I often listen to the radio whilst travelling between my clinics, so, this is a bit of a radio blog this time. Both the bad and the good from BBC Radio 4.
Opiate danger: three things all GPs should do
First the bad, I heard a horrific story on the Radio 4 Today programme recently. It was about how opiate problems are spreading to the UK. It focused on an interview with a lady who had suffered an injury, been in chronic pain, and was prescribed morphine. No doctor ever explained to her how addictive morphine could be. She went to the same GP practice but no-one seemed to consider that she should be looked after in any other way. When she became concerned and asked how she could come off of the medication her concerns were not taken seriously, and no-one would confront the possibility that she was addicted.
This is such a litany of failure. It made me ask:
What could be done differently?
Here is my list.
There are alternatives to medication. Sometimes a short course of opiates may be necessary, but this should always go along with support, information and coaching on other ways to manage chronic pain.
There should be regular reviews where opiates are being used. This can go alongside encouragement to try other ways of managing chronic pain.
The possibility of addiction should be taken seriously and help should be available. It is not easy to come off of opiate medication and it may take clinical intervention to ensure this can be done safely.
I believe these three things should become a standard protocol in the NHS. Otherwise we are in danger of ending up with an opiate addiction crisis on a United States scale. I am afraid I already see this in my chronic pain clinics. There are alternatives to opioid medication and we need to start using them more.
Professor Irene Tracey: new research
Now for the good story. On Tuesday mornings on Radio 4 there is an excellent series called The Life Scientific where leading scientists are interviewed about their life and work. Recently, the wonderful Irene Tracey, whom I have long admired, was the subject.
Professor Tracey is a neuroscientist who holds the Nuffield Chair of Anaesthetic Science and is the Head of Department of Clinical Neurosciences at Oxford University. She works on chronic pain and the brain using the most up to date brain imaging technology.
Her research is very wide-ranging, and is constantly showing us how malleable pain is. As she has looked at how the brain behaves when we feel pain, it has become clearer and clearer how personal the experience of pain is. We all experience it differently according to our individual beliefs, make-up and disposition.
She says we need to understand the good side of pain, it is the body’s alarm system, warning us when something is wrong.
But, Professor Tracey says, there is a dark side of pain too. This is when tissue damage has healed but the person is still experiencing pain.
Pain is complex…
We are still at the start of understanding the complexities of this process, but through the work of Professor Tracey and her team there are some areas where real progress is being made.
She stresses that no two experiences of pain are the same. As she put it in the radio programme, if we stand on a drawing pin, we all experience the same feeling of a pin prick. But as the feeling moves up the central nervous system through the spinal cord the whole of each individual’s life journey is involved. We all experience the same injury differently, with our expectations and our goals affecting how we process the initial events.
Using the most up to date brain scanning MRI technology, Professor Tracey has been able to see that many brain areas are active in response to painful stimuli. She is able to look at the cells of the brain as they are working to process pain and she says now the trick is to unravel how the emotional state and reaction of the individual impacts upon that. Already, through using this imaging technology, she has been able to track how anxiety and depression can change the processing of pain signals.
We now know, through this research, that the brain stem has a key role in controlling the signals in the spinal cord which register pain. Professor Tracey describes this as the ‘good cop, bad cop’. The volume of the signals can be turned up, heightening the pain, or turned down, lessening that pain. This controls what is actually allowed into the brain from the spinal cord.
Once in the brain there is another level of modulation. One thing which Professor Tracey has recently discovered, through using recently developed scanners, is that many different areas of the brain are active when processing pain, including both he left and right sides (the rational and the creative sides).
This shows just how complex our response to pain is and it involves many experiences and thought processes.
Complexity of pain means we can alter perceptions
I believe this is exciting and positive. This complexity gives us the chance to look at behaviours and belief systems and the way we can work with them to alter perceptions of pain and thereby control and lessen it.
This is especially important to our understanding of chronic pain. This is now the largest medical problem in the western world with one in five adults experiencing chronic pain.
We know that the drugs we have available currently do not work very well. Another approach is needed. We can work with the ‘good cop bad cop’ amplifying signals in the brain stem.
Professor Tracey is hoping that we can develop better medications as we understand this.
She also sees value in the sort of work people like myself do, working with thought processes to change these perceptions. She says that we do not yet know whether some people have an inherent vulnerability which predisposes them to chronic pain. She may be right, but I notice something else. That is the importance of habit and learned behaviours when we are looking at chronic pain. I truly believe, and I see this in my psychology/ hypnotherapy for pain clinics all the time, that through hypnotherapeutic and various cognitive techniques, we can change thinking patterns to make pain much less of a problem.
Professor Tracey has shown us that the brain adapts to constant signals of pain. If anxiety is heightened then the amplifier ‘bad cop’ system is triggered. If it is lessened the ‘good cop’ is strengthened. The brain has the ability to change experience.
Harnessing this knowledge, what Professor Tracey calls the ‘new biology’ of the brain is opening up a whole new way of understanding. It may lead to new drugs in the future. Professor Tracey also says, this new understanding has already shown why talking therapies aimed at changing our thinking habits work.
New biology and new habits
So, to sum up our radio journey. Opiates are very dangerous because of their addictive properties and some of our medical establishment seems not to be taking this threat seriously. At the same time, cutting edge research is finding out more and more about how our brains process pain and how much this is influenced by individual thought processes.
I hope that if you are suffering from pain you contact me at my chronic pain clinics in Milton Keynes or in Bedford or via video call. Or buy my books, which will help you set up new habits and thinking patterns which can help you get in control of your life and your pain.
Wishing you a less pain day