for the management of pain actually preceded the now widely accepted and heuristic bio-psycho-social approach. This bio-psycho-social model views physical disorders—such as pain—as the result of a dynamic interaction among physiological, psychological and social factors that perpetuates and may worsen the clinical presentation. A wide range of psychological and socioeconomic factors can interact with physical pathology to modulate a patient’s report of symptoms and subsequent disability. Thus, “knowing the whole person” is important in this model as well as in the osteopathic approach. It has been recently noted that, in general, this bio-psycho-social model is quite congruent with osteopathic principles and that it provides a great deal of empirical evidence that supports the osteopathic approach."
This osteopathic approach is based on four principles, namely;
- The body is a unit; the person is a unit of body, mind, and spirit.
- The body is capable of self-regulation, self-healing, and health maintenance.
- Structure and function are reciprocally interrelated.
- Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.
Gradually we are seeing that while the stimulation of a nerve may, but does not always lead to pain, this in turn does not always lead to suffering and the behaviour that pain and or suffering engenders can be very different depending on multiple bio-psycho-social factors, which can include a wide range of aspects just because pain is both an unpleasant sensory and emotional experience which is always filtered through our psycho-social expectations and experiences.
This can explain the well proven efficacy of such, once derided, approaches as the clinical use of mindfulness meditation for the self-regulation of chronic pain. So while this bio-psycho-social approach was widely embraced by osteopathic medicine, well before conventional allopathic medicine, perhaps sometimes in the past we had a tendency to forget these facts as we got caught up with our own physical techniques and interventions. However most clinicians these days are well aware of the wider model discussed here.
An interesting newish example is the OsteoMAP programme. This is an NHS funded initiative, developed by the British School of Osteopathy combining Mindfulness and Osteopathy and is designed to support people with long-term musculoskeletal pain, which may be alleviated but is unlikely to be completely resolved by manual therapy alone. It aims to help people with pain find their own pathways to living a more fulfilling life, despite on-going symptoms. OsteoMAP is based on the ‘third wave’ Cognitive Behavioural Therapy (CBT) approaches currently used in group-based pain management programmes within the NHS.
The day after I finished writing this blog I was interested to see the BBC ran a programme entitled The Doctor Who Gave Up Drugs, with Infectious disease and TV Dr. Chris van Tulleken. With half the NHS's drug use in General Practice and a 50% increase in drug consumption in the last 15 years and an estimated 100,000-lifetime-pill average consumption for healthy people, we have become a nation of druggies...and I am not consuming many at all, so someone must be consuming mine and possibly your share too!
With this massive over prescription of drugs that often do not work very well and sometimes kill us, we have created a dysfunctional system that is both unsustainable, unhealthy and dangerous. Long term use of common drugs like ibuprofen and paracetamol can lead to potentially life threatening kidney and liver damage, while many of the drugs that are often brought over the counter only work on a minority of people. Truly, as Van Tulleken says, a mad way to do medicine. But what to do?
To his credit he did have a go at being a GP for a day or so to see the huge pressure GP's are under to do medicine in ten minute bouts, always aware that if they miss something and don't prescribe the right medicine and a patient dies they are very vulnerable to being sued.
Tulleken showed in no uncertain terms how so many patients who are taking handfuls of pain medication every day, sometimes for decades, if they were to come off them and just move, let alone see an expert like an osteopath for their back or shoulder pain, could both reduce or eradicate their pain and greatly reduce their risks of toxic drug reactions. In a young woman on antidepressants for eight years, since she was 16, he introduced her to wild swimming. Both the exercise and the cold shock stimulus to the hormonal system as good evidence shows, have the power to change our depressed state.
However, even for those of us who know and accept these things and are not sleep walking to a drug filled future, the challenge for us, as a nation, is how do we organise health care so that those old-fashioned home visits and intensive enquiry as to a better way of helping our patients can be introduced along side any drugs that may well be vital to a few?
Seeing Tulleken made me hope that one day we might have a functional medicine speciality that is charged, much as he did for TV, with attaching to GP surgeries and coaching the many people who can get a much better, safer and more effective kind of medicine by applying all the new (and old) knowledge we have that can lead us away from this unsustainable and unhealthy way of doing medicine. Expensive perhaps in the short term but life saving and economical in the longer term.
Well enough of pain for now, before I go have you checked your vitamin D levels recently? While I have written about the ever-growing understanding into the many roles of vitamin D in our health elsewhere I was interested to see this recent research in relation to Asthma.
Vitamin D & Asthma
334 million people around the world are effected by asthma and there are 185 hospital admissions and three deaths each day in the UK from asthma. A new study that showed that vitamin D supplements can half the risk of acute asthma attacks. An official estimate suggest one in five adults and one in six children in England may have low levels. Now, an extensive review of the evidence, carried out by the Scientific Advisory Committee on Nutrition (SACN), suggests everyone over the age of one needs to consume 10 micrograms of vitamin D each day in order to protect bone and muscle health.
Coming soon, reflections on encouraging life-style and nutrition research from America on reversing early Alzheimer's disease, and the exciting and advancing world of the humanbiome.
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