Heroes Not Zombies

This strikes me as a shocking graph. Oxycodone is an opiate painkiller, and this graph charts its annual consumption from 1980 to 2015.

The first thing is astonishing explosion of consumption in the USA since around 1996, and the second is the contrast between the USA and Europe.

What are we to make of this? Did Americans suddenly develop many more painful conditions than Europeans? Why did their consumption remain pretty steady from 1980 to 1995, then rapidly go through the roof?

The answers, of course, are complicated. They relate to the marketing of products by drug companies in different countries, the differences between cultures and changes in economic and social conditions….amongst a host of other things.

It’s true that whilst the great health success story of the last century has been the decline of infectious disease, the not so great story is of ever increasing rates of chronic, non-communicable diseases. In 2014 60% of American adults reported having at least one chronic disease, and 12% actually had at least five at the same time. A report from the NHS in England and Wales today states that men are being diagnosed with their first “significant long-term condition” at the age of 56, and women at 55. In the poorest areas, these figures drop down to the ages of 49 and 47. It found that women in the UK are living “in poor health” for 29 years, and men for 23 years.

Not all of these conditions cause pain, but what does?

Kurt Kroenke has published many research studies showing that symptoms, including pain, are not good indicators of underlying disease. In fact, he has shown that the top ten commonest symptoms patients present to doctors are all highly unlikely to be associated with clear underlying diseases –

Notice that four of these top ten symptoms are pain.

One question then is what is the cause of this patient’s pain? If there is a modifiable cause, then the best treatment is to deal with that. For example, if someone’s pain is due to a severely arthritic hip, then a replacement hip joint will most likely solve the problem. Sadly, most underlying causes are not that straightforward to deal with. Painful chronic inflammatory conditions and incurable cancers are not so easily dealt with. But it gets more complicated, because we also know there is no direct, reliable relationship between the amount of pain a person experiences and the size, severity or extent of any pathology in their body.

So what do we do?

I suspect that what we mainly do is treat pain as if it is an entity in its own right.

The answer to pain, we think, is a painkiller. It’s just a matter of finding the one which kills the most pain for this particular patient. The trouble is this approach has two particularly unhelpful downsides. Firstly, painkiller after painkiller has been shown to be ineffective in the longer term. The longer someone uses a particular painkiller, the less benefit they get from it. Worse than that, the longer they use it, the more likely they are to suffer harm from it. Secondly, by treating pain as if it is an entity in its own right, we lose sight of the causes of the pain. We lose sight of its origins and its variable, daily contexts.

At a population level we have to address the causes of chronic ill health, including poverty, inequality, poor housing, environmental and food chain pollutants, and increasing levels of insecurity and fear.

At a personal level, people need understanding, support, and reassurance. They need to have underlying diseases treated as effectively as possible, and they need to be helped to develop both their coping strategies and the life skills which enhance the daily quality of life. None of this is possible without adequate consultation times, good quality relationships between doctors and patients, continuity of care, and the treatment of every patient as a unique human being.

There will always be a place for good painkillers, but they are never going to be THE answer.