tag:theconversation.com,2011:/fr/topics/painkillers-1941/articlesPainkillers – The Conversation2022-10-26T12:29:17Ztag:theconversation.com,2011:article/1925902022-10-26T12:29:17Z2022-10-26T12:29:17ZDrugs – 4 essential reads on how they’re made, how they work and how context can make poison a medicine<figure><img src="https://images.theconversation.com/files/489907/original/file-20221016-16-3m74ut.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Constraining drugs to a single function in the body may be limiting their full potential.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/red-and-white-pharma-pill-pattern-on-pastel-blue-royalty-free-image/1288588418">Israel Sebastian/Moment via Getty Images</a></span></figcaption></figure><p>Pandemics and disease outbreaks put a spotlight on the hurdles researchers face to get a drug on the shelves. From finding prospective drug candidates to balancing time and financial pressures with ensuring safety and efficacy, there are many aspects of drug development that determine whether a treatment ever makes it out of the lab. </p>
<p>Broadening the definition of “medicine” and where it can be found, however, could help expand the therapeutic options available for both researchers and patients.</p>
<p>Here are four facets of how drugs are developed and how they work in the body, drawn from stories in The Conversation’s archive.</p>
<h2>1. Matching drug to target</h2>
<p>The most effective drugs are, in a sense, the product of good matchmaking – they bind to a specific disease-causing receptor in the body, elicit a desired effect and ideally ignore healthy parts of the body.</p>
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<figcaption><span class="caption">Factors such as your age, genetics and diet can affect how well your body processes a drug.</span></figcaption>
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<p>Drugs <a href="https://theconversation.com/how-do-drugs-know-where-to-go-in-the-body-a-pharmaceutical-scientist-explains-why-some-medications-are-swallowed-while-others-are-injected-182488">travel through the bloodstream</a> to reach their targets. Because of this, most drugs circulate throughout the body and can bind to unintended sites, potentially causing undesired side effects.</p>
<p>Researchers can increase the precision and effectiveness of a drug by designing different ways to take it. An inhaler, for example, delivers a drug directly to the lungs without its having to travel through the rest of the body to get there.</p>
<p>Whether patients take drugs as prescribed is also essential to ensuring the right dose gets to where it needs to be often enough to have a desired effect. “Even with all the science that goes into understanding a disease well enough to develop an effective drug, it is often up to the patient to make it all work as designed,” writes pharmaceutical scientist <a href="https://www.researchgate.net/profile/Thomas-Anchordoquy">Tom Anchordoquy</a> of the University of Colorado Anschutz.</p>
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<a href="https://theconversation.com/how-do-drugs-know-where-to-go-in-the-body-a-pharmaceutical-scientist-explains-why-some-medications-are-swallowed-while-others-are-injected-182488">How do drugs know where to go in the body? A pharmaceutical scientist explains why some medications are swallowed while others are injected</a>
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<h2>2. Searching for drug candidates</h2>
<p>Researchers have discovered a number of drugs by chance, including <a href="https://www.pbs.org/newshour/health/the-real-story-behind-the-worlds-first-antibiotic">penicillin</a> for bacterial infections, <a href="https://www.bbc.com/future/article/20200928-how-the-first-vaccine-was-born">vaccines for smallpox</a> and <a href="https://doi.org/10.1038/nrcardio.2017.172">warfarin</a> for blood clots. While serendipity still plays a role in modern drug discovery, most drug developers take a systematic approach.</p>
<p>Scientists typically start by identifying a particular molecular target, usually receptors that trigger a specific response in the body. Then, they look for chemical compounds that react with that target. Technology called <a href="https://theconversation.com/discovering-new-drugs-is-a-long-and-expensive-process-chemical-compounds-that-dupe-screening-tools-make-it-even-harder-175972">high-throughput screening</a> allows researchers to quickly test thousands of potential drug candidates at once. Compounds that match screening criteria advance to further development and refinement. Once optimized for their intended use, compounds go on to safety and efficacy testing in animals and people.</p>
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<figcaption><span class="caption">Scientists have been isolating medicinal compounds from natural products for centuries.</span></figcaption>
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<p>One way to ease the search for optimal drug candidates is to work with compounds that are already optimized to work in living beings. <a href="https://theconversation.com/nature-is-the-worlds-original-pharmacy-returning-to-medicines-roots-could-help-fill-drug-discovery-gaps-176963">Natural products</a>, derived from organisms like microbes, fungi, plants and animals, share similar structures and functions across species. Though not without their own development challenges, they could aid the search for related compounds that work in people.</p>
<p>“There are thousands of microorganisms in the ocean left to explore as potential sources of drug candidates, not to mention all the ones on land,” writes medical chemist <a href="https://scholar.google.com/citations?user=8_T1ueYAAAAJ&hl=en">Ashu Tripathi</a> of the University of Michigan. “In the search for new drugs to combat antibiotic resistance, natural products may still be the way to go.”</p>
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<a href="https://theconversation.com/nature-is-the-worlds-original-pharmacy-returning-to-medicines-roots-could-help-fill-drug-discovery-gaps-176963">Nature is the world's original pharmacy – returning to medicine's roots could help fill drug discovery gaps</a>
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<h2>3. A drug by any other name may be just as effective</h2>
<p>Existing drugs can find a second (or third, fourth and fifth) life through repurposing. </p>
<p>Most drugs <a href="https://theconversation.com/many-medications-affect-more-than-one-target-in-the-body-some-drug-designers-are-embracing-the-side-effects-that-had-been-seen-as-a-drawback-184922">have many functions</a> beyond what researchers originally designed them to do. While this multifunctionality is often the cause of unwanted side effects, sometimes these results are exactly what’s needed to treat a completely unrelated condition.</p>
<p>Sildenafil, for example, failed to treat severe chest pain from coronary artery disease, but proved to be potent at inducing erections as Viagra. Similarly, thalidomide, a compound that caused birth defects in thousands of infants around the world as a morning sickness drug, found redemption as a cancer treatment. </p>
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<figcaption><span class="caption">While thalidomide was disastrous for morning sickness, it has proved effective for other diseases.</span></figcaption>
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<p>Because drugs inherently have more than one function in the body, <a href="https://theconversation.com/repurposing-generic-drugs-can-reduce-time-and-cost-to-develop-new-treatments-but-low-profitability-remains-a-barrier-174874">repurposing existing drugs</a> can help fill a gap where pharmaceutical companies and other developers cannot or will not. <a href="https://scholar.google.com/citations?user=iDKZaA4AAAAJ&hl=en">Gregory Way</a>, a researcher at the University of Colorado Anschutz, uses artificial intelligence to predict the various effects a drug can have and believes that this lack of specificity is something to explore rather than eliminate. Instead of trying to home in on one specific target, he suggests that scientists “embrace the complexity of biology and try to leverage the multifaceted effects drugs can offer.”</p>
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<a href="https://theconversation.com/many-medications-affect-more-than-one-target-in-the-body-some-drug-designers-are-embracing-the-side-effects-that-had-been-seen-as-a-drawback-184922">Many medications affect more than one target in the body – some drug designers are embracing the 'side effects' that had been seen as a drawback</a>
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<h2>4. Poison as medicine</h2>
<p>If so many drugs can have toxic effects in the body, be it through side effects or taking the wrong dose or for the wrong condition, what determines whether a drug is a “medicine” or a “poison”?</p>
<p>Biomedical scientists evaluate drugs based on their active ingredient, or a specific compound that has a specific effect in the body. But reducing medicines to just a single molecule ignores another important factor that determines whether a drug is therapeutic – the context in which it is used. Opioids treat intractable pain but can lead to debilitating and lethal addiction when improperly administered. Chemotherapy kills tumors but causes collateral damage to healthy tissues in the process.</p>
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<span class="caption">Aconite is a poisonous herb that was used to treat cold symptoms in ancient Chinese medical practice.</span>
<span class="attribution"><a class="source" href="https://www.loc.gov/resource/lcnclscd.2012402216.1A010/?sp=3">Library of Congress, Asian Division, Chinese Rare Books</a></span>
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<p>Another pharmaceutical paradigm, <a href="https://theconversation.com/poison-or-cure-traditional-chinese-medicine-shows-that-context-can-make-all-the-difference-163337">traditional Chinese medicine</a>, has historically acknowledged the malleability of drugs through the use of poisons as therapeutics. </p>
<p><a href="https://scholar.google.com/citations?user=4q0hYSwAAAAJ&hl=en">Yan Liu</a>, a medical historian at University of Buffalo who studies this practice, notes that ancient texts did not distinguish between poisons and nonpoisons – rather, Chinese doctors examined drugs based on a continuum of potency, or ability to harm and heal. They used different processing and administration techniques to adjust the potency of poisons. They also took a personalized approach to treatment, aware that each drug works differently based on a number of different individual factors.</p>
<p>“The paradox of healing with poisons in traditional Chinese medicine reveals a key message: There is no essential, absolute or unchanging core that characterizes a medicine,” Liu writes. “Instead, the effect of any given drug is always relational – it is contingent on how the drug is used, how it interacts with a particular body and its intended effects.”</p>
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Read more:
<a href="https://theconversation.com/poison-or-cure-traditional-chinese-medicine-shows-that-context-can-make-all-the-difference-163337">Poison or cure? Traditional Chinese medicine shows that context can make all the difference</a>
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<p><em>Editor’s note: This story is a roundup of articles from The Conversation’s archives.</em></p><img src="https://counter.theconversation.com/content/192590/count.gif" alt="The Conversation" width="1" height="1" />
Despite technological advancements, many challenges remain in getting a drug from lab to pharmacy shelf. Reframing what is a “medicine” could expand treatment options for researchers and patients.Vivian Lam, Associate Health and Biomedicine EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1738042022-06-24T11:52:20Z2022-06-24T11:52:20ZHow do painkillers actually kill pain? From ibuprofen to fentanyl, it’s about meeting the pain where it’s at<figure><img src="https://images.theconversation.com/files/470376/original/file-20220622-11-ijs4h6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A variety of pain-relieving drugs are available both over the counter and by prescription.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-woman-looking-at-prescription-bottles-royalty-free-image/150684340">SelectStock/Vetta via Getty Images</a></span></figcaption></figure><p>Without the ability to feel pain, life is more dangerous. To avoid injury, pain tells us to use a hammer more gently, wait for the soup to cool or put on gloves in a snowball fight. Those with <a href="https://www.ncbi.nlm.nih.gov/books/NBK481553/">rare inherited disorders</a> that leave them without the ability to feel pain are unable to protect themselves from environmental threats, leading to broken bones, damaged skin, infections and ultimately a shorter life span.</p>
<p>In these contexts, pain is much more than a sensation: It is a protective call to action. But pain that is too intense or long-lasting can be debilitating. So how does modern medicine soften the call?</p>
<p>As a <a href="https://scholar.google.com/citations?user=Hn7sPk0AAAAJ&hl=en">neurobiologist</a> and an <a href="https://www.anesthesiology.pitt.edu/people/benedict-alter-md-phd">anesthesiologist</a> who study pain, this is a question we and other researchers have tried to answer. Science’s understanding of how the body senses tissue damage and perceives it as pain has progressed tremendously over the past several years. It has become clear that there are <a href="https://doi.org/10.1126/science.aaf8933">multiple pathways</a> that signal tissue damage to the brain and sound the pain alarm bell. </p>
<p>Interestingly, while the brain uses different pain signaling pathways depending on the type of damage, there is also redundancy to these pathways. Even more intriguing, these neural pathways morph and amplify signals in the case of <a href="https://doi.org/10.1097/j.pain.0000000000001384">chronic pain</a> and pain caused by <a href="https://doi.org/10.1152/physrev.00045.2019">conditions affecting nerves themselves</a>, even though the protective function of pain is no longer needed.</p>
<p>Painkillers work by tackling different parts of these pathways. Not every painkiller works for every type of pain, however. Because of the multitude and redundancy of pain pathways, a perfect painkiller is elusive. But in the meantime, understanding how existing painkillers work helps medical providers and patients use them for the best results.</p>
<h2>Anti-inflammatory painkillers</h2>
<p>A bruise, sprain or broken bone from an injury all lead to tissue <a href="https://my.clevelandclinic.org/health/symptoms/21660-inflammation">inflammation</a>, an immune response that can lead to swelling and redness as the body tries to heal. Specialized nerve cells in the area of the injury called <a href="https://www.verywellhealth.com/what-are-nociceptors-2564616">nociceptors</a> sense the inflammatory chemicals the body produces and send pain signals to the brain. </p>
<p>Common over-the-counter <a href="https://doi.org/10.1016/j.anclin.2017.01.020">anti-inflammatory painkillers</a> work by decreasing inflammation in the injured area. These are particularly useful for musculoskeletal injuries or other pain problems caused by inflammation such as arthritis. </p>
<p>Nonsteroidal anti-inflammatories like ibuprofen (Advil, Motrin), naproxen (Aleve) and aspirin do this by blocking an enzyme called <a href="https://www.ncbi.nlm.nih.gov/books/NBK549795/">COX</a> that plays a key role in a biochemical cascade that produces inflammatory chemicals. Blocking the cascade decreases the amount of inflammatory chemicals, and thereby reduces the pain signals sent to the brain. While acetaminophen (Tylenol), also known as paracetamol, doesn’t reduce inflammation as NSAIDs do, it also inhibits COX enzymes and has similar pain-reducing effects.</p>
<p>Prescription anti-inflammatory painkillers include other COX inhibitors, corticosteroids and, more recently, drugs that target and <a href="https://doi.org/10.1186/s10194-017-0807-1">inactivate the inflammatory chemicals</a> themselves.</p>
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<figcaption><span class="caption">Aspirin and ibuprofen work by blocking the COX enzymes that play a key role in pain-causing processes.</span></figcaption>
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<p>Because inflammatory chemicals are involved in other important physiological functions beyond just sounding the pain alarm, medications that block them will have side effects and potential health risks, including irritating the stomach lining and affecting <a href="https://doi.org/10.1161/01.hyp.0000116221.27079.ea">kidney function</a>. <a href="https://medlineplus.gov/ency/article/002123.htm">Over-the-counter medications</a> are generally safe if the directions on the bottle are followed strictly.</p>
<p><a href="https://www.verywellhealth.com/using-corticosteroids-for-pain-control-2564537">Corticosteroids</a> like prednisone block the inflammatory cascade early on in the process, which is probably why they are so potent in reducing inflammation. However, because all the chemicals in the cascade are present in nearly every organ system, long-term use of steroids can pose many health risks that need to be discussed with a physician before starting a treatment plan.</p>
<h2>Topical medications</h2>
<p>Many <a href="https://doi.org/10.1002/14651858.cd008609.pub2">topical medications</a> target nociceptors, the specialized nerves that detect tissue damage. Local anesthetics, like lidocaine, prevent these nerves from sending electrical signals to the brain. </p>
<p>The protein sensors on the tips of other sensory neurons in the skin are also targets for topical painkillers. Activating these proteins can elicit particular sensations that can lessen the pain by reducing the activity of the damage-sensing nerves, like the cooling sensation of menthol or the burning sensation of capsaicin.</p>
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<span class="caption">Certain topical ointments, like menthol and capsaicin, can crowd out pain signals with different sensations.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/topical-ointment-royalty-free-image/1328896655">Photography By Tonelson/iStock via Getty Images</a></span>
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<p>Because these topical medications work on the tiny nerves in the skin, they are best used for pain directly affecting the skin. For example, a <a href="https://doi.org/10.2147%2FJMDH.S106340">shingles infection</a> can damage the nerves in the skin, causing them to become overactive and send persistent pain signals to the brain. Silencing those nerves with topical lidocaine or an overwhelming dose of capsaicin can reduce these pain signals.</p>
<h2>Nerve injury medications</h2>
<p><a href="https://doi.org/10.1152/physrev.00045.2019">Nerve injuries</a>, most commonly from arthritis and diabetes, can cause the pain-sensing part of the nervous system to become overactive. These injuries sound the pain alarm even in the absence of tissue damage. The best painkillers in these conditions are those that dampen that alarm.</p>
<p><a href="https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/in-depth/pain-medications/art-20045004">Antiepileptic drugs</a>, such as gabapentin (Neurontin), suppress the pain-sensing system by blocking electrical signaling in the nerves. However, gabapentin can also reduce nerve activity in other parts of the nervous system, potentially leading to sleepiness and confusion.</p>
<p><a href="https://www.mayoclinic.org/pain-medications/art-20045647">Antidepressants</a>, such as duloxetine and nortriptyline, are thought to work by increasing certain neurotransmitters in the spinal cord and brain involved in regulating pain pathways. But they may also alter chemical signaling in the gastrointestinal tract, leading to an upset stomach.</p>
<p>All these medications are prescribed by doctors.</p>
<h2>Opioids</h2>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/18443637/">Opioids</a> are chemicals found or derived from the opium poppy. One of the earliest opioids, morphine, was purified in the 1800s. Since then, medical use of opioids has expanded to include many natural and synthetic derivatives of morphine with varying potency and duration. Some common examples include codeine, tramadol, hydrocodone, oxycodone, buprenorphine and fentanyl.</p>
<p>Opioids decrease pain by activating the body’s endorphin system. <a href="https://www.ncbi.nlm.nih.gov/books/NBK470306/">Endorphins</a> are a type of opioid your body naturally produces that decreases incoming signals of injury and produces feelings of euphoria – the so-called “runner’s high.” Opioids simulate the effects of endorphins by acting on similar targets in the body.</p>
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<figcaption><span class="caption">While opioids can provide strong pain relief, they are not meant for long-term use because they are addictive.</span></figcaption>
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<p>Although opioids can decrease some types of acute pain, such as after surgery, musculoskeletal injuries like a broken leg or <a href="https://doi.org/10.1002%2F14651858.CD012592.pub2">cancer pain</a>, they are often ineffective for <a href="https://doi.org/10.1001/jama.2018.18472">neuropathic injuries and chronic pain</a>. </p>
<p>Because the body uses opioid receptors in other organ systems like the gastrointestinal tract and the lungs, side effects and risks include constipation and potentially fatal suppression of breathing. Prolonged use of opioids may also lead to <a href="https://www.merckmanuals.com/home/drugs/factors-affecting-response-to-drugs/tolerance-and-resistance-to-drugs">tolerance</a>, where more drug is required to get the same painkilling effect. This is why opioids can be addictive and are not intended for long-term use. All opioids are controlled substances and are carefully prescribed by doctors because of these side effects and risks.</p>
<h2>Cannabinoids</h2>
<p>Although cannabis has received a lot of attention for its potential medical uses, there <a href="https://doi.org/10.1002/phar.2115">isn’t sufficient evidence available</a> to conclude that it can effectively treat pain. Since the use of cannabis is <a href="https://www.investopedia.com/marijuana-legality-by-state-4844504">illegal at the federal level</a> in the U.S., high-quality clinical research funded by the federal government has been lacking. </p>
<p>Researchers do know that the body naturally produces <a href="https://doi.org/10.1038/npp.2017.204">endocannabinoids</a>, a form of the chemicals in cannabis, to decrease pain perception. Cannabinoids may also reduce inflammation. Given the lack of strong clinical evidence, physicians typically don’t recommend them over FDA-approved medications.</p>
<h2>Matching pain to drug</h2>
<p>While sounding the pain alarm is important for survival, dampening the klaxon when it’s too loud or unhelpful is sometimes necessary. </p>
<p>No existing medication can perfectly treat pain. Matching specific types of pain to drugs that target specific pathways can improve pain relief, but even then, medications can fail to work even for people with the same condition. More research that deepens the medical field’s understanding of the pain pathways and targets in the body can help lead to more effective treatments and improved pain management.</p><img src="https://counter.theconversation.com/content/173804/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Seal receives funding from National Institutes of Health</span></em></p><p class="fine-print"><em><span>Benedict Alter receives funding from National Institutes of Health, Foundation for Anesthesia Education and Research, and the International Anesthesia Research Society. </span></em></p>Different painkillers provide relief in different ways. The most effective medication is the one that best targets the type of pain you’re experiencing with minimal side effects.Rebecca Seal, Associate Professor of Neurobiology, University of PittsburghBenedict Alter, Assistant Professor of Anesthesiology and Perioperative Medicine, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1657322021-08-20T15:16:24Z2021-08-20T15:16:24ZOpioid lawsuit payout plans overlook a vital need: Pain management care and research focused on smarter use of addictive drugs<figure><img src="https://images.theconversation.com/files/417080/original/file-20210819-25-qghrw5.jpg?ixlib=rb-1.1.0&rect=14%2C0%2C4927%2C3823&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The improper prescription of opioids for pain treatment is one of the central drivers of the opioid epidemic.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/men-and-women-suffering-with-pain-trapped-royalty-free-illustration/901762524">ah_designs/iStock via Getty Images Plus</a></span></figcaption></figure><p>The opioid crisis has resulted in <a href="https://wonder.cdc.gov/controller/saved/D77/D205F251">more than 500,000 overdose deaths</a> over the past two decades. The federal government, states and other entities have <a href="https://doi.org/10.1056/NEJMp1710756">filed litigation</a> against drug manufacturers, suppliers and pharmacies as one approach to address the harm and suffering caused by inappropriate opioid prescribing practices. <a href="https://www.wsj.com/articles/states-announce-26-billion-settlement-to-resolve-opioid-lawsuits-11626890613">Billions</a> of <a href="https://www.cnn.com/2021/07/20/investing/opioid-settlement-new-york-1-1-billion/index.html">dollars</a> of <a href="https://www.wsj.com/articles/purdue-pharma-reaches-8-34-billion-settlement-over-opioid-probes-11603292613">funds</a> have since been awarded, and more is likely to come. </p>
<p>To ensure these funds are used in areas relevant to opioids, policy and public health groups led by experts at <a href="https://opioidprinciples.jhsph.edu/">Johns Hopkins University</a>, <a href="https://fxb.harvard.edu/warondrugstoharmreduction/">Harvard University</a> and other organizations have <a href="https://www.lac.org/resource/opioid-settlement-recommendations-from-the-addiction-solutions-campaign">proposed</a> <a href="https://www.lac.org/resource/evidence-based-strategies-for-abatement-of-harms-from-the-o">frameworks</a> detailing priorities on what to do with the money. But none of them address the needs of one critical group: patients who suffer from acute and chronic pain.</p>
<p>Gaps in pain care and treatment, one of the key factors that enabled inappropriate opioid prescribing in the first place, persist. I am a <a href="https://scholar.google.com/citations?user=mQswfH4AAAAJ&hl=en">physician scientist specializing in pain medicine</a>. My colleagues, law professor <a href="https://michigan.law.umich.edu/faculty-and-scholarship/our-faculty/barbara-l-mcquade">Barbara McQuade</a> and anesthesiologist <a href="https://scholar.google.com/citations?user=FQIBJYEAAAAJ&hl=en">Chad Brummett</a>, and I believe there are <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2783468">three key ways</a> these funds could be used to improve pain treatment and address resource gaps for patients with acute and chronic pain.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Health care provider holding a person's bent leg below the knee." src="https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=361&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=361&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=361&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=453&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=453&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=453&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Expanding pain treatment beyond medication could help curb the opioid epidemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-man-having-medical-exam-royalty-free-image/846421676">gilaxia/E+ via Getty Images</a></span>
</figcaption>
</figure>
<h2>1. Comprehensive pain management</h2>
<p>There are two common types of pain. <a href="https://doi.org/10.1016/S0140-6736(99)03313-9">Acute pain</a> is usually sharp and sudden. It’s the pain typically felt after a cut or an injury, and helps warn the body about tissue damage. Acute pain is very common, and generally goes away once the body heals. </p>
<p><a href="https://medlineplus.gov/chronicpain.html">Chronic pain</a>, on the other hand, persists even after tissue has healed and the injury has resolved. When this happens, pain can transform from a symptom into a chronic disease. Many conditions can cause chronic pain, ranging from <a href="https://medlineplus.gov/arthritis.html">arthritis</a> and <a href="https://medlineplus.gov/migraine.html">migraines</a> to <a href="https://medlineplus.gov/fibromyalgia.html">fibromyalgia</a> and nerve pains like <a href="https://medlineplus.gov/sciatica.html">sciatica</a> and <a href="https://www.cdc.gov/shingles/about/complications.html">postherpetic neuralgia from shingles</a>, among others. Why acute pain transforms into chronic pain is not always clear. </p>
<p>Due to a <a href="https://dx.doi.org/10.1016%2Fj.drugalcdep.2016.12.002">combination of factors</a>, recent approaches to pain treatment, such as the concept of the <a href="https://dx.doi.org/10.1016%2Fj.pmn.2017.10.010">fifth vital sign</a> which reduced pain to a number on a scale between 0 and 10, led to an over-reliance on medications and limited approaches to treatment, all of which persist to this day.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/I7wfDenj6CQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">People have different responses to different levels of pain. What may be an effective treatment for one person might not be for someone else.</span></figcaption>
</figure>
<p>The most effective care for chronic pain, however, typically includes therapy beyond pills. <a href="https://www.ncbi.nlm.nih.gov/books/NBK82511/">Comprehensive pain management</a> involves care from a <a href="https://doi.org/10.1016/0304-3959(92)90145-2">diverse team of clinicians</a>, such as physical therapists and pain psychologists, to name a few. It also involves a suite of treatment approaches and care methodologies, including <a href="https://doi.org/10.1136/bmj.h444">behavioral therapy</a> which focuses on the psychological and social aspects of pain. <a href="https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name">Complementary and integrative approaches</a>, such as acupuncture, biofeedback and yoga, can also be combined with <a href="https://doi.org/10.1016/j.cger.2016.06.003">interventional approaches</a> like injections, dry needling and electrical stimulation.</p>
<p>While the right combination of therapies depends on the individual patient, the goal is to alleviate their pain, help them regain their ability to perform everyday activities and improve their quality of life.</p>
<p>This multidisciplinary and multimodal approach to pain management became less common due to <a href="https://dx.doi.org/10.1016%2Fj.drugalcdep.2016.12.002">financial pressures after the rise of managed care</a> in the late 1980s and early 1990s. Limited access to comprehensive pain management can lead to worse outcomes for patients. One study found that insurance policies that <a href="https://www.healthychildren.org/English/family-life/health-management/health-insurance/Pages/What-Is-an-Insurance-Carve-Out.aspx">carve out</a> physical therapy from pain management programs led to <a href="https://doi.org/10.1213/01.ane.0000058886.87431.32">worse physical and psychosocial function</a> up to one year after treatment in patients with chronic pain compared to patients whose insurance policies directly covered physical therapy.</p>
<p>Funding to bolster team-based and multidisciplinary approaches to treatment could not only improve care for patients in pain, but also increase their <a href="https://doi.org/10.1037/a0035514">accessibility outside of academic medical centers</a>.</p>
<h2>2. Evidence-based care models</h2>
<p><a href="https://doi.org/10.1136/bmj.a1714">Translating research into evidence-based care models</a> will help bring the best treatment approaches to patients in pain. These models of care <a href="https://www.ahrq.gov/opioids/evidence.html">review the evidence provided by clinical studies</a> and implement their findings to improve patient care. </p>
<p>For example, there is <a href="https://www.doi.org/10.23970/AHRQEPCCER240">evidence to support the use</a> of heat therapy and acupuncture for acute lower back pain, and non-opioid pills for kidney stone pain. Yet patients may not be offered these treatments due in part to <a href="https://doi.org/10.1001/jamanetworkopen.2018.0235">wide variation</a> <a href="https://doi.org/10.1001/jamanetworkopen.2018.3044">in coverage</a> of these treatments.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Health care provider performing acupuncture on a person's back." src="https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=358&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=358&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=358&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=450&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=450&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=450&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Complementary therapies can be integrated with traditional interventional approaches to treat pain.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/physio-performing-acupuncture-on-a-patient-royalty-free-image/1290749382">Catherine Falls Commercial/Moment via Getty Images</a></span>
</figcaption>
</figure>
<p>Opioid prescribing represents another area where several gaps in evidence exist for their effectiveness in treating both <a href="https://doi.org/10.17226/25555">acute</a> and <a href="https://stacks.cdc.gov/view/cdc/38026">chronic</a> pain. Until a few years ago, there was no data-driven answer as to what dose of opioids should be prescribed <a href="https://michigan-open.org/prescribing-recommendations/">after common types of surgery</a>. This was partly based on an assumption that patients needed prescription opioids after certain surgeries, which is <a href="https://doi.org/10.1097/sla.0000000000004965">not always the case</a>. Building evidence-based pain management recommendations to prevent unnecessary exposure to prescription opioids remain a focus of organizations like the <a href="https://michigan-open.org/">Michigan Opioid Prescribing Engagement Network</a>. </p>
<h2>3. Research on acute and chronic pain</h2>
<p>Additional research is needed to advance therapies to treat acute and chronic pain. A recent summary of acute pain treatments noted a <a href="https://www.doi.org/10.23970/AHRQEPCCER240">lack of evidence to support current therapies</a> for patients with sickle cell, acute nerve and neck pain, among others.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Group of five health care providers sitting around a table in discussion." src="https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Multidisciplinary care teams offer a more holistic way to manage pain.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/multidisciplinary-meetings-make-for-a-more-thorough-royalty-free-image/1248714799">shapecharge/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>The National Institutes of Health has boosted funding for research on pain and opioids in recent years via the <a href="https://heal.nih.gov/">HEAL Initiative</a>, a program focusing on opioid addiction and pain management. In 2019, the NIH <a href="https://www.nih.gov/news-events/news-releases/nih-funds-945-million-research-tackle-national-opioid-crisis-through-nih-heal-initiative">awarded US$945 million to projects</a> on improving chronic pain treatment, reducing opioid misuse and overdose and facilitating recovery from opioid addiction. Despite this effort, however, significant gaps still exist in both <a href="https://www.nap.edu/read/24781/chapter/6#120">lab-based</a> and <a href="https://doi.org/10.23970/AHRQEPCTB33">clinical</a> pain research. </p>
<h2>Giving patients with pain a seat at the table</h2>
<p>The economic impact of pain has been estimated to have a <a href="https://www.ncbi.nlm.nih.gov/books/NBK92521/">more than $700 billion dollar price tag</a> in the U.S. when adjusted for inflation. A little more than half of that amount comes from care costs, while the other half comes from reduced productivity or the inability to work. </p>
<p>[<em>Over 100,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>Addressing gaps in <a href="https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR090120.htm#fig64">addiction treatment</a> and <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">overdose prevention</a> is vital to turning the tide on the opioid epidemic. But implementing even some of these three ways to improve pain care could also put a dent in how much the U.S. spends on pain. Giving patients with pain a say in how funds from the opioid lawsuits are distributed can help make sure they’re not forgotten.</p><img src="https://counter.theconversation.com/content/165732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Bicket receives grant funding from the National Institutes of Health (R01DA042859, R01DA044987, R01DA049789), the Arnold Foundation, Michigan Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, and the US Centers for Disease Control and Prevention. He served as a consultant in the past for Axial Healthcare and Alosa Health. </span></em></p>Ending the opioid epidemic requires addressing not only treatment gaps in addiction and overdose, but also inadequate pain management.Mark C. Bicket, Assistant Professor of Anesthesiology, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1545192021-02-15T16:12:12Z2021-02-15T16:12:12ZHeadaches: three tips from a neuroscientist on how to get rid of them<figure><img src="https://images.theconversation.com/files/383754/original/file-20210211-19-1q3m9x4.jpg?ixlib=rb-1.1.0&rect=4850%2C1383%2C7131%2C4455&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/group-people-over-vintage-colors-background-1125851795">Krakenimages.com/Shutterstock.com</a></span></figcaption></figure><p>Everyone experiences headaches. From dull throbbing dehydration headaches to incapacitating migraines, a sore head is an extremely common complaint. This is perhaps especially true at the moment. COVID-19 <a href="https://covid.joinzoe.com/us-post/covid-clusters">can cause them</a>, as can sitting at desks for too long and not getting out of the house enough.</p>
<p>When headaches strike, many people’s reaction is to reach for a painkiller. And these can do the job. But a better solution is often to probe the reasons behind the pain – especially if you get similar types of headaches a lot.</p>
<p>Even though they all entail pain, where the pain is can clue us into what type of <a href="https://www.nhs.uk/conditions/headaches/">headache</a> we are experiencing. Pain in the face and forehead are markers of sinus-related headache whilst the sensation of a pneumatic drill somewhere in our cranium is often <a href="https://www.nhs.uk/conditions/migraine/">migraine</a>.</p>
<figure class="align-center ">
<img alt="Illustration of four different types of headache – migraine, sinus, tension and cluster – on green background." src="https://images.theconversation.com/files/383759/original/file-20210211-17-134ihn5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/383759/original/file-20210211-17-134ihn5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=491&fit=crop&dpr=1 600w, https://images.theconversation.com/files/383759/original/file-20210211-17-134ihn5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=491&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/383759/original/file-20210211-17-134ihn5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=491&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/383759/original/file-20210211-17-134ihn5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=617&fit=crop&dpr=1 754w, https://images.theconversation.com/files/383759/original/file-20210211-17-134ihn5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=617&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/383759/original/file-20210211-17-134ihn5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=617&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Where you experience the pain can be some clue as to what type of headache you have.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-man-different-types-headache-on-622158569">Africa Studio/Shutterstock</a></span>
</figcaption>
</figure>
<p>But ultimately, all headaches are caused by vasodilation in the head – the widening of blood vessels near the brain. This stretches sensory receptors in the vessel wall and we feel that sensation as pain.</p>
<p>To understand why we need to think about the constraints the contents of our head are working under. Blood is toxic to brain tissue and so is kept separate through the blood-brain barrier. If a blood vessel leaks or breaks, this results in a haemorrhage and the death of the brain tissue the blood seeps into. So, if our blood vessels dilate beyond comfortable limits, the sensory receptors will fire off signals to the brain, which we interpret as pain. </p>
<p>Headaches are an early warning system. The best way to counteract them is to work out what they are warning us about.</p>
<h2>1. Think beyond your head</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/383758/original/file-20210211-23-ykcyo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/383758/original/file-20210211-23-ykcyo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=918&fit=crop&dpr=1 600w, https://images.theconversation.com/files/383758/original/file-20210211-23-ykcyo1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=918&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/383758/original/file-20210211-23-ykcyo1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=918&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/383758/original/file-20210211-23-ykcyo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1154&fit=crop&dpr=1 754w, https://images.theconversation.com/files/383758/original/file-20210211-23-ykcyo1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1154&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/383758/original/file-20210211-23-ykcyo1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1154&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Bloomsbury Publishing</span></span>
</figcaption>
</figure>
<p>This means thinking beyond your head. Yes, headache pain is generated somewhere in our head and we feel it in our head and that is why it is called headache. But headache is so much more than that – which is why I’m fascinated by them, have studied them for the past 20 years and recently published <a href="https://www.bloomsbury.com/uk/splitting-9781472971418/">a book</a> on the subject.</p>
<p>It’s a two-way street. The cause of our headache can sometimes come from our body or our behaviour. And of course headaches affect both our body and our behaviour. If we see headache as something isolated to our cranium then we will never truly understand its cause, our experience of it, or how we can best mitigate it. </p>
<p>Frequent migraine sufferers intimately understand this and often <a href="https://www.migrainetrust.org/living-with-migraine/coping-managing/keeping-a-migraine-diary/">religiously track</a> their food intake and their activities as well as the weather in order to work out what triggers them. But the normal headache sufferer is often less in tune with the causes of their pain.</p>
<p><a href="https://www.nhs.uk/conditions/tension-headaches/">Tension headache</a> is a really good example of how this works. It feels like a tight band squeezing around your head with a tonne weight sitting on top for good measure. We are all aware of their occurrence at times of great emotional stress (lockdown homeschooling anyone?) but they can equally be caused by the stress we put on our body, with bad posture for example, or recovery from injury.</p>
<p>Both entail over-activity of the musculature around the head and neck, which sets up an inflammatory response involving prostaglandins and nitric oxide, both of which are chemicals that act to widen blood vessels. Inflammatory chemicals also directly activate the <a href="https://www.healthline.com/human-body-maps/trigeminal-nerve">trigeminal nerve</a> – the most complex of the cranial nerves and the one responsible for sensation and movement in the face.</p>
<p>Taking too many things on, rushing around trying to get things done in negative time, and trying to be all things to all people are common behavioural markers that will predict a tension headache. That and the actions we take when the pain begins.</p>
<figure class="align-center ">
<img alt="Woman sitting at desk clutches her neck and back in pain." src="https://images.theconversation.com/files/383762/original/file-20210211-14-rvfpk9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/383762/original/file-20210211-14-rvfpk9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/383762/original/file-20210211-14-rvfpk9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/383762/original/file-20210211-14-rvfpk9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/383762/original/file-20210211-14-rvfpk9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/383762/original/file-20210211-14-rvfpk9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/383762/original/file-20210211-14-rvfpk9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Bad posture – especially that associated with desk work – can lead to tension in the neck and then to headache.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/back-pain-bad-posture-woman-sitting-1772913518">Andrey_Popov/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>2. Listen to the pain</h2>
<p>If you have a pain in your leg, it might stop you from playing in that tennis match or turning up for five-a-side football. You know that if you play on it, you might do more damage and your recovery will take longer. But we don’t tend to do that with headache. We take a painkiller or an anti-inflammatory and carry on as normal even though our pain receptors are screaming at us that there is something wrong.</p>
<p>Taking paracetamol or ibuprofen will act to avert the danger, reducing the inflammation, the dilation and the perception of pain, but the headache will reoccur unless we can address the cause. Sometimes it’s obvious – if you have a sinus headache you’re just going to have to wait for your sinuses to clear, so taking a painkiller or a decongestant may be a good approach – but sometimes our coping strategy can make things worse.</p>
<p>We may decide a bottle of wine and a takeaway is just the kind of treat we need to relax and de-stress. But both lead to dehydration, another ubiquitous cause of headache. With your brain made of <a href="https://www.usgs.gov/special-topic/water-science-school/science/water-you-water-and-human-body?qt-science_center_objects=0#qt-science_center_objects">more than 70%</a> water, if your kidneys need borrow some to dilute alcohol or salts and spices, it usually comes from this oasis. The brain loses water such that it literally shrinks in volume, tugging on the membranes covering the brain and triggering pain.</p>
<h2>3. Use the brain’s natural painkillers</h2>
<p>So what else can we do? One way is to lean into the brain’s natural painkiller system and to boost neurochemicals associated with happiness (such as serotonin and oxytocin) and reward (dopamine). Having a laugh at a comedy, enjoying a good friend’s company or indulging in some intimacy with a partner will all boost these hormones to various degrees. </p>
<p>Each block pain signals coming from the body, not only helping you get a handle on your headache but also redressing the balance of neurochemicals that were the mechanism of your upset emotional state.</p>
<p>The knowledge that we can leverage our behaviour and our body to keep our brain’s neurochemicals in balance gives us a way to break the headache cycle. So next time you have a headache for which the causes aren’t glaringly obvious – you’re not otherwise sick and you’ve been keeping hydrated – take a look at your life and see what you can change there. The pain, after all, is trying to tell you something.</p><img src="https://counter.theconversation.com/content/154519/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amanda Ellison does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When headaches strike, many people reach for a painkiller. Probing the reasons behind the pain is often a better idea.Amanda Ellison, Professor of Neuroscience, Durham UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1439302020-08-06T16:25:52Z2020-08-06T16:25:52ZFewer opioid prescriptions in the UK look likely – and the consequences could be dire<figure><img src="https://images.theconversation.com/files/351535/original/file-20200806-14-l4ovgb.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4000%2C2664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/prescription-bottle-backlit-oxycodone-tablets-generic-1478645945">Tomas Nevesely/Shutterstock</a></span></figcaption></figure><p>Painkillers such as morphine have transformed the way pain can be controlled – but there are drawbacks, not least the risk of <a href="https://europepmc.org/article/nbk/nbk470415">overdose</a> or becoming dependent. The havoc and misery caused by over-prescribing these drugs in <a href="https://theconversation.com/roots-of-opioid-epidemic-can-be-traced-back-to-two-key-changes-in-pain-management-50647">the US</a> has seen hundreds of thousands of people die prematurely. </p>
<p><a href="https://theconversation.com/what-is-chronic-pain-and-why-is-it-hard-to-treat-57943">Chronic pain</a> can be caused by a range of <a href="https://www.nhsinform.scot/illnesses-and-conditions/brain-nerves-and-spinal-cord/chronic-pain">conditions</a>, including diabetes, back problems and fibromyalgia. In England alone, 5.6 million people were given a <a href="https://www.gov.uk/government/publications/prescribed-medicines-review-report">prescription</a> for an opiate-based medicine in 2018. And at least 25% of these people are thought to have been using the drugs for three months or more. This three-month cut-off is significant as it is the point at which the risk of dependence on these drugs develops.</p>
<p>The growing number of patients prescribed these drugs and the duration of the prescription was revealed in a <a href="https://www.gov.uk/government/publications/prescribed-medicines-review-report">recent report</a> by Public Health England. This triggered a review by the National Institute for Health and Care Excellence (Nice) examining the effectiveness of this class of pain medicines. Nice has just <a href="https://www.nice.org.uk/guidance/indevelopment/gid-ng10069/consultation/html-content-2">published its guidance</a> for treating chronic pain. </p>
<p>Contrary to what many believe, these drugs were found not to be effective at managing anything more than short-term pain – three months or less. Nice suggests alternatives, including exercise, talking therapy or acupuncture. This is a radical move by Nice and will surprise many patients and doctors. </p>
<p>Doctors know how challenging it can be to wean patients off opioids, especially when patients have been taking them for decades. Patients who for whatever reason have missed a dose of their pain medication will also know how uncomfortable it can make them feel. Withdrawal <a href="http://www.naabt.org/documents/cows_induction_flow_sheet.pdf">symptoms</a> can feel like extreme flu, shivering, raised temperature, aching, vomiting and irritability. </p>
<figure class="align-center ">
<img alt="Elderly man in bed with a fever." src="https://images.theconversation.com/files/351620/original/file-20200806-18-138u22x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/351620/original/file-20200806-18-138u22x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/351620/original/file-20200806-18-138u22x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/351620/original/file-20200806-18-138u22x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/351620/original/file-20200806-18-138u22x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/351620/original/file-20200806-18-138u22x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/351620/original/file-20200806-18-138u22x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Withdrawal can feel like an extreme case of influenza.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/coronavirus-warning-old-people-senior-man-1505023982">simona pilolla 2/Shutterstock</a></span>
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<p>Opioids are <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1360-0443.1994.tb03745.x">known</a> to cause physical and psychological dependence, so withdrawal can be a psychological as well as a physical challenge. It is not surprising then that patients will want to avoid experiencing this double discomfort. </p>
<p>Some doctors will view the managed withdrawal process as a job <a href="https://cks.nice.org.uk/opioid-dependence#!scenario:1">for a specialist</a>, even if just to start the process, which they can then supervise once established. For some, this will be a process that will take years as they are <a href="https://www.nejm.org/doi/full/10.1056/NEJMra1604339">gradually weaned</a> off their prescribed drug, sometimes just a few milligrams a month. Although a carefully managed professional withdrawal programme won’t be life threatening, it is not without risk.</p>
<p>Beyond the withdrawal symptoms already mentioned, which could be brought on if the reduction of opioids is too rapid, there are more severe risks to patients. Many will have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628209/">built up a tolerance</a> to these drugs which will fall as their managed reduction takes place. This makes any relapse during this time potentially fatal. The patient may return to the dose they started on and risk a fatal overdose. This phenomenon <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1360-0443.2007.02081.x?casa_token=AhwFTMY6SlIAAAAA%3ADxVX-FOOyMuggedow4vZLXJbXEdKGPolZC2bn8lMHR_D301AMZAcIr6ZPRIrpzyCoY5g7BLbWAv-wR_F1Q">has been witnessed</a> in previously heroin-dependent prisoners when released from prison.</p>
<p>But, of course, it’s not just prisoners who are at risk. Some patients whose opioid prescriptions will be reduced will find ways to maintain their usual dose. Doctor <a href="https://journals.sagepub.com/doi/full/10.1177/1178221817696077">shopping</a> is one way patients shop around for extra medication over and above the medication prescribed by their primary doctor. This can be a difficult situation for doctors to recognise. Even if they drug-test their patients – and many won’t – most tests merely show the presence or absence of a substance, not the quantity consumed. </p>
<h2>Scarcity of specialists</h2>
<p>These risks add to the case for ensuring doctors and patients receive professional and experienced support during this process. Unfortunately, this will be extremely difficult to find as the one group of professionals that they would naturally turn to have been made <a href="https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2020/02/17/addiction-psychiatry-could-be-wiped-out-in-a-decade-without-urgent-government-funding">almost extinct</a>: addiction psychiatrists. </p>
<p>Since specialist addiction was effectively contracted out to the third sector in the UK, there have been <a href="https://www.bbc.co.uk/news/uk-england-44039996">significant cuts</a> to this area of healthcare. With addiction psychiatrists being the most expensive personnel involved, it isn’t surprising that this group has rapidly shrunk to ensure the survival of services.</p>
<p>It will take years for the number of these specialists to be restored and have the ability to meet the demand that this guidance will trigger. In the meantime, doctors and patients will be left to manage the process themselves. It will be a miracle if no one dies as a consequence.</p><img src="https://counter.theconversation.com/content/143930/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new Nice guidance suggests exercise, talk therapy and acupuncture to treat chronic pain. Where does this leave those dependent on painkillers?Ian Hamilton, Associate Professor, Addiction and Mental Health, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1378912020-05-06T19:50:33Z2020-05-06T19:50:33Z1 in 5 Aussies over 45 live with chronic pain, but there are ways to ease the suffering<figure><img src="https://images.theconversation.com/files/332996/original/file-20200506-49542-99e45m.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6679%2C4476&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> </figcaption></figure><p>Around 1.6 million Australians aged 45 or over have been living with persistent pain, according to newly released data from the Australian Institute of Health and Welfare.</p>
<p>The figures, which cover 2016-17, reveal that GP consultations for chronic pain increased by 67% in the preceding decade. The number of visits for lower back pain increased by 400,000. </p>
<p>Dealing with chronic pain also means you are likely to face longer hospital stays, much poorer mental health and are three times more likely than normal to be taking painkillers regularly. About 105,000 people were hospitalised with chronic pain in 2017-18, with a typical hospital stay three times longer than average. </p>
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Read more:
<a href="https://theconversation.com/ouch-the-drugs-dont-work-for-back-pain-but-heres-what-does-72283">Ouch! The drugs don't work for back pain, but here's what does</a>
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<p>Behind those figures lies the human cost. As a clinical specialist in pain medicine, I see the jobs lost, the mortgage defaults, the superannuation withdrawals, and the family roles given up because of debilitating pain. </p>
<p>Lower back pain, migraine and pain following trauma are among the top 10 causes of years lost to disability worldwide, and this has <a href="http://www.healthdata.org/gbd">barely changed over the past 20 years</a>. Because chronic pain can happen at any stage of life, many people have to live with it for decades.</p>
<p>A <a href="https://www.painaustralia.org.au/static/uploads/files/the-cost-of-pain-in-australia-final-report-12mar-wfxbrfyboams.pdf">2019 Deloitte Access Economics report</a> commissioned by advocacy group <a href="https://www.painaustralia.org.au/">Painaustralia</a> estimated the annual cost to Australia’s economy at A$139.3 billion per year, more than A$20 billion of which comes directly out of the pockets of pain patients. </p>
<h2>A fresh approach</h2>
<p>The most expensive and inefficient way to manage this national crisis is pretty much the way we are currently doing it. Chronic pain care <a href="https://www.painaustralia.org.au/static/uploads/files/the-cost-of-pain-in-australia-final-report-12mar-wfxbrfyboams.pdf">is too fragmented</a> and too often delivered by those without the most up-to-date training.</p>
<p>Yet most of the really effective treatments can be delivered at a relatively low cost and with low-tech means. Here are some potential solutions that pain doctors and researchers are confident will work.</p>
<ul>
<li><p>Medications need to be carefully chosen and ruthlessly abandoned if they are not helping. The <a href="http://www.pbs.gov.au/statistics/expenditure-prescriptions/2018-2019/PBS_Expenditure_and_Prescriptions_Report_1-July-2018_to_30-June-2019.pdf">Pharmaceutical Benefits Scheme</a> (PBS) currently spends more than A$170m a year on drugs such as sustained-release opioids and pregabalin. This could be reduced if more doctors prescribed them in accordance with <a href="https://www.nps.org.au/professionals/opioids-chronic-pain">best practice</a> knowledge. This would help patients and taxpayers alike. </p></li>
<li><p>Skilled interventions such as inpatient infusions of medications like ketamine, or invasive procedures such as <a href="https://www.mayoclinic.org/tests-procedures/radiofrequency-neurotomy/about/pac-20394931">radiofrequency neurotomy</a>, need to be provided according to <a href="http://fpm.anzca.edu.au/documents/fpm-procedures-in-pain-medicine-ccs-v1-0-20191003.pdf">appropriate quality standards</a> so resources are not wasted and patients are not put at risk.</p></li>
<li><p>PBS funding should be extended to cover effective treatments for specific conditions such as <a href="https://link.springer.com/article/10.1007/s11916-019-0768-y">migraines</a>. </p></li>
<li><p>Proven treatments such as group pain programs and individual therapy sessions with credentialed allied health specialists need to be supported by Medicare. These are essential for building the self-management skills needed to reduce patients’ reliance on pain medication. </p></li>
<li><p>We need a massive investment in training and service redesign for agencies that deal with chronic pain as a result of work or transport injuries. </p></li>
<li><p>High-quality pain care should be viewed not as a luxury for hospitals, but an essential part of the health-care ecosystem. Pain care should be integrated throughout the public health system, in both acute and subacute care, where it can shorten inpatient stays and improve rehabilitation. </p></li>
<li><p>We should restrict access to low-value treatments like repeated surgery or medications that have not been working.</p></li>
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Read more:
<a href="https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829">Needless treatments: spinal fusion surgery for lower back pain is costly and there's little evidence it'll work</a>
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<p>In the void created by the huge unmet need and the limited availability of expert pain care, an industry of highly dubious usefulness has been allowed to flourish. Social media is full of false hope. Supplements such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/27477804">glucosamine</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/28470851">curcumin</a> and <a href="https://journals.lww.com/jclinrheum/fulltext/2017/09000/omega_3_fatty_acids_in_rheumatic_diseases__a.6.aspx">fish oil</a> are not supported by credible studies, yet they are still promoted commercially as effective. </p>
<p>Dodgy arthritis “cures” and devices that claim to relieve pain using magnets or electricity are everywhere. Despite <a href="https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-treatment-chronic-non-cancer-pain-australia">dismal supporting evidence</a>, the medical cannabis industry continues to sell itself to chronic pain patients.</p>
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Read more:
<a href="https://theconversation.com/im-taking-glucosamine-for-my-arthritis-so-whats-behind-the-new-advice-to-stop-131648">I'm taking glucosamine for my arthritis. So what's behind the new advice to stop?</a>
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<p>While the COVID-19 pandemic continues, it can be hard to focus on other health issues. But Australia already has a path to improving life for many thousands of chronic pain sufferers. The federal government has developed a <a href="https://www.painaustralia.org.au/static/uploads/files/national-action-plan-11-06-2019-wftmzrzushlj.pdf">strategic plan for pain management</a> that offers a blueprint for future action. </p>
<p>The plan calls for upskilling of all primary care health professionals to help them recognise the early stages of a chronic pain problem and nip it in the bud. If implemented, it will bring the dream of timely access to well-resourced expert interdisciplinary pain teams in the regions and outer suburbs closer to reality. </p>
<p>Most importantly, we need a community-wide effort to destigmatise persistent pain and those who suffer from it. After all, the chances are you either have it or you live or work with someone who does.</p><img src="https://counter.theconversation.com/content/137891/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Vagg is the current Dean of the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists</span></em></p>Chronic pain is everyone’s problem. It’s costly, debilitating and, according to new statistics, increasingly common. Reversing the trend is achieveable but far from easy.Michael Vagg, Conjoint Clinical Associate Professor, Deakin University School of Medicine and Specialist Pain Medicine Physician, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1282462020-01-29T12:41:41Z2020-01-29T12:41:41ZSecret histories of drugs – legal and illegal – in southern Africa<figure><img src="https://images.theconversation.com/files/311110/original/file-20200121-117907-1k57lih.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>If you want to score heroin in some of the historically black suburbs, or townships, of Johannesburg, South Africa, you need to find yourself a ‘Snyman’. A ‘Snyman’ is a drug dealer. The word is used in <a href="https://link.springer.com/chapter/10.1057/978-1-137-01593-8_18">tsotsitaal</a>, the creole, urban dialect that emerged during the colonial and apartheid eras of segregation. </p>
<p>‘Snyman’ entered this lexicon in the late 1960s and early 1970s. It was around this time that cannabis smugglers supplying the gold mining compounds and nearby settlements began to diversify into pharmaceuticals. One drug of choice was methaqualone, also known as Mandrax. </p>
<p>Today, most young people who rely on a Snyman to supply them with a
bit of a heroin admixture locally known as <a href="https://www.sciencedirect.com/science/article/pii/S037907381830481X">nyaope</a> aren’t aware that they are invoking the name of a mid-century professor of medicine at the University of Pretoria, Dr HW Snyman. In 1961 Snyman headed a governmental commission that bore his name. Its recommendations led to the Medicines and Related Substances <a href="https://www.nda.agric.za/vetweb/Legislation/Other%20acts/R_Medicines_and_related_substances.htm">Control Act</a> of 1965.</p>
<p>This means that, at the height of the apartheid era, black entrepreneurs trading in illicit pharmaceuticals adopted and repurposed the name of a white medical expert who enacted the state’s vision of drug regulation. In calling themselves ‘Snyman’, they showed a hefty dose of defiance as well as ironic humour.</p>
<p>The anecdote may be read as a metaphor of grassroots challenges to apartheid statecraft. But it also confirms growing, global evidence that drug prohibitions have never been far from the workings of ‘shadow’ economies. Indeed, chemically and socially, the <a href="https://www.strath.ac.uk/humanities/schoolofhumanities/history/centreforthesocialhistoryofhealthhealthcare/beyondthemedicinesdrugsdichotomyhistoricalperspectivesongoodandevilinpharmacy/">dichotomies</a> historically crafted between (legitimated) medicines and (illicit) drugs just don’t hold in practice. </p>
<p>We see this currently, for example, in the rapidly <a href="https://www.economist.com/international/2019/08/29/a-global-revolution-in-attitudes-towards-cannabis-is-under-way">shifting legal status</a> of cannabis (including in <a href="http://theconversation.com/south-african-court-frees-cannabis-from-colonial-and-apartheid-past-103644">South African law</a>) and its speedy absorption into <a href="https://www.marketwatch.com/story/10-largest-marijuana-companies-2019-01-02">corporate commerce</a>; in <a href="https://www.theguardian.com/us-news/2019/oct/04/purdue-pharma-oxycontin-sacklers-opioid-lawsuits">painkiller</a> ‘opioid crises’ and <a href="https://www.cdc.gov/nchs/pressroom/podcasts/20190911/20190911.htm">fentanyl overdose deaths</a> in the US; in the <a href="https://www.unodc.org/nigeria/en/key-findings-of-unodc-study-on-tramadol-trafficking-in-west-africa-discussed-at-regional-meeting.html">illicit trade</a> in the painkiller Tramadol in West Africa; and in clandestine exports of Chinese Xanax into the hands of South African <a href="https://www.newframe.com/prescription-drug-poses-new-threat-to-youths/">school kids</a>.</p>
<p>A special issue of the <a href="https://www.tandfonline.com/toc/rshj20/current">South African Historical Journal</a>, Drug Regimes in Southern Africa, showcases research about some of the ‘secret’ histories of drugs from the southern region of the African continent. These range from Cape Town’s opium dens to cannabis experiments on cats; from big pharma bio-prospecting to the politics of synthetic sedatives and controversial cow vaccines.</p>
<p>But why spend time reading about the past when today’s drug dilemmas seem so urgent?</p>
<h2>Why history matters</h2>
<p>Historical research can offer critical perspectives that help make sense of current dilemmas. Historians don’t generally set out to inform policy. Nevertheless complex understandings of the past are key to sound decision-making in both legislative and medical practices. Historians know that debates about substances commonly called ‘drugs’ are far from new. As was pointed out by organisers of a recent <a href="https://www.strath.ac.uk/humanities/schoolofhumanities/history/changingmindssocietiesstatesthesciencesandpsychoactivesubstancesinhistory/">history conference</a> held in Shanghai:</p>
<blockquote>
<p>After all, experts offering definitive accounts of psychoactive substances, vacillating bureaucrats and politicians, unyielding moralists and fickle consumers are all among the figures familiar to historians from other periods and a range of places.</p>
</blockquote>
<p>Historical research on ‘drugs’, whether defined as <a href="https://www.intoxicatingspaces.org/">intoxicants</a> or medicines, is an established field among scholars in the global North. This is shown in the work of the <a href="https://alcoholanddrugshistorysociety.org/about/">Alcohol and Drugs History Society</a> and its excellent journal, <a href="https://www.journals.uchicago.edu/toc/shad/current">Social History of Alcohol and Drugs</a>. </p>
<p>But drugs history scholarship from and about the global South grows ever more vibrant. Histories of <a href="https://uncpress.org/book/9780807859056/andean-cocaine/">cocaine </a> in South America and <a href="https://www.strath.ac.uk/humanities/schoolofhumanities/history/centreforthesocialhistoryofhealthhealthcare/ourresearch/theasiancocainecrisis/">Asia</a>, <a href="https://uncpress.org/book/9781469613727/home-grown/">cannabis in Mexico </a> and <a href="https://www.cambridge.org/core/journals/journal-of-modern-african-studies/article/politics-of-law-enforcement-in-nigeria-lessons-from-the-war-on-drugs/8B56707532B2902B3C2A26354C97966B">Nigeria</a>, <a href="https://brill.com/view/title/13754">khat in Kenya</a> and the politics of <a href="https://www.cambridge.org/core/books/drugs-politics/E2EFB2A2A59AC5C2D6854BC4C4501558">drug use in Iran</a> are a few examples. </p>
<p><a href="https://www.palgrave.com/gp/book/9781137321893">Histories of drugs in Africa</a> are of growing interest worldwide.</p>
<p>Since the late 19th century especially, global flows of neurochemical substances and products have deepened the entanglements of consumers in Africa in networks of legal and illicit drugs production, flow, profit and risk. Historical perspectives bring to light the social processes through which bioactive plants, manufactured pharmaceuticals and techniques of treatment come to figure in diverse and changing human experiences. </p>
<p>In the 20th century, the contexts of colonialism, apartheid and democracy shaped <a href="https://mh.bmj.com/content/44/4/253">drug control, provision and regulation</a> in South Africa.</p>
<p>Today media reports on drug issues in this country often invite panicked responses. Journalism frequently reproduces the hyperbole and moralism that have – for over a century – shaped public opinion here. Narratives that sometimes exaggerate or even mislead the public about new forms of substances, coming across borders, or the behaviours they allegedly cause, have had very negative consequences. These have included fuelling <a href="https://www.theguardian.com/world/2019/sep/10/we-are-a-target-wave-of-xenophobic-attacks-sweeps-johannesburg">xenophobic sentiments</a> as well as <a href="https://www.hsrcpress.ac.za/books/opioids-in-south-africa">the stigma</a> attached to people using drugs. </p>
<p>At the same time, there are hopeful signs of change in public opinion. And there are positive indications of a quest for evidence-based policy and treatment solutions. An example is the case of <a href="https://www.hsrcpress.ac.za/books/opioids-in-south-africa">harm reduction approaches</a> to opioid addiction.</p>
<h2>What’s needed</h2>
<p>The promises of pharmaceutical technologies are evident. So are the challenges. In today’s global world, we need the evidence offered by history to develop more informed, nuanced and less reactionary responses.</p>
<p>The <a href="https://www.tandfonline.com/toc/rshj20/current">special issue</a> ‘Drug Regimes in Southern Africa’ is proof of a growing body of work on the histories of drugs – illegal and legal – across the continent. </p>
<p><em>The information that ‘Snyman’ is used as a word for drug dealer was provided by Msawenkosi Gibson Nzimande, a University of Johannesburg Masters student currently doing research on substance use in Johannesburg.</em></p>
<p><em>This is the first article in a <a href="https://theconversation.com/africa/search?utf8=%E2%9C%93&q=DRSA">series</a> on drug regimes in southern Africa. They are based on research done for a special edition for the <a href="https://www.tandfonline.com/toc/rshj20/current">South African Historical Journal</a>. Read the full paper over <a href="https://www.tandfonline.com/doi/full/10.1080/02582473.2019.1681073">here</a>.</em></p><img src="https://counter.theconversation.com/content/128246/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thembisa Waetjen receives funding from the National Research Foundation (NRF).</span></em></p><p class="fine-print"><em><span>Julie Parle receives funding from the National Research Council (NRF).</span></em></p><p class="fine-print"><em><span>Rebecca Hodes receives funding from the Medicines Research Council and the Human Sciences Research Council of South Africa, the Medical Research Council of the United Kingdom, the Fogarty International Centre and the National Institute of Mental Health at the National Institutes of Health, United States, the European Research Council, and the Desmond Tutu HIV Foundation.</span></em></p>From colonial poppy fields to pharmatrash, southern Africa offers a fascinating history of drug regimes – one that helps us make sense of drug policies and legislation today.Thembisa Waetjen, Associate Professor of History, University of JohannesburgJulie Parle, Honorary Professor in History, University of KwaZulu-NatalRebecca Hodes, Director, AIDS and Society Research Unit, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1222852019-08-29T14:11:17Z2019-08-29T14:11:17ZTaking opioids for chronic pain: here’s what the experts recommend<figure><img src="https://images.theconversation.com/files/289203/original/file-20190823-170910-gzqojh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/drug-epidemic-illustration-about-mass-consumption-706093327">Shutterstock</a></span></figcaption></figure><p>Chronic pain – acute pain that lasts for longer than three months – affects around <a href="https://onlinelibrary.wiley.com/doi/full/10.1016/j.ejpain.2005.06.009">one in five people</a> in Europe. The increase in use of strong morphine-type drugs (opioids) for the treatment of chronic pain is an area of much concern, <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(17)30479-0/fulltext">particularly in North America</a>.</p>
<p>Termed an “<a href="http://theconversation.com/opioid-epidemic-the-global-spread-explained-101649">opioid epidemic</a>”, most developed countries have seen a major increase in opioid prescribing over the last decade or so. Our latest <a href="https://www.sign.ac.uk/sign-136-management-of-chronic-pain.html">research</a> assesses how good the evidence is that opioids can help chronic pain effectively, balanced against any harms they can cause.</p>
<p>Chronic pain <a href="https://onlinelibrary.wiley.com/doi/full/10.1016/j.ejpain.2005.06.009">very often doesn’t get better</a>, so people can be prescribed opioids for a long time – years, or even decades. Is there evidence that opioids continue to work well to reduce chronic pain and improve quality of life? The majority of clinical trials only study opioid use for three months, so we don’t really know much about their effectiveness over the longer term.</p>
<hr>
<p><em><strong>Read more: <a href="https://theconversation.com/what-is-chronic-pain-and-why-is-it-hard-to-treat-57943">What is chronic pain and why is it so hard to treat?</a></strong></em> </p>
<hr>
<p>One of the few studies that has looked at how effective opioids are after 12 months, <a href="https://jamanetwork.com/journals/jama/fullarticle/2673971">found</a> that people who took opioid painkillers were not any more active than those on other types of painkillers.</p>
<p>There is also <a href="https://www.ncbi.nlm.nih.gov/pubmed/25581257">evidence</a> that long-term use of opioids may be harmful. This is likely to be dose-related as risks increase at higher doses. Known harms include increased risks of:</p>
<ol>
<li><p><a href="https://www.theguardian.com/science/audio/2018/sep/21/opioid-addiction-can-the-uk-curb-the-looming-crisis-science-weekly-podcast">Addiction and misuse</a>: this can affect anyone who is prescribed opioids for pain. Prescribers and patients need to be aware of, and minimise, the risk from the beginning. </p></li>
<li><p>Overdose and death: deaths from prescription opioids are <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">increasing dramatically in the US</a> for example.</p></li>
<li><p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590093/">Interfering with the endocrine system</a>: changes in hormone levels that can impact on sexual function and fertility.</p></li>
<li><p><a href="https://www.ncbi.nlm.nih.gov/pubmed/25581257">Heart problems</a>: heart attack risk is more than doubled in people taking long-term opioids. </p></li>
<li><p>Being in a <a href="https://www.ncbi.nlm.nih.gov/pubmed/25581257">road traffic accident</a>: the risk is higher among drivers taking even relatively low doses of opioids.</p></li>
<li><p>Worsening pain or “<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30430-1/fulltext?rss=yes">opioid-induced hyperalgesia</a>”: when long-term use makes pain worse. This is often difficult to recognise.</p></li>
<li><p><a href="https://insights.ovid.com/article/00006396-201208000-00011">Opioid tolerance</a>: when the body becomes used to opioids and requires a bigger dose to get the same painkilling effect.</p></li>
<li><p>Adverse effects on the <a href="https://www.ncbi.nlm.nih.gov/pubmed/28213891">immune system</a>: people taking opioids eventually become more prone to infections.</p></li>
</ol>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">One in five Europeans suffers from chronic pain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/lower-back-pain-590676011">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Should we use opioids for chronic pain?</h2>
<p>Yes, when appropriate – but with caution. The <a href="https://www.sign.ac.uk/what-we-do.html">Scottish Intercollegiate Guideline Network</a> (SIGN) publishes high-quality evidence-based management guidelines. <a href="https://www.sign.ac.uk/assets/sign136.pdf">SIGN 136</a> was the first comprehensive guideline on the management of chronic pain, published in 2013.</p>
<p>As a result of <a href="https://www.sign.ac.uk/sign-136-management-of-chronic-pain.html">new evidence</a>, SIGN 136 has specifically reviewed the section on opioid use and <a href="https://www.sign.ac.uk/sign-136-management-of-chronic-pain.html">updated recommendations</a> have recently been published. New research since 2013 has been critically reviewed to ensure that the new recommendations are based on the best available evidence. Some of the key points in the new advice include the following:</p>
<ol>
<li><p>Opioids should be used for as short a time as possible, in carefully selected people with chronic pain. This should happen when other treatments haven’t worked to manage the pain and where the benefits outweigh the risks of the serious harms listed above.</p></li>
<li><p>Before starting treatment, the person with chronic pain and the prescriber should agree what the treatment aims are. These might include reduced pain, increased activity and/or better quality of life. If this doesn’t happen then there should be an agreed action plan to reduce and stop opioids. </p></li>
<li><p>There should be ongoing, regular review by a member of the primary healthcare team, especially if the daily dose is equivalent to more than 50mg of morphine. Review should be frequent in the early stages, and at least annually, after treatment is established. If problems arise – such as opioids no longer providing good pain relief, increasing the dose provides no sustained pain relief or then there is evidence of addiction – then more frequent review will be needed and consideration given to reducing/stopping treatment.</p></li>
<li><p>We should always use the lowest effective dose. Higher doses (equivalent to more than 90mg/day of morphine) should only be prescribed alongside review by a pain specialist.</p></li>
</ol>
<p>These recommendations are consistent with those of <a href="https://www.iasp-pain.org/Advocacy/Content.aspx?ItemNumber=7194">The International Association for the Study of Pain</a> (IASP). The organisation emphasises that the use of other approaches, including behavioural therapies and increasing physical activity to improve quality of life, is preferred.</p>
<h2>Where do we go from here?</h2>
<p>Current evidence indicates that widespread, long-term opioid prescribing for chronic pain is likely to cause more harm than benefit in society. But some individuals with chronic pain do benefit. They should continue to be prescribed opioids, with the recommended caution, careful monitoring and review, and use of proven non-pharmacological therapies. Some people may also need support to reduce and stop long-term opioids, where the harms outweigh the benefits.</p>
<p>There is an urgent need for research to understand how to manage chronic pain better, including the safe use of and withdrawal from opioids. In tandem we need national policies, based on best available evidence and approaches to educate healthcare professionals and patients. This is likely to require investment in the short term, but it may be a small price to pay for the longer term benefits and probable cost savings of improving chronic pain management, which is the <a href="https://www.thelancet.com/gbd">leading cause of disability</a> globally.</p><img src="https://counter.theconversation.com/content/122285/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Colvin receives funding from Scottish Government for quality improvement work on chronic pain. She is a member of SIGN Council and chaired the original Guideline Development Group (2013). She is a member of the MHRA Opioid Expert Working Group, and an Editor for the British Journal of Anaesthesia</span></em></p><p class="fine-print"><em><span>Within the last five years, Blair H. Smith has received research funding from the European Union, Medical Research Council, and Scottish Government, and previously from Pfizer Ltd, for research into causes and management of chronic pain. He is a member of the Scottish National Party. Ailsa Stein and colleagues at the Scottish Intercollegiate Guideline Network contributed a major component of the work described in this article.</span></em></p>Advice from the people who’ve reviewed all the latest evidence about the effectiveness of these painkillers.Lesley Colvin, Deputy Head of Division - Population Health & Genomics & Chair in Pain Medicine, University of DundeeBlair H. Smith, Professor of Population Health Science, University of DundeeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1061632018-11-25T19:06:01Z2018-11-25T19:06:01ZAmbulance call-outs for pregabalin have spiked – here’s why<figure><img src="https://images.theconversation.com/files/246806/original/file-20181122-182071-2lpqex.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">At higher-than-prescribed doses, pregabalin causes sedation and euphoria.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/i4rOpdj444c">Bruno van der Kraan</a></span></figcaption></figure><p>Pregabalin (sold under the brand name Lyrica) is prescribed as an anti-epileptic and a painkiller for nerve pain. Australian prescriptions of pregabalin have risen significantly in the past five years. It’s now in the <a href="https://www.nps.org.au/australian-prescriber/articles/top-10-drugs-2015-16">top ten most expensive medications for the Pharmaceutical Benefits Scheme</a> (PBS). </p>
<p>We’ve also seen a rise in “off-label” prescription of pregabalin. This means it’s being prescribed for conditions for which there is limited evidence of effectiveness. Pregabalin is <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1704633">often prescribed</a> for chronic or persisting pain, for example, even when there is no clear nerve-related cause. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-why-are-off-label-medicines-prescribed-44783">Explainer: why are off-label medicines prescribed?</a>
</strong>
</em>
</p>
<hr>
<p>Pregabalin is thought to have effects in the brain similar to those of benzodiazepines such as diazepam (Valium) by indirectly increasing levels of the neurotransmitter GABA. </p>
<p>Until recently, researchers and doctors <a href="https://europepmc.org/abstract/med/24849194">did not think pregabalin was addictive</a>. But now studies suggest pregabalin may also have an indirect effect on the brain’s reward chemical, dopamine. </p>
<p>Our research, published today in the <a href="https://www.mja.com.au/">Medical Journal of Australia</a>, shows ambulance call-outs associated with the misuse of pregabalin have increased tenfold in Victoria since 2012. This mirrors an increase in prescription rates.</p>
<h2>Growing evidence of misuse</h2>
<p>In 2010, the <a href="https://link.springer.com/article/10.1007/s00228-010-0853-y">first study</a> was published that reported on a trend of pregabalin misuse. </p>
<p>Since then, several <a href="https://link.springer.com/article/10.1007/s40263-014-0164-4">international research articles</a> have documented misuse, including <a href="https://link.springer.com/article/10.1007/s40265-017-0700-x">using higher doses than are recommended</a>. At higher-than-prescribed doses, pregabalin causes sedation and euphoria.</p>
<p>People who use opioids – painkillers like oxycodone, or illicit opioids such as heroin – have a particularly <a href="https://link.springer.com/article/10.1007/s40263-014-0164-4">high risk</a> of misusing pregabalin. So do those with a history of substance use problems. </p>
<p>People who use illicit drugs report often using pregabalin in combination with other drugs. Pregabalin <a href="https://link.springer.com/article/10.1007/s40263-014-0164-4">has been implicated</a> in drug-related deaths in individuals who weren’t prescribed the medication, and often in combination with other sedative medications or illicit drugs. </p>
<p>High rates of pregabalin use are also reported in secure environments, such as prisons, in both <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4657313/pdf/austprescr-38-160.pdf">Australia</a> and <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/385791/PHE-NHS_England_pregabalin_and_gabapentin_advice_Dec_2014.pdf">the United Kingdom</a>. </p>
<h2>What did we find?</h2>
<p>We analysed a unique database (<a href="https://www.turningpoint.org.au/research/population-health">the Ambo Project</a>) that documents all ambulance attendances related to alcohol and drug use and mental health in Victoria. </p>
<p>We found pregabalin-related ambulance attendances increased tenfold between 2012 and 2017, from 0.28 cases per 100,000 population to 3.32 cases per 100,000. Pregabalin misuse contributed significantly to 1,201 call-outs from 2012 to 2017. </p>
<p>Pregabalin has a sedative effect, which can be compounded when used with other drugs that cause sedation, including alcohol, or other prescribed medications such as benzodiazepines and sleeping tablets (such as Valium). </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/despite-escalating-prescriptions-nerve-pain-drug-offers-no-relief-for-sciatica-74699">Despite escalating prescriptions, nerve pain drug offers no relief for sciatica</a>
</strong>
</em>
</p>
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<p>More than two-thirds of pregabalin-related ambulance call-outs were for people who also used other sedatives. Almost 90% required transport to hospital. In some situations, such sedation could be life-threatening.</p>
<p>Our findings of rising harms, especially from co-use with other drugs, echo findings from a <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/add.14412">New South Wales</a> research group that used data from poisons hotline calls, hospital admissions, and coronial reports from drug-related deaths. </p>
<h2>How to reduce the harms</h2>
<p>Doctors need to ensure patients are provided with the opportunity for careful and considered informed consent.</p>
<p>Pregabalin is a high-risk medication, especially when used with other sedatives. Although some doctors are aware of the side effects and harms associated with pregabalin, many are not. </p>
<p>The <a href="https://www.racgp.org.au/yourracgp/faculties/queensland/newsletter/september-2018/">Royal College of General Practitioners recently warned doctors</a> to carefully assess the risks when prescribing these medications, particularly for people who are also prescribed opioids or benzodiazepines. <a href="https://www.nps.org.au/news/gabapentinoid-misuse-an-emerging-problem">NPS MedicineWise</a> also recently highlighted the need for prescribers to exercise caution.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-why-can-you-feel-groggy-days-after-an-operation-74989">Health Check: why can you feel groggy days after an operation?</a>
</strong>
</em>
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<p>Better regulation is also needed. </p>
<p>Some Australian states including Victoria plan to implement <a href="https://www2.health.vic.gov.au/public-health/drugs-and-poisons/safescript">real-time prescription monitoring (RTPM)</a>. This would allow authorities to monitor and regulate access to high-risk medications such as opioid painkillers (oxycodone or similar) or benzodiazepines. </p>
<p>But pregabalin is not on the list of medications that will be captured by real-time prescription monitoring. To reduce the high risk of harm from pregabalin misuse, we should consider adding this drug to the list.</p>
<p>In the United Kingdom, pregabalin will become a “scheduled” or <a href="https://www.bmj.com/content/363/bmj.k4364">controlled medication</a> from April 2019. This means doctors will need to apply for a permit before prescribing it. </p>
<p>If this is found to be successful, Australia should consider following suit.</p><img src="https://counter.theconversation.com/content/106163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>We would like to acknowledge the contribution of our co-authors Karen Smith, Debbie Scott and Paul Dietze. Thanks to Ambulance Victoria for providing the data and the Population Health team at Turning Point who code it to create this unique data set.
Shalini Arunogiri has previously received a scholarship from the National Health and Medical Research Council (NHMRC), and the Society for Mental Health Research (SMHR).
</span></em></p><p class="fine-print"><em><span>Dan Lubman has received funding from the National Health and Medical Research Council, the Australian Research Council, beyondblue, Movember, Victorian Department of Health and Human Services, Commonwealth Department of Health, Victorian Gambling Research Foundation and the Victorian Health Promotion Foundation. He has also received speaking honoraria from AstraZeneca, Indivior, Janssen, Servier, Shire and Lundbeck and has provided consultancy advice to Lundbeck and Indivior. </span></em></p><p class="fine-print"><em><span>Rose Crossin has previously received an RTP scholarship from the Australian Department of Education and Training. </span></em></p>Ambulance call-outs associated with the misuse of pregabalin (Lyrica) have increased tenfold in Victoria since 2012, mirroring an increase in prescription rates.Shalini Arunogiri, Addiction Psychiatrist, Lecturer, Monash UniversityDan Lubman, Director, Turning Point Alcohol and Drug Centre & Professor of Addiction Studies, Monash UniversityRose Crossin, Research Officer in Addiction Studies , Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1062352018-11-07T19:19:20Z2018-11-07T19:19:20ZPain isn’t just physical: why many are using painkillers for emotional relief<figure><img src="https://images.theconversation.com/files/244237/original/file-20181107-74757-ezlayn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The biological pathways related to physical and emotional pain overlap. </span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/NuzqLqEIRjM">Issam Hammoudi/Unsplash</a></span></figcaption></figure><p>Australians are increasingly using prescription or over-the-counter painkillers to ease emotional, rather than physical, pain. Our cultural understanding of pain is changing, and as a result it’s becoming more difficult to distinguish intoxication from relief.</p>
<p>In my recently published book <a href="https://www.palgrave.com/us/book/9789811319747">A Fine Line: Painkillers and Pleasure in the Age of Anxiety</a>, interviewees who used painkillers non-medically said they did so mainly to ease forms of suffering they acknowledge may not be medically defined as pain. Yet they experienced them as “painful”. </p>
<p>The US is currently going through what many term an “opioid epidemic”, while more than 1,000 Australians <a href="https://ndarc.med.unsw.edu.au/news/majority-opioid-overdose-deaths-australia-are-related-pharmaceutical-opioids">died of an opioid overdose</a> in 2016, with 76% of these deaths related to prescription opioids. Recently, the <a href="https://www.abc.net.au/news/2017-09-03/opioid-crisis-creeping-up-in-regional-australia/8859996">ABC reported</a> that the high-dose opioid patch fentanyl has fuelled an opioid dependence crisis in regional Australia.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-we-can-reduce-dependency-on-opioid-painkillers-in-rural-and-regional-australia-79896">How we can reduce dependency on opioid painkillers in rural and regional Australia</a>
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</em>
</p>
<hr>
<p>These statistics paint a troubling picture of an emerging public health crisis. But what is often missing from reports about overdose and addiction is an explanation of why people are using these medications more often. Perhaps the answer can be found by exploring the evolving definition of pain in an age of growing anxiety.</p>
<h2>Pain and suffering</h2>
<p>The medical profession has spent the best part of a century trying to find a way to objectively measure physical pain. Despite developing verbal, visual and numerical <a href="https://www.sciencedirect.com/science/article/abs/pii/S0936655511006674">rating scales</a>, it’s been difficult to find consensus on a <a href="https://www.jpsmjournal.com/article/S0885-3924(04)00452-X/fulltext">form of measurement</a> that can be considered objective. A national pain summit held in Australia in 2010 <a href="https://www.painaustralia.org.au/static/uploads/files/national-pain-strategy-2011-exec-summary-with-stakeholders-wftfjtpbdaij.pdf">concluded</a>: </p>
<blockquote>
<p>all pain is an individual human experience that is entirely subjective and that can only be truly appreciated by the individual experiencing the pain.</p>
</blockquote>
<p>Of course physical pain isn’t the only type of human suffering medicine has tried to address. The expansion of psychiatry and psychology in the 1950s and ‘60s has resulted in a range of <a href="http://journals.sagepub.com/doi/abs/10.2190/3H2H-3XJN-3KAY-G9NY">everyday emotions</a> being given medical labels with pharmaceutical solutions. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/244250/original/file-20181107-74778-1d675s5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/244250/original/file-20181107-74778-1d675s5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/244250/original/file-20181107-74778-1d675s5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=392&fit=crop&dpr=1 600w, https://images.theconversation.com/files/244250/original/file-20181107-74778-1d675s5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=392&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/244250/original/file-20181107-74778-1d675s5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=392&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/244250/original/file-20181107-74778-1d675s5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=492&fit=crop&dpr=1 754w, https://images.theconversation.com/files/244250/original/file-20181107-74778-1d675s5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=492&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/244250/original/file-20181107-74778-1d675s5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=492&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Pain is an entirely subjective experience.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/wuo8KnyCm4I">Francisco Moreno/Unsplash</a></span>
</figcaption>
</figure>
<p>During the 1950s, tranquilisers were an early example of the medical profession’s attempt to <a href="https://academic.oup.com/jhmas/article-abstract/52/3/338/776180?redirectedFrom=PDF">intervene into anxiety</a>, panic and social phobia. Colloquially referred to as “happiness pills” and “emotional aspirin”, these medications have contributed to a growing cultural promise that medicine can control the body’s emotional responses to stressful circumstances.</p>
<p>The 1980s saw a new wave of “mood medicine” with the introduction of antidepressants. American society’s eager <a href="https://books.google.com.au/books?id=teTSe-eBrB0C&dq=listening+to+prozac&hl=en&sa=X&ved=0ahUKEwjL6pTA7rbeAhUXTY8KHTt8B3cQ6AEILjAB">embrace of Prozac</a> (or Lovan in Australia) was a cultural phenomena that sparked debate about the role of medicine in not just alleviating depression, but providing a form of self-enhancement according to social norms.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-pain-and-what-is-happening-when-we-feel-it-49040">Explainer: what is pain and what is happening when we feel it?</a>
</strong>
</em>
</p>
<hr>
<h2>Redefining pain</h2>
<p>One of the participants in my research, Jessica, is 41-year-old mother of twin boys who works a demanding administrative job. She uses painkillers to manage intense periods of stress at work and with her children. She recalled one time where she took Mersyndol Forte (a strong painkiller which consists of paracetamol and codeine) in anticipation of getting a headache:</p>
<blockquote>
<p>I was feeling really really tense and was almost expecting a migraine to come. I was almost anticipating it and medicating before-hand.</p>
</blockquote>
<p>Another interviewee, Sean, is a quick-witted 26-year-old who lives in an inner-city Sydney suburb. He said he uses painkillers to relieve emotional discomfort. He compared the emotional loss experienced after a break-up with physical pain:</p>
<blockquote>
<p>There’s definitely a physical component. Because you feel like you’re carrying a heavy necklace inside or something, and it’s weighing you down.</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-depression-a-mental-or-physical-illness-unravelling-the-inflammation-hypothesis-37410">Is depression a mental or physical illness? Unravelling the inflammation hypothesis</a>
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<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/244255/original/file-20181107-74783-1j3fxgk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/244255/original/file-20181107-74783-1j3fxgk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/244255/original/file-20181107-74783-1j3fxgk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/244255/original/file-20181107-74783-1j3fxgk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/244255/original/file-20181107-74783-1j3fxgk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/244255/original/file-20181107-74783-1j3fxgk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/244255/original/file-20181107-74783-1j3fxgk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/244255/original/file-20181107-74783-1j3fxgk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">More people are using painkillers in an attempt to numb their emotional pain.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Jake is a laid back 29-year-old who grew up in south-western Sydney. He started using oxycontin (a strong opiate) at the recommendation of a friend who said it would help him sleep after his partner was murdered. Jake explained that:</p>
<blockquote>
<p>it was a mental pain because of what had happened to my girlfriend and I wanted to block that out.</p>
</blockquote>
<h2>The line between pleasure and pain</h2>
<p>Even when using painkillers for physical pain, people may still take pleasure in the feeling it produces. Eastern suburbs resident Jane said she enjoyed the “zoned out” feeling that accompanied pain relief. </p>
<p>Felix is a former injecting drug user who used painkillers for a range of reasons, including to stop withdrawal, relieve anxiety and for the pleasure of intoxication. He said:</p>
<blockquote>
<p>The line between just use and dependency is really hard to work out. You don’t know where the line is until you’ve crossed it.</p>
</blockquote>
<p>People who use painkillers for non-medical reasons redefine pain according to colloquial uses of the word. They often justify their use as being a form of self-medication for legitimate conditions such as depression, anxiety and stress.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-different-cultures-experience-and-talk-about-pain-49046">How different cultures experience and talk about pain</a>
</strong>
</em>
</p>
<hr>
<p>This expansion of pain to include social and emotional suffering seems to be confirmed by the science. A growing body of research has found the neurological pathways associated with physical pain also “light up” when exposed to <a href="http://psycnet.apa.org/record/2005-01973-004">social and emotional forms of suffering</a>.</p>
<p>Taking painkillers outside of medical direction certainly involves health risks, including overdose and drug dependence. This research does not condone or decry such use, but had set out to explore the underlying reasons why people may be using such medications. </p>
<p>Because the definition of pain now includes social and emotional discomfort, intoxication is difficult to separate from relief – the pleasurable effects of a painkiller are thus seen by many as an unconventional but effective form of pain relief.</p><img src="https://counter.theconversation.com/content/106235/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kev Dertadian does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People who use painkillers for non-medical reasons often justify it as a form of self-medication for legitimate medical diagnoses such as depression, anxiety and stress.Kev Dertadian, Lecturer in Criminology, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/933772018-03-20T12:22:03Z2018-03-20T12:22:03ZIf your knee hurts, keep exercising, says expert<figure><img src="https://images.theconversation.com/files/210801/original/file-20180316-104663-17yoko7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/362666585?src=R-3i5sdfLvegquCMQseEcw-1-1&size=medium_jpg">AstroStar/Shutterstock.com</a></span></figcaption></figure><p>If you take up exercise later in life, as a treatment for joint or hip pain, you should expect a <a href="https://www.ncbi.nlm.nih.gov/pubmed/26564575">small, temporary increase in pain</a>. But if you proceed sensibly, you will be rewarded with pain relief <a href="https://www.ncbi.nlm.nih.gov/pubmed/25569281">similar</a> to that of a non-steroidal anti-inflammatory drug, such as ibuprofen, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/24462672">twice</a> that of a non-prescription painkiller, such as paracetamol. In fact, the pain relief from taking up exercise is large enough that many people <a href="https://www.ncbi.nlm.nih.gov/pubmed/26488691">put their knee or hip surgery on hold</a>.</p>
<p>Physical activity is important for good health and is prescribed by doctors to treat a range of diseases, including diabetes and cardiovascular disease. But many people don’t follow this advice because of aching joints and the fear that exercise may harm these joints. </p>
<p>Paradoxically, the last 20 years of research has found that <a href="https://www.ncbi.nlm.nih.gov/pubmed/25569281">exercise is a good pain reliever</a>. Today, <a href="https://www.ncbi.nlm.nih.gov/pubmed/24462672">exercise is recommended</a> worldwide as a treatment for painful joints in middle-aged and older people. However, recommending is one thing. Putting this recommendation into practice is something else altogether. </p>
<p>Most people experience a <a href="https://www.ncbi.nlm.nih.gov/pubmed/26564575">10% pain increase</a> when they start to exercise – some experience more, others less. This is not a warning sign but the body signalling that you are doing something you are not used to. Our bodies, including bone, muscle and cartilage are great at adapting and their <a href="https://www.ncbi.nlm.nih.gov/pubmed/16258919">quality improves</a> when we exercise.</p>
<p>How much pain relief you will get depends on how much exercise you do. In our <a href="https://www.ncbi.nlm.nih.gov/pubmed/28173795">study</a> of 10,000 people with knee and hip <a href="https://www.nhs.uk/conditions/osteoarthritis/">osteoarthritis</a>, we found that people who exercised twice a week for six weeks experienced <a href="https://www.ncbi.nlm.nih.gov/pubmed/28173795">25% pain relief</a>, on average. </p>
<p>Earlier research also shows that people who exercise in groups, supervised by a physiotherapist, experience <a href="https://www.ncbi.nlm.nih.gov/pubmed/25569281">greater pain relief</a> than those who exercise at home, unsupervised. Reasons for this difference may be that we work harder and dare to do more when guided by a physiotherapist with specialist knowledge. </p>
<p>To get the most from exercise, you should feel short of breath, or sweat a little, and increase the level of difficulty of the exercises as your body gets stronger.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/210845/original/file-20180316-104645-1i4d7ic.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Participants in the Danish GLAD study.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Two simple rules</h2>
<p>You can exercise safely by following <a href="https://www.ncbi.nlm.nih.gov/pubmed/20565735">two simple pain rules</a>. One, the pain you experience after exercise should be at a level that is tolerable. And, two, you shouldn’t experience any increase in pain from day to day. </p>
<p>Pain should be assessed daily after exercise on a zero-to-ten scale. On this scale, zero to two is considered “safe”, two to five “acceptable”, and five to ten “avoid”. </p>
<p>Let’s say your usual pain is three, and after exercising you rate it five. That’s fine. If your usual pain is three and after exercising you rate it a seven, you have done too much and should cut back the next time. </p>
<p>If your pain goes up to five after exercising, but the next morning is back at three – your usual morning pain – that’s fine. If your pain goes up to five after exercising, and is still at four or five the next morning (that is, more than your usual morning pain), you have done too much and should cut back. Keep at it, but at a lower level. </p>
<h2>Exercising with arthritis</h2>
<p>Interestingly, our research shows that it is safe to exercise with severe arthritis. When people with severe or bone-on-bone arthritis followed these two simple pain rules, <a href="https://www.ncbi.nlm.nih.gov/pubmed/20565735">95% of all exercise sessions</a> were performed with acceptable pain, and pain was relieved after a few weeks. </p>
<p>In a <a href="https://www.ncbi.nlm.nih.gov/pubmed/26488691">recent study</a>, we enrolled people with mostly severe arthritis who fulfilled all the criteria to have a knee replacement op. All the participants received information on arthritis and its treatments, including self-help advice. They also took part in supervised exercise sessions twice weekly for eight weeks, and saw a dietitian if they were overweight. </p>
<p>Half of the participants were randomised to have their knee replaced. Among those not having their joint replaced immediately, only <a href="https://www.ncbi.nlm.nih.gov/pubmed/26488691">a quarter</a> chose to have their joint replaced within a year. In other words, the pain relief that people experienced as a result of the exercise was enough for three-quarters of the participants to delay surgery for at least a year.</p>
<p>Exercise, especially when supervised, provides effective pain relief, but requires physical effort and sweat. Passive treatments, such as manual therapy, deep tissue massage and muscle stretches, given by a physiotherapist, doesn’t seem to work for people with <a href="https://www.ncbi.nlm.nih.gov/pubmed/24846036">hip</a> or <a href="https://www.ncbi.nlm.nih.gov/pubmed/29307722">knee</a> pain.</p><img src="https://counter.theconversation.com/content/93377/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ewa M. Roos receives funding from Swedish Research Council, EU, EIT Health and a number of smaller national funds including the Swedish and Danish Rheumatism Associations, Health Care Regions Skåne and Southern Denmark.</span></em></p>Middle-aged and elderly people taking up exercise shouldn’t be put off by joint pain. It will pass.Ewa M Roos, Professor of Muscle and Joint Health, University of Southern DenmarkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/824952018-02-13T23:35:33Z2018-02-13T23:35:33ZCurious Kids: How does pain medicine work in the body?<p><em>This is an article from <a href="https://theconversation.com/au/topics/curious-kids-36782">Curious Kids</a>, a series for children. The Conversation is asking kids to send in questions they’d like an expert to answer. All questions are welcome – serious, weird or wacky!</em> </p>
<hr>
<blockquote>
<p><strong>I want to understand how pain medicine like Panadol works in our body. – Freddie, age 6, Melbourne.</strong></p>
</blockquote>
<hr>
<p>In short, pain medicine is able to block the processes that cause the feeling of pain. To understand why, we need to explain a bit more about how pain works.</p>
<p>Pain happens when electrical signals travel from the spot where you hurt yourself up your nerves, to the spinal cord and then up to the brain. </p>
<p>When the pain signal gets to the brain, it lets your brain know there’s a big problem happening so we can respond. </p>
<p>So when we feel pain from a burnt hand, we quickly remove it from a fire. Or if a dog bites us, the pain tells us to run away.</p>
<p>So even though pain hurts, pain is important. It can protect us from more injury. Feeling no pain at all is actually quite dangerous.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/curious-kids-do-animals-sleep-like-people-do-snails-sleep-in-their-shells-90941">Curious Kids: Do animals sleep like people? Do snails sleep in their shells?</a>
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</em>
</p>
<hr>
<p>But your question was about pain medicine like Panadol. Panadol is just one brand of medicine called <em>paracetamol</em> – there are a lot of different brands.</p>
<p>Inside our bodies, paracetamol is able to block the processes that cause the feeling of pain.</p>
<p>Paracetamol not only acts at the site of the pain (like your burnt hand or sore arm) but also in the brain where the pain is felt.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/curious-kids-why-dont-cats-wear-shoes-75308">Curious Kids: Why don’t cats wear shoes?</a>
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</em>
</p>
<hr>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1556&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1556&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1556&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1956&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1956&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1956&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Paracetamol, and also other pain medicines such as ibuprofen (you might know it as Nurofen), block the formation of prostaglandins.</span>
<span class="attribution"><span class="source">Marcella Cheng/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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</figure>
<p>At the place where pain starts, such as a sore throat, a burnt finger or a broken arm, a lot of chemicals are made and released. These chemicals make you feel pain and also make your body send more blood flowing to the painful area. This is why the painful area is often red and swollen. </p>
<p>The extra blood flowing to the area includes white blood cells – special parts of our blood that fight disease. These white blood cells bring important chemicals. One of these chemicals goes by the name of “prostaglandin”. It increases pain and inflammation (swelling).</p>
<p>Paracetamol, and also other pain medicines such as ibuprofen (you might know it as Nurofen), stop your body from making prostaglandins. </p>
<p>When you swallow some paracetamol, it dissolves in your tummy and most of it is absorbed into your blood. The paracetamol then travels around the body to reach both the painful spot and your brain, where it then starts to reduce the feeling of pain. </p>
<p>Paracetamol is very safe if the dose taken over 24 hours (that’s one day and one night) is kept below a maximum amount. It is very important not to take too much paracetamol, as it can be very dangerous if you take too much. </p>
<p>So make sure to never, ever take paracetamol without being sure that the dose has been checked by an adult who has read the instructions on the box. Otherwise you could take too much and get very sick or even die.</p>
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<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=376&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=376&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=376&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=472&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=472&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=472&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p><em>Please tell us your name, age, and which city you live in. You can send an audio recording of your question too, if you want. Send as many questions as you like! We won’t be able to answer every question but we will do our best.</em></p><img src="https://counter.theconversation.com/content/82495/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Day has received consulting fees, paid to his institution, from
GlaxoSmithKline Australia, and fees for meeting participation from Reckitt
Benckiser.</span></em></p><p class="fine-print"><em><span>Garry Graham has received support from GlaxoSmithKline for research on paracetamol.</span></em></p>In short, pain medicine is able to block the processes that cause the feeling of pain. To understand why, you need to know a bit about how pain works.Ric Day, Professor of Clinical Pharmacology, UNSW SydneyGarry Graham, Honorary Professor of Pharmacology, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/860442017-11-21T23:15:23Z2017-11-21T23:15:23ZSurgeons and the opioid crisis: We need prescription guidelines<figure><img src="https://images.theconversation.com/files/195533/original/file-20171120-18528-15tojzu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">At present, surgeons vary widely in their approach to opioid prescription and some patients use opioids for prolonged periods post-surgery.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Of all the possible ways of <a href="http://theconversation.com/why-canada-should-declare-a-national-opioid-emergency-too-87325">alleviating the opioid crisis</a>, one has so far garnered far less attention than it deserves: prescription guidelines for surgeons.</p>
<p>Surgeons are the third-biggest prescribers of opioids, often choosing them to help patients who have undergone hysterectomies, gall bladder removal, tendon repairs and other procedures where pain relief is a critical part of the recovery process. </p>
<p>And research shows that patients who are given opioids to treat surgical pain are at significant risk of dependence on the painkillers. One study estimates that every year in the United States, <a href="http://dx.doi.org/10.1001/jamasurg.2017.0504">more than two million patients become addicted to the opioids that their surgeons prescribed</a>. </p>
<p>According to a national report, <a href="http://www.ccsa.ca/Resource%20Library/Canada-Strategy-Prescription-Drug-Misuse-Report-en.pdf">prescription opioid deaths are climbing, and Canadians are the world’s second-highest users of prescription opioids per capita</a>. Our use of opioids is rising faster than in the U.S. And over half of Ontario patients who suffered an opioid overdose were given an opioid prescription within four weeks of their death.</p>
<p>And yet, while <a href="http://www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.170363/-/DC1">detailed guidelines are in place for dentists and for doctors</a> who prescribe opioid-based painkillers for long-term pain, there are none for surgeons. </p>
<h2>Prescribing with caution</h2>
<p>As a plastic and reconstructive surgeon, I often treat and prevent surgery-related pain. I sometimes prescribe opioids for patients who have had surgery. But I try to take care to prescribe only enough to help with the most severe pain that cannot be relieved by ibuprofen (Advil) or acetaminophen (Tylenol). </p>
<p>I also insist that these medications should only to be used if other pain-avoidance techniques — like resting and elevating the area — have failed. Or, I give it in the smallest possible doses to patients who can’t tolerate ibuprofen or acetaminophen. </p>
<p>My prescriptions last for only a few days and I caution patients to use the drug only if their pain is keeping them up at night. I came to this approach because I was trained to be conservative with opioids, and I have seen many patients whose pain was managed successfully without opioids. </p>
<p>But not all surgeons are the same. For example, while I do not prescribe opioids after carpal tunnel surgery, some of my colleagues give Tylenol #3, which contains codeine, an opioid. </p>
<p>And although I give breast reduction patients a small prescription for hydromorphone, another opioid, a colleague recommends only acetaminophen and ibuprofen. He tells me that he hasn’t “prescribed opioids in a long time for almost anything.” </p>
<h2>Dangers of post-surgery addiction</h2>
<p>This anecdotal evidence is supported by research. Studies show that surgeons have different approaches to how they treat pain stemming from surgery. An April 2017 study <a href="http://dx.doi.org/10.1097/SLA.0000000000001993">of general surgeons in New Hampshire</a> revealed that “there was a wide variation in the number of opioid pills prescribed to patients undergoing the same operation.” </p>
<p>A wrong move can have grave consequences. If pain is not treated, the patient may suffer unnecessarily, and end up in the doctor’s office or the emergency department. I’ve known desperate patients to use a relative’s leftover pain medication, or even buy drugs on the street. </p>
<hr>
<p><em><strong>Read more: <a href="https://theconversation.com/ca/topics/canadas-opioid-crisis-46272">Solutions to Canada’s opioid crisis</a></strong></em></p>
<hr>
<p>Dr. Norman Buckley, a pain specialist at McMaster University in Hamilton, Ont., acknowledges that we don’t always get pain management right. “We still see very large numbers of people reporting moderate to severe pain which is not effectively treated after surgery,” Dr. Buckley said. </p>
<p>Yet if we over-prescribe an opioid, there’s a real risk of the drugs getting into the wrong hands. For example, if a patient has a prescription for 30 Percocet tablets, but ends up taking only five, there are 25 unswallowed tablets up for grabs. “They could be stolen, they could be diverted into a party by somebody’s kids, or the individual could sell them,” said Dr. Buckley.</p>
<p>There’s also a real danger that patients can end up addicted to the drugs. </p>
<h2>Persistent opioid use</h2>
<p>Pain typically disappears a few weeks after surgery; the worst is usually over within the first week. But a June 2017 <a href="http://dx.doi.org/10.1001/jamasurg.2017.0504">study by doctors at the University of Michigan</a> noted that some patients continued taking opioids for more than three months after surgery. The researchers concluded that “persistent opioid use is more common than previously reported and can be considered one of the most common complications after elective surgery.” </p>
<p>They added that “there has been little attention placed on post-operative prescribing,” and “the effect of post-operative use on the opioid overdose epidemic has been less recognized.” </p>
<p>In Canada, many aspects of the opioid crisis have been closely analyzed by agencies such as <a href="http://www.healthcarecan.ca/2017/10/05/healthcarecan-convenes-and-spreads-best-practices-amid-opioid-crisis/">HealthcareCan</a> and the <a href="http://www.ccdus.ca/Eng/collaboration/Partnerships-to-Address-Prescription-Drug-Misuse/Pages/default.aspx">Canadian Centre on Substance Use and Addiction</a>.</p>
<p>In May 2017, <a href="http://www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.170363/-/DC1">guidelines for long-term pain</a> were released by the DeGroote Pain Research Group at McMaster. These were updated from 2010 guidelines following a scientifically rigorous process that involved the input of numerous clinicians, researchers and patients.</p>
<p>We don’t yet have anything comparable for surgical pain. Health Quality Ontario is <a href="http://www.cpso.on.ca/CPSO/media/documents/CPSO%20Members/Opioids/MOHLTC-letter-to-physicians-re-appropriate-opioid-prescribing-17May17.pdf">developing quality standards for opioid prescribing</a> for both acute and chronic care. These quality standards may not meet the rigour of an official guideline, however, notes Dr. Buckley, who is also DeGroote’s scientific director. </p>
<h2>Managing patient expectations</h2>
<p>Guidelines for surgeons are critical to addressing the opioid crisis. </p>
<p>They would improve communication between physicians and nurses. The profession increasingly favours a multi-disciplinary approach to prescribing medications to ensure that the family doctor, emergency physician, nurse, surgeon and even patients are all on the same page. </p>
<p>Sometimes the insights of non-surgical colleagues play a role in a surgeon’s decision to prescribe opioids. </p>
<p>Guidelines would also help manage patients’ expectations. Some patients fear becoming addicted to opioids; others fear not having enough medication to relieve their pain. </p>
<p>As one colleague noted: “It’s tricky. Most people expect to be prescribed something after most procedures so Tylenol #3 isn’t uncommon, but I prefer to avoid it if possible.”</p><img src="https://counter.theconversation.com/content/86044/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tola Afolabi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Surgeons are big prescribers of opioids. But while guidelines are in place for dentists and for doctors who prescribe opioid-based painkillers for long-term pain, there are none for surgeons.Tola Afolabi, Munk Global Journalism Fellow, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/816032017-08-13T23:17:38Z2017-08-13T23:17:38ZLegal weed: An accidental solution to the opioid crisis?<figure><img src="https://images.theconversation.com/files/180476/original/file-20170801-28766-1erdw7h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There is growing evidence for the use of cannabis in treating opioid addiction.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>It’s hard to go a day in Canada without hearing about at least one of two types of drugs – but for vastly different reasons. One class of drug — opioids — <a href="https://www.thestar.com/news/canada/2017/04/19/death-toll-reaches-almost-4-a-day-in-overdose-crisis-in-bc-coroner.html">kills four people a day in British Columbia</a>. The other — cannabis — will be legal for adult purchase and consumption <a href="https://www.canada.ca/en/health-canada/news/2017/04/canada_takes_actiontolegalizeandstrictlyregulatecannabis.html">by this time next year.</a></p>
<p>The opioid overdose epidemic is Canada’s gravest public health crisis since the emergence of HIV in the 1980s. With its roots in the over-prescription of high-potency painkillers, sparked by the contamination of the illicit drug supply with fentanyl and related drugs, the crisis has reached across demographic divides. Experts agree on the need for creative responses based in scientific evidence. </p>
<p>Could cannabis legalization be a part of this solution? Increasingly, this is what the latest scientific research indicates. </p>
<h2>Fatal overdoses</h2>
<p>The opioid crisis is a product of the medical system’s <a href="https://theconversation.com/how-to-fix-canadas-opioid-crisis-it-starts-with-pain-and-the-prescription-pad-78512">over-reliance on opioids</a> for pain relief. Almost <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298051/">one in five Canadians</a> live with some form of chronic pain. Twenty years ago, pharmaceutical companies began to develop <a href="https://theconversation.com/oxycontin-how-purdue-pharma-helped-spark-the-opioid-epidemic-57331">slow-release formulations of opioids</a> (e.g. OxyContin) and marketed them as safe and effective medications for the treatment of chronic non-cancer pain. </p>
<p>We know now that these drugs carry an extremely high risk of dependence and fatal overdose. Despite this, <a href="https://www.theglobeandmail.com/news/national/sales-of-opiod-drug-prescriptionsskyrocketing/article26008639/">more than 20 million opioid prescriptions</a> are filled each year in Canada. Drug overdoses are now the <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">leading cause of death</a> among Americans under the age of 50. And prescription opioids are involved in <a href="https://www.cdc.gov/drugoverdose/data/overdose.html">nearly half</a> of these deaths. It is also becoming apparent that opioids might be less effective than initially thought in treating certain types of chronic non-cancer pain (<a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006146.pub2/abstract;jsessionid=F7C9469935C456F6BDD34331871E1FEA.f03t01?systemMessage=Wiley+Online+Library+will+be+unavailable+on+Saturday+01st+July+from+03.00-09.00+EDT+and+on+Sunday+2nd+July+">e.g. neuropathic pain</a>).</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Canada will soon be the first country in the G-20 to legalize cannabis for non-medicinal purposes.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Cannabis, derived from the Cannabis sativa plant, contains several compounds. These include tetrahydrocannabinol (THC, the primary psychoactive component of cannabis) and cannabidiol (CBD). Beyond the well-known psychoactive effects of cannabinoids, new research has shown that they also interact with <a href="https://academic.oup.com/bja/article-lookup/doi/10.1093/bja/aen119">systems in the body involved in the regulation of pain</a>. </p>
<p>This discovery has led researchers to investigate the potential for cannabis to treat various pain conditions for which opioids are currently first- or second-line therapies. High-quality clinical research involving cannabis has been <a href="https://www.theatlantic.com/politics/archive/2014/06/its-hard-to-study-marijuanas-medical-benefits-when-its-illegal/373603/">stunted by its prohibited legal status</a>. But a recent <a href="https://link-springer-com.ezproxy.library.ubc.ca/article/10.1007%2Fs11481-015-9600-6">review of clinical studies</a> involving cannabis-based medicines (including smoked or vapourized cannabis) found strong evidence for relief of chronic non-cancer pain.</p>
<h2>Ground-breaking findings</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/15731502">The substitution effect</a> is an idea from behavioural economics that describes how the use of one product might decrease when the availability of another increases. Substance use researchers have recently <a href="http://www.tandfonline.com/doi/abs/10.3109/16066359.2012.733465">adapted this theory</a> to understand the substitution potential between cannabis and opioids. In other words, does the use of opioids decrease with increasing access to cannabis?</p>
<p><a href="https://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.4005">In a landmark 2014 study</a>, a team of researchers analzyed data from across the United States over a 10-year period. They found that states that had legalized medical cannabis saw 25 per cent fewer opioid-related deaths compared to states where medical cannabis remained illegal. </p>
<p>These findings broke ground for others in the field to find associations between U.S. medical cannabis laws and reduced state-level estimates of <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2016.303426?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed">opioid use</a> and <a href="http://www.nber.org/papers/w21345">dependence</a>. But, because these population-level studies cannot observe <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2210572">individual-level changes in cannabis and opioid use</a>, a closer look at these trends among different sub-populations of people affected by the opioid crisis is needed.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Legalizing cannabis will enable researchers to investigate the clinical and public health impacts of the drug.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Not surprisingly, findings from surveys conducted among patients using medical cannabis across North America demonstrate a clear preference for cannabis over opioids. For example, roughly one-third of a sample of patients enrolled in Health Canada’s Marihuana for Medical Purposes Regulations (MMPR) program in B.C. <a href="http://www.sciencedirect.com/science/article/pii/S0955395917300130">report substituting cannabis for prescription opioids.</a></p>
<p>For chronic pain patients, this substitution effect appears even more pervasive, with cannabis substitution occurring in roughly <a href="http://www.sciencedirect.com/science/article/pii/S1526590016005678?via%3Dihub">two-thirds</a> of a sample of former prescription opioid patients in Michigan who started using medical cannabis. </p>
<p><a href="http://online.liebertpub.com/doi/full/10.1089/can.2017.0012">In the most recent study</a>, 80 per cent of medical cannabis patients in California reported that taking cannabis alone was more effective at treating their medical condition than taking cannabis with opioids. More than 90 per cent agreed they would choose cannabis over opioids to treat their condition if it were readily available.</p>
<h2>Illicit opioid use</h2>
<p>But what about the relationship between cannabis and opioids among some of those most affected by the opioid crisis — people with long-term experience using illicit opioids?</p>
<p>Untreated pain and substance use have a high degree of overlap. Pain was reported by almost half of people who inject drugs surveyed in a recent <a href="https://substanceabusepolicy.biomedcentral.com/articles/10.1186/s13011-017-0112-7">San Francisco study.</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962749/">Research from our colleagues in Vancouver</a> found that under-treatment of pain in this population is common. It results in self-management of pain by obtaining heroin or prescription opioids on the street.</p>
<p>This means there could be a role for cannabis even among individuals with extensive experience using illicit opioids. <a href="http://www.sciencedirect.com/science/article/pii/S0376871615002501?via%3Dihub">A study from California</a> of people who inject drugs found that those who used cannabis used opioids less often. It’s still unclear if this difference is directly due to cannabis use and more research is needed.</p>
<h2>Potential as anxiety treatment</h2>
<p>Even without chronic pain, cannabis may prove an effective alternative among individuals wanting to reduce or stop their opioid use. There is growing evidence for the use of cannabis in treating opioid addiction. CBD, the non-psychoactive component of cannabis, is known to interact with <a href="https://link.springer.com/article/10.1007%2Fs13311-015-0387-1">several receptors involved in regulating fear and anxiety-related behaviours</a>. It shows potential for the treatment of several anxiety disorders. </p>
<p>Research is also investigating CBD’s role in modulating cravings and relapses — behaviours that are tightly linked to anxiety — among individuals with opioid addiction. <a href="https://link.springer.com/article/10.1007%2Fs13311-015-0373-7">Recent preliminary studies</a> suggest that CBD reduces opioid cravings. A <a href="https://clinicaltrials.gov/ct2/show/NCT02539823?lead=Hurd&cntry1=NA%3AUS&rank=1">larger clinical trial</a> is now underway in the United States.</p>
<h2>A bold response?</h2>
<p>Canada will soon be the first country in the G-20 to introduce a legal framework regulating the use of cannabis by adults for non-medical purposes. This will create a country-wide natural experiment for the world to observe. Legalizing cannabis will break down traditional barriers to understanding the clinical and public health impacts of the drug. </p>
<p>This massive drug policy change could not come at a more desperate time. By increasing access to the drug for therapeutic and recreational purposes, we will have the opportunity to investigate substitution effects within different populations of people who use opioids.</p>
<p>Protection of youth and removal of organized crime aside, the Cannabis Act may just be the unintentionally bold government response to the opioid crisis that our country so desperately needs.</p><img src="https://counter.theconversation.com/content/81603/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephanie Lake is supported by funding from the Canadian Institutes of Health Research and the Pierre Elliott Trudeau Foundation. She is affiliated with Canadian Students for Sensible Drug Policy. </span></em></p><p class="fine-print"><em><span>M-J Milloy is supported by funding from the United States National Institute on Drug Abuse, the Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research. His institution has received an unstructured gift from NG Biomed Ltd., a private firm seeking a licence to produce medical cannabis, to support him.</span></em></p>As Canada moves towards legalization of cannabis in 2018, there is growing evidence of the drug’s potential to treat opioid addiction itself, as well as the chronic pain that often drives it.Stephanie Lake, PhD student in Population and Public Health, University of British ColumbiaM-J Milloy, Research Scientist, BC Centre on Substance Use and Assistant Professor in the Division of AIDS, UBC Department of Medicine, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/811062017-07-31T08:26:02Z2017-07-31T08:26:02ZOpioid misuse is increasing in middle-aged Britons – here’s how it could cause an addiction crisis<figure><img src="https://images.theconversation.com/files/179428/original/file-20170724-21564-1t4nyv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tramadol.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/648598822?src=8LcxAx728VBlsGx7MZkQHQ-1-0&size=medium_jpg">chatuphot/Shutterstock</a></span></figcaption></figure><p>The older we get, the more likely we are to suffer with long-term health problems. Life expectancy may be increasing, but so are the number of years we spend in ill health. In people aged 50 and over, the leading causes of chronic ill health are <a href="https://www.gov.uk/government/publications/health-profile-for-england/chapter-3-trends-in-morbidity-and-behavioural-risk-factors">lower-back and neck pain</a>. It’s hardly surprising, then, that so many middle-aged people are hooked on painkillers.</p>
<p>Painkillers are often the first port of call for anyone seeking to rid themselves of discomfort from damage done to joints and muscles as part of the ageing process. Paracetamol was once the <a href="http://journals.lww.com/americantherapeutics/Abstract/2000/07020/Paracetamol__Past,_Present,_and_Future.11.aspx">mainstay of treatment</a>, but stronger painkillers are now <a href="http://bmjopen.bmj.com/content/6/5/e010276">more commonly prescribed</a>, especially highly addictive opioid painkillers, such as buprenorphine, fentanyl and oxycodone.</p>
<p>A study of prescribing in Tayside, Scotland, between 1995 and 2010, found an <a href="https://www.ncbi.nlm.nih.gov/labs/articles/24807782/">18-fold increase</a> in the number of people prescribed strong opioids. And between 2002 and 2013, the number of people in the UK prescribed strong opioids for chronic pain <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4912234/">rose six-fold</a>.</p>
<p>Opioid drugs, being derivatives of morphine, have a huge potential for misuse, particularly if used at high doses or over long periods of time. In older adults, these drugs are eventually taken for their <a href="http://www.sciencedirect.com/science/article/pii/S0376871615000472">pleasurable effects</a> rather than their pain-relieving potential – the slippery path to addiction.</p>
<p>Addiction to opioid painkillers in middle-aged people has resulted in a sharp increase in deaths associated with drug toxicity. A case in point being the drug tramadol. </p>
<p>In the UK, the Advisory Council on the Misuse of Drugs called for tighter controls on tramadol prescribing, as a result of its <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/144116/advice-tramadol.pdf">increasing misuse</a>. In 2000, in England and Wales, there were three deaths associated with tramadol in the 50-69 age group. This rose to a staggering <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathsrelatedtodrugpoisoningenglandandwalesreferencetable">70 deaths</a> by 2015. </p>
<p>Ageing also means changes to the way opioid drugs affect the body. Not only is there a higher chance of these drugs taking longer to clear from the bloodstream, opioid drugs are highly likely to cause more problems with <a href="http://www.cmaj.ca/content/174/11/1589.short">breathing, blood pressure, drowsiness and falls</a>. They also interact with other drugs, either <a href="https://www.rcpsych.ac.uk/pdf/Substance%20misuse%20in%20Older%20People_an%20information%20guide.pdf">increasing their side effects or changing their levels in the blood</a>.</p>
<h2>The baby boomer problem</h2>
<p>Unlike previous generations of middle-aged people, today’s “baby boomers” grew up in a permissive society. As a result, they are at considerably higher risk of addiction to both <a href="https://theconversation.com/grandmothers-little-helper-a-new-drug-problem-emerges-66377">non-opioid painkillers</a> and <a href="https://theconversation.com/having-lived-hedonistic-lives-the-baby-boomers-are-drinking-themselves-into-an-early-grave-64016">alcohol</a> compared with previous generations. And baby boomers in the 50-64 age group who are addicted to illicit drugs are also at high risk of <a href="http://www.tandfonline.com/doi/abs/10.1080/01634372.2017.1327469">opioid painkiller addiction</a>. Opioid painkillers appear to be part of a wider picture of addiction.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/179467/original/file-20170724-23039-1yk9k38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179467/original/file-20170724-23039-1yk9k38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179467/original/file-20170724-23039-1yk9k38.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179467/original/file-20170724-23039-1yk9k38.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179467/original/file-20170724-23039-1yk9k38.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179467/original/file-20170724-23039-1yk9k38.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179467/original/file-20170724-23039-1yk9k38.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Baby boomers grew up in a permissive era.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/vwcampin/35256750001/in/photolist-4z9Nv5-nzxBHZ-VHw4s2-4cTa1X-ooXhnX-81kP2V-fJMhck-2hYsBf-iJYKMV-qshR27-5JzMzH-qwnbHF-6dxx1N-aJ3pda-8BpENW-8Pomnt-aewwRS-4z5B84-5uauhW-6jUuyX-oH3ygj-dvDsSw-sucfr-6g93pG-qshbJ3-4Tp2sb-5tnDLQ-c261NA-BBqGp-fMo8Yg-9Qwduw-4UjKR5-eiqx4D-6d36Hh-6yuXEg-EjMzn-7Ghbsb-9t8YbZ-6aJa6r-5oxLjk-6pxmQV-6aAuQG-aaV3M1-hEEjVD-piCuJT-4ienTz-cxzJ7C-534KTK-dbJRb3-4oCymi">Shelby Bell/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Tackling opioid painkiller addiction in middle-aged people should start at a national policy level, but the Home Office’s new <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/628148/Drug_strategy_2017.PDF">drugs strategy</a> makes little mention of the risks posed by opioid painkillers, choosing instead to focus exclusively on illicit opioid drugs such as heroin. </p>
<p>The increasing use of prescription opioid painkillers in baby boomers shows little sign of slowing down. The problem is that it’s an invisible addiction where an easy fix with opioid painkillers is all too common. Prescribing drugs for pain may leap straight from paracetamol to opioids, with few alternative drug treatments in between for numbing the pain and discomfort caused by the ravages of ageing. </p>
<p>Curbing the inevitable and relentless descent into greater harm from opioid painkillers in baby boomers means that medical specialists need to work closer together. GPs will need to work more closely with pain clinics, as well as mental health services. Joint clinics between GPs and old-age psychiatry or geriatrics services could also reduce opioid prescribing by treating the mental and physical consequences of pain more effectively.</p>
<p>We are probably many years away from developing the <a href="https://theconversation.com/a-possible-alternative-to-morphine-inspired-by-spit-71394">perfect, harmless, non-addictive painkiller</a>. In the meantime, we need GPs to be more vigilant over the potential for addiction with opioid painkillers and to think about non-drug treatments for pain such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797112/">lifestyle changes and psychological interventions</a>. Without this, Britain faces a major public health crisis.</p><img src="https://counter.theconversation.com/content/81106/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tony Rao does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More and more baby boomers are getting hooked on oxycodone, vicodin and tramadol.Tony Rao, Visiting Lecturer in Old Age Psychiatry, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/792432017-06-12T11:06:54Z2017-06-12T11:06:54ZThe opioid epidemic in 6 essential reads<figure><img src="https://images.theconversation.com/files/173219/original/file-20170609-4841-1pp3o4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drug related deaths are on the rise, but federal funds to programs that mitigate drug abuse are being cut in 2018.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/grumpy-puddin/5161819684/in/photolist-8S8Fa7-6vaLox-635Ju-6veWuj-6vaLnk-cHhoMy-6vaLg4-GsU3t-6veWAd-7MhkvW-jzZsMe-9kC6Km-qznEaT-bXUPx-cHhfjS-SXxwYB-dp5X6i-9sS84N-6vaLpB-8knpCN-6veWC5-efgp16-gXH688-Mqex-54dH9T-9Cg59v-aQ71vK-6QyKwT-6VnSDE-bPuPbV-4xcHp9-ei6szp-8QZM9R-9KRmfw-dFHZpC-7w88Br-8R9Kkm-oW2aQ-9aTME3-49TkM1-aCEmz6-8FJMJJ-dJGAyL-SSga5W-6Q3N14-4wP9QZ-6SbB7V-9vCtht-mA7Hua-aAYbYp">Me/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p><em>Editor’s note: The following is a roundup of archival stories related to opioids.</em></p>
<p>The opioid crisis appears to be getting worse, not better. </p>
<p><a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">According to The New York Times</a>, drug deaths are rising faster than ever, with more than 59,000 overdose deaths in 2016. </p>
<p>The situation has been dire for a few years, with <a href="http://www.cdc.gov/media/releases/2015/p1218-drug-overdose.html">six in 10 drug overdose deaths</a> in 2014 involving an opioid, such as a painkiller or heroin.</p>
<p>In May, Donald Trump <a href="http://thehill.com/homenews/administration/332871-trump-appoints-opioid-commission">appointed a commission</a> on the opioid epidemic, which he’s described as “<a href="http://abcnews.go.com/Politics/donald-trump-sounds-alarm-citing-tremendous-problem-deep/story?id=41309801">a tremendous problem</a>.” However, <a href="https://www.vox.com/policy-and-politics/2017/5/23/15680096/trump-budget-opioid-epidemic">his proposed budget includes cuts</a> to agencies like the Office of National Drug Control Policy and the Substance Abuse and Mental Health Services Administration.</p>
<p>At The Conversation, scholars have been examining the many facets of the epidemic for months. Here are six articles that explain the background of the epidemic and where were might go from here. </p>
<h2>How did we get here?</h2>
<p>Ted Cicero and Matthew Ellis, who study opioid abuse at Washington University in St. Louis, argue that the epidemic is rooted in two events: the introduction in 1996 of OxyContin, an extended-release high-dose opioid, and a 2001 report on pain treatment from the Joint Commission on Accreditation of Healthcare Organizations. </p>
<p>As Cicero and Ellis <a href="https://theconversation.com/roots-of-opioid-epidemic-can-be-traced-back-to-two-key-changes-in-pain-management-50647">write</a>:</p>
<blockquote>
<p>“The change in pain treatment ushered in by the Joint Commission report lead to an increase in the number of opioid prescriptions in the U.S., and the increase in prescriptions for this particular high dose opioid helped to introduce an unprecedented amount of prescription drugs into the marketplace, generating a whole new population of opioid users.”</p>
</blockquote>
<p>Jeannie D. DiClementi, a professor of psychology, points out that the increase in opioid prescriptions led to an <a href="https://theconversation.com/from-the-clinic-to-the-street-how-the-explosion-in-prescription-painkillers-has-created-more-heroin-users-50344">increase in heroin use</a>:</p>
<blockquote>
<p>“[N]early 80 percent of heroin users report having become addicted to prescription pain medications first, while just 3.6 percent had a history of heroin use before beginning prescription pain medications.”</p>
</blockquote>
<p>Fentanyl, a synthetic opioid 100 times more powerful than heroin, was first introduced in the 1960s as a <a href="https://theconversation.com/fentanyl-widely-used-deadly-when-abused-60511">painkiller during major surgery</a>. Illictly made fentanyl is now found on the street, often in counterfeit drugs. So are novel synthetic opioids that are chemically unrelated to anything used in medicine but act on the same receptors in the body and brain. These drugs are generally manufactured in clandestine labs in China and Mexico. </p>
<p>However, adding these illicitly made versions of fentanyl and other new opioids to Schedule I – the category of the Controlled Substances Act for illegal drugs like heroin – can be a lengthy process. And as Samuel Banister, Roy Gerona and Axel Adams, who study these new synthetic substances, <a href="https://theconversation.com/fentanyl-and-other-synthetic-opioids-sold-as-counterfeits-in-deadly-new-trend-62814">explain</a>:</p>
<blockquote>
<p>“The trouble is that as individual illicit synthetic opioids are added to Schedule I, clandestine chemists in China and Mexico ‘tweak’ molecular structures to circumvent the law by creating new drugs with similar effects.”</p>
</blockquote>
<h2>Treating addiction</h2>
<p>Last year, the federal government passed legislation aimed at expanding access to addiction treatment and took steps to improve treatment options for people in the criminal justice system. </p>
<p>William Greene and Lisa J. Merlo from the University of Florida <a href="https://theconversation.com/some-good-news-on-opioid-epidemic-treatment-options-are-expanding-61483">wrote that</a>: </p>
<blockquote>
<p>“This stepped-up policy response is giving doctors the means to better treat people with opioid addiction. When combined with improvements in public understanding that addiction is a disease requiring treatment, we as a society are creating an environment that supports treatment. We believe this will save many thousands of lives.”</p>
</blockquote>
<h2>We still need opioids</h2>
<p>Pain, <a href="https://theconversation.com/what-is-chronic-pain-and-why-is-it-hard-to-treat-57943">explains Robert Caudle at the University of Florida</a>, is complex and multifaceted, something that we can experience in many dimensions. Opioids can suppress incoming pain signals, prevent those signals from being amplified and improve the emotional states of the patient, all critical things for people with chronic pain. </p>
<p>In many ways, opioids are the most effective treatment we have currently, but Caudle notes out that we aren’t investing much in finding better ones:</p>
<blockquote>
<p>“In 2015 the National Institutes of Health spent US$854 million on pain research, compared to more than $6 billion for cancer. It is no wonder that pain patients muddle through with what amounts to centuries-old therapies.”</p>
</blockquote>
<p>While the opioid epidemic wears on in the U.S., parts of South America, Africa and Asia face a very different opioid crisis: too few of them. People in those parts of the world often cannot access pain medication stronger than acetaminophen. </p>
<p>Luke Messac argues that policies from the International Narcotics Control Board aimed at preventing opioids from being diverted for illict use have wound up keeping these medicines out of the hands of <a href="https://theconversation.com/the-other-opioid-crisis-people-in-poor-countries-cant-get-the-pain-medication-they-need-56205">people who truly need them</a>. “Pain is universal,” writes Messac, “but its relief is still a function of geography.”</p>
<p><em>This is an updated version of <a href="http://theconversation.com/the-opioid-epidemic-in-6-essential-reads-66227">a story that originally ran on October 6, 2016</a>.</em></p><img src="https://counter.theconversation.com/content/79243/count.gif" alt="The Conversation" width="1" height="1" />
Drug deaths are rising faster than ever. How did we get here and what to do about it?Jessie Schanzle, Aviva Rutkin, Data EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/780572017-05-25T15:14:01Z2017-05-25T15:14:01ZRub on pain products – what you need to know<figure><img src="https://images.theconversation.com/files/170949/original/file-20170525-23279-bwbmch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/475173484?src=xFpFdgyOpPBFS8_lu57YCA-1-65&size=medium_jpg">WAYHOME studio/Shutterstock</a></span></figcaption></figure><p>I was a clumsy child and had more than my fair share of bumps and knocks. As a result, I was the recipient of a considerable amount of repetitive advice to “rub it better”. My younger self did not regard this as helpful; I wanted the pain gone, now. </p>
<p>A bit of a brat, perhaps, but if you ask people with pain – any kind of pain, be it acute pain after a fall or operation, a headache, or chronic pain like arthritis – what they want from treatment, it is the same as I wanted all those years ago. <a href="https://www.ncbi.nlm.nih.gov/pubmed/23347230">Pain gone, now</a>. </p>
<p>There may be something in the idea that rubbing a painful area might actually help. We rub the skin over a painful area almost instinctively. Touch applied at particular frequency can be pleasant. And while there is research that shows that it might help, it is a big jump to demonstrate that rubbing alone is a useful treatment for pain if that pain is moderate or severe.</p>
<p>But what about rubbing something on to a painful area – a cream or a gel? There are all sorts of these. Some aim to cool, some to produce a sense of heat, some contain drugs like nonsteroidal anti-inflammatory drugs (NSAIDs), or capsaicin, an extract of chilli. Some are for acute pain, some for chronic, some you can buy over the counter from the chemist, and others need a prescription. Any large pharmacy has a bewildering array of products. How do you choose? Are any better than just rubbing?</p>
<p>Help comes in the form of a new <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008609.pub2/abstract">Cochrane overview review</a> that draws together all the current evidence. The overview pulled together results from 13 Cochrane reviews, with 206 individual trials and around 30,700 participants, to assess the benefits and harms of a range of topical (applied to the skin) painkillers for a range of conditions. </p>
<p>The main outcome was whether people with moderate or severe pain had their pain reduced to no worse than mild pain with treatment. And the comparison was between rubbing on the test medicine and rubbing on a placebo medicine that was identical in every way except that it had no active ingredient. Both were rubbed on in the same way to discount the effects of rubbing itself.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/170956/original/file-20170525-23241-hfpvfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170956/original/file-20170525-23241-hfpvfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=367&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170956/original/file-20170525-23241-hfpvfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=367&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170956/original/file-20170525-23241-hfpvfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=367&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170956/original/file-20170525-23241-hfpvfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=461&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170956/original/file-20170525-23241-hfpvfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=461&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170956/original/file-20170525-23241-hfpvfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=461&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some topical painkillers contain capsaicin, an extract of chilli.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/237514420?src=AWI0mTU1AYBR0Z8-PAo_NQ-1-3&size=medium_jpg">Kovaleva_Ka/Shutterstock</a></span>
</figcaption>
</figure>
<h2>There’s good news and bad</h2>
<p>First, the good news. In acute pain conditions, such as strains and sprains, two topical NSAID products, a diclofenac gel (Emulgel) and a ketoprofen gel produced good pain relief in about 70 to 80% of people, which was 40 to 60% more than with placebo. A good result here as the pain was reduced from moderate or severe to no worse than mild after about a week. The gel is important, because the same drugs in creams or plasters were not so effective (and there are probably good reasons for that). That’s about it for acute pain products available, with or without prescription.</p>
<p>In chronic pain conditions, the news is less good. For musculoskeletal conditions, like osteoarthritis, ketoprofen and diclofenac gel produced good pain relief – after about two weeks – in just 15-20% more people than a placebo gel. (Good pain relief was going from moderate or severe pain to no worse than mild pain.) Curiously, placebo responses were quite high, so when we included the placebo response in the figures we found that 40% to 60% do well with diclofenac or ketoprofen. </p>
<p>There is also a product from chillies (capsaicin at a high 8% concentration) that is useful in about 10% of people with nerve pain; but that’s a treatment used by specialists, often in hospital.</p>
<p>For many other rubbed-on products for pain relief (herbal remedies, salicylates, menthols, and some NSAID preparations) we have no evidence or so little evidence that we cannot trust it. It may work, but if you buy it, you have no idea whether you are buying something really good or just wasting your money. Experience suggests the latter, but if you have a remedy you swear by, stick with it. I know a chap who swears by rubbing WD40 on a sore back, but I wouldn’t recommend it.</p>
<p>Rubbed-on painkillers are designed to work locally, however. While there may be some local reactions (such as itching or redness), the good news is that effects on other parts of the body (such as nausea or dyspepsia) and serious side effects (such as bleeding) are rare because blood levels of drugs that are rubbed on are much lower than when they are taken orally.</p><img src="https://counter.theconversation.com/content/78057/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Moore has consulted with companies that manufacture analgesics, including topical analgesics. Andrew Moore is an author and editor for the Cochrane Pain, Palliative, and Supportive care group, and until recently was the chairman of the International Study of Pain special interest group on systematic reviews and evidence.</span></em></p>A new review of painkilling gels reveals what works and what doesn’t.Andrew Moore, Honorary Senior Research Fellow, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/713942017-02-14T12:53:47Z2017-02-14T12:53:47ZA possible alternative to morphine – inspired by spit<figure><img src="https://images.theconversation.com/files/154350/original/image-20170126-23858-1sz8gu9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Opium poppies.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/551723470?size=medium_jpg">Ruud Morijn Photographer/Shutterstock.com</a></span></figcaption></figure><p>Would you take a painkiller that had been developed from human saliva? A <a href="http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2548332">recent study</a> suggests you might in future.</p>
<p>Pain is an essential sensation. Sensory nerves with endings in our skin, tissues and organs, are activated by heat, cold or pressure, or by chemicals that are released from cells after tissue injury. The fibres of these nerves reach the central nervous system, activating neurons in the spinal cord which in turn connect with and activate neurons in a part of the brain known as the cerebral cortex. The cortex gives you the conscious perception of pain - that “ouch!” The system has evolved to produce a quick response. It takes a split second for you to withdraw your hand from a burning flame. </p>
<p>While pain is essential for survival <a href="https://theconversation.com/explainer-why-dont-some-people-feel-pain-18569">and good health</a>, unless you have masochistic tendencies, too much pain isn’t a good thing. Especially if it persists. Millions of people live with chronic pain. And chronic pain, whether backache, joint pain or <a href="http://www.webmd.com/pain-management/guide/neuropathic-pain">neuropathic pain</a> (neuralgia) can make people’s lives unbearable.</p>
<h2>Two centuries of morphine</h2>
<p>Throughout recorded human history we have searched for substances to dull pain. The most powerful painkillers are the opioids. Morphine, derived from the opium poppy, is an opioid that has been known to alchemists and medics for centuries. Morphine was one of the first ever medicines and has been available in a pure pharmacological form since 1817.</p>
<p>Morphine and synthetic opioids, such as codeine and fentanyl, bind to opioid receptors located on neurons in the spine and inhibit their activity. This prevents them signalling pain sensations to the brain. Some of our nerve cells, positioned in key places on the path along which pain signals travel, release opioid peptides (fragments of proteins) such as enkephalin. These enkephalins attach to opioid receptors and block pain signals reaching the brain. In the 1970s we discovered that opioids like morphine, codeine or fentanyl act as mimics of these naturally-occurring opioid peptides.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/154357/original/image-20170126-23867-jpdd11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/154357/original/image-20170126-23867-jpdd11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=425&fit=crop&dpr=1 600w, https://images.theconversation.com/files/154357/original/image-20170126-23867-jpdd11.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=425&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/154357/original/image-20170126-23867-jpdd11.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=425&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/154357/original/image-20170126-23867-jpdd11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=534&fit=crop&dpr=1 754w, https://images.theconversation.com/files/154357/original/image-20170126-23867-jpdd11.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=534&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/154357/original/image-20170126-23867-jpdd11.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=534&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Morphine - effective but dangerous.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/thumb/2/2b/Hydrochloras_Morphini_%26_Hydrobromas_Scopolamine.JPG/1024px-Hydrochloras_Morphini_%26_Hydrobromas_Scopolamine.JPG">Henk Albert de Klerk/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>So what has this all got to do with saliva? Well in 2006, a peptide named opiorphin was <a href="http://www.pnas.org/content/103/47/17979.short">found in human saliva</a> by researchers at Institut Pasteur International in Paris, France.</p>
<p>Opiorphin resembles enkephalin, but, rather than binding to opioid receptors to inhibit their activity, they prevent enkephalins from being broken down. So the amount of enkephalin – the body’s natural painkiller – is increased and pain signals are blocked. When you experience pain, enkephalins are released and opiorphin boosts their action. </p>
<p>Opiorphin should only work in the places where enkephalin is being actively released and not affect other neural systems. So unlike conventional opioids it would only have a localised effect. In theory it would have the same effect on pain but without the wider unwanted side effects, such as addiction, tolerance with long-term use, and suppressed breathing.</p>
<h2>Opiorphin with a tweak</h2>
<p>One problem is that opiorphin would be broken down in the digestive system or in the bloodstream so would not be able to get to particular sites in the body to block pain. So the researchers at Institut Pasteur worked with a company, Stragen, to create a modified version of opiorphin called STR-324, designed to increase its stability. STR-324 should be able to be taken orally or intravenously, though so far only an injectable form is being tested.</p>
<p>The team’s <a href="http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2548332">most recent study</a> looking at post-operative pain showed that STR-324, when injected, is effective at blocking pain in rats. The response compares well to morphine, with a lower painkilling effect than morphine.</p>
<p>Later this year, the company developing STR-324 will be testing the drug on humans for the first time. The <a href="http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2548332">current evidence</a> suggests that STR-324 will work well for some types of pain, when injected. </p>
<p>The scientists will have a bigger challenge to show that the oral form of the drug is also effective. </p>
<p>A clinical trial for neuropathic pain (pain caused by problems with nerves themselves rather than through tissue damage) has been announced to begin in 2019. Neuropathic pain is common in people with poorly controlled diabetes and can occur following some viral infections. Neuropathic pain and other chronic pain syndromes are notoriously difficult to treat and are often resistant to conventional opioid drugs. If STR-324 is more effective for neuropathic pain that other opioids, it will be a significant new painkiller. That is a big if. The researchers have not yet modelled this type of pain in their experiments. </p>
<p>The main advantage of STR-324 over conventional opioids is that it is predicted not to cause respiratory depression, a reduction in breathing rate. This side effect is linked to <a href="http://www.who.int/substance_abuse/information-sheet/en/">fatalities</a> with opioid use. While mostly this is unintentional drug overdose by people with heroin addiction, concerns about respiratory depression limit the medical use of opioids for pain management. The researchers will need to prove the advantages of STR-324 over other medicines. There is already a receptor-binding opioid, <a href="https://www.drugs.com/cdi/buprenorphine.html">buprenorphine</a>, where respiratory depression is less of significant clinical problem than for drugs like morphine and fentanyl.</p>
<p>The data for STR-324 is promising with a benefit that it works in a different way to theoretically provide a more targeted effect on pain systems than conventional opioids. The underlying scientific evidence that it will work in chronic pain, however, is light. The world does need new painkillers and, ultimately, it is only clinical trial data that will show whether STR-324 provides new hope for people living with chronic pain.</p><img src="https://counter.theconversation.com/content/71394/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marcus Rattray does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For two centuries, the only serious painkillers have been derived from opium. Scientists may have found a less deadly alternative.Marcus Rattray, Head, School of Pharmacy, University of BradfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/722832017-02-06T04:51:07Z2017-02-06T04:51:07ZOuch! The drugs don’t work for back pain, but here’s what does<figure><img src="https://images.theconversation.com/files/155399/original/image-20170202-1685-1i6mbi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Common over-the-counter drugs such as paracetamol and ibuprofen offer little proven relief for back pain. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/245834140?size=huge_jpg">from shutterstock.com </a></span></figcaption></figure><p>How’s your back? About a quarter of Australia’s population experience a <a href="https://www.ncbi.nlm.nih.gov/pubmed/15148462">back pain</a> episode at any point in time, and nearly all of us (<a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60610-7/abstract">around 85%</a>) will have at least one lifetime experience with back pain.</p>
<p>But treating it seems very difficult. Backing up a <a href="http://www.bmj.com/content/350/bmj.h1225">2015 study</a> showing paracetamol is ineffective for back pain, our <a href="http://ard.bmj.com/content/early/2017/01/20/annrheumdis-2016-210597.short?g=w_ard_ahead_tab">latest research</a> shows non-steroidal anti-inflammatory drugs (NSAIDs), such as Nurofen and Voltaren, provide minimal benefits and high risk of side effects.</p>
<p>Yet it’s not a cause for despair. There are effective approaches to managing back pain, but they’re not as simple as taking a pill.</p>
<h2>A move away from oral painkillers</h2>
<p>People with back pain are usually told by their health care practitioners to take <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/415588">analgesic medications</a> to relieve their pain.</p>
<p>Out of date <a href="https://www.nhmrc.gov.au/guidelines-publications/cp94-cp95">Australian guidelines</a> for managing back pain recommend paracetamol as first choice analgesic, NSAIDs as second, and oral opioids as the third line medicines. Paracetamol is still the <a href="http://www.aihw.gov.au/publication-detail/?id=60129549469">most purchased</a> over-the-counter painkiller in Australia, but we’ve shown it to be <a href="http://www.bmj.com/content/350/bmj.h1225">ineffective for back pain</a>. </p>
<p>The UK 2017 National Institute for Health and Care Excellence (<a href="https://www.nice.org.uk/guidance/ng59">NICE</a>) guidelines now no longer recommend paracetamol as a stand-alone intervention for back pain. In the UK, NSAIDs are recommended as the analgesic of first choice for back pain, and opioids as second.</p>
<p>However in <a href="http://ard.bmj.com/content/early/2017/01/20/annrheumdis-2016-210597.short?g=w_ard_ahead_tab">research</a> published last week, we show NSAIDs like ibuprofen (such as Nurofen) and diclofenac (such as Voltaren) offer only marginal relief from back pain compared to a placebo (sugar pill). Only one in six patients treated with NSAIDs achieved any significant reduction in pain.</p>
<p>We also found people taking NSAIDs are more than twice as likely to experience vomiting, nausea, stomach ulcers or bleeding compared to those taking placebo.</p>
<p>The study raises the question of whether the benefits of NSAIDs outweigh the risk of side effects offered by these drugs.</p>
<p>These results were obtained by reviewing 35 studies of 6,065 people with various types of spinal pain, including lower back pain, neck pain and sciatica (pain that extends into the leg, often experienced as pins and needles, reduced sensation or loss of strength).</p>
<p>Opioids such as oxycodone should also be avoided for back pain, since they have shown to increase the chances of having serious <a href="http://jamanetwork.com/journals/jama/fullarticle/2503508">side effects</a>, including misuse, overdose and dependency. In Australia, about 20% of people who see a GP for back pain are prescribed an <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/415588">opioid painkiller</a>, but recent research has shown it provides <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2522397">minimal benefit</a> for people with back pain.</p>
<h2>Other treatments and activities that don’t help</h2>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007612.pub2/abstract">Bed rest</a> is not helpful for back pain, and might even slow recovery. However <a href="https://www.ncbi.nlm.nih.gov/pubmed/19136234">heavy physical work</a> should also be avoided in the first few days after a back pain episode starts. </p>
<p>Other treatment options – including acupuncture, ultrasound, electrical nerve simulation, and corsets or foot orthotics – are <a href="https://www.nice.org.uk/guidance/ng59">not recommended</a>, since there is no strong evidence supporting their use.</p>
<p>Even if the cause of back pain is unknown, <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60172-0/abstract">imaging</a> (x-rays, MRI) is unlikely to influence management or provide meaningful information.</p>
<h2>Help, I’ve got back pain!</h2>
<p>Back pain is a problem we need to solve. Treatment costs are almost <a href="http://trove.nla.gov.au/work/185011445?selectedversion=NBD51957119">A$5 billion</a> every year in Australia, and it is the main health condition forcing older people to <a href="https://www.mja.com.au/journal/2008/189/8/chronic-disease-and-labour-force-participation-among-older-australians">retire prematurely</a>. In the United States, loss of workdays due to back pain cost <a href="https://www.ncbi.nlm.nih.gov/pubmed/16595438">US$100 billion annually</a>.</p>
<p>So, if the most commonly used medications and interventions for managing back pain do not work, what should people do instead?</p>
<p>First, there needs to be a stronger focus on preventing back pain. We know <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2481158">education and exercise programs</a> can substantially reduce the risk of developing a new episode of back pain. In addition, we also know what can trigger back pain, such as manual tasks involving heavy loads, awkward postures and <a href="http://www.thespinejournalonline.com/article/S1529-9430(16)30851-8/fulltext">being fatigued or tired during an activity</a>.</p>
<p>Second, once people have back pain, they should be given tailored advice and information to help them self-manage their condition. Patients should be reminded of the <a href="http://onlinelibrary.wiley.com/doi/10.1002/art.24853/abstract;jsessionid=B29F8971F60D05982D3A0652B545CCF7.f04t03">benign nature of back pain</a>. Most of us will have some pain in our lower back but very rare cases will be associated with more serious causes (cancer, fracture). Reminding people of the importance of keeping active within their own limitations is also crucial. This includes going for a short walk or avoiding prolonged sitting.</p>
<p>Further, people with back pain should consider <a href="https://academic.oup.com/rheumatology/article-lookup/doi/10.1093/rheumatology/kei242">physiotherapy treatments</a> and engage in exercise programs, including <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000335.pub2/abstract">aerobic exercises, strengthening, stretching</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010265.pub2/abstract">Pilates</a> or <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010671.pub2/abstract">yoga</a>. These interventions have small but <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000963.pub3/abstract">proven</a> efficacy in relieving back pain symptoms with small or no side effects.</p>
<p>For people with ongoing or persistent back pain, an alternative to taking “strong” painkillers such as opioids is to become part of a <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000963.pub3/abstract">pain management program</a>. These treatments are delivered by practitioners from different clinical backgrounds and include components that target not only physical issues but also psychosocial factors, such as depression, stress and anxiety.</p>
<p>Back pain has many causes and presentation scenarios, and a quick fix is not the answer. Although we would all like back pain to be resolved with painkillers, evidence points us to a different direction.</p>
<p>Controlling our body weight, having a healthy diet, engaging in regular physical activity, and lowering stress and anxiety are likely to offer long term benefits not only to people’s lower back, but also to their <a href="https://www.ncbi.nlm.nih.gov/pubmed/16639173">health</a> in general.</p><img src="https://counter.theconversation.com/content/72283/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gustavo Machado received funding from Australian Department of Education and Training. </span></em></p><p class="fine-print"><em><span>Manuela L Ferreira receives funding from government and industry for unrelated research. Her fellowship is also supported by Sydney Medical Foundation/The University of Sydney. </span></em></p>Although common, back pain has many causes, and a quick drug fix is not the answer. But there are things you can do to get back on track.Gustavo Machado, Research fellow, George Institute for Global HealthManuela Ferreira, Associate Professor in Medicine, The University of Sydney, Sydney Medical Foundation Fellow & Senior Research Fellow, George Institute for Global HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/580672016-06-22T02:42:08Z2016-06-22T02:42:08ZWeekly Dose: codeine doesn’t work for some people, and works too well for others<figure><img src="https://images.theconversation.com/files/121819/original/image-20160510-20595-1ormpu7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Though the codeine we take today is made synthetically, small amounts of codeine are actually found in the opium poppy.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/sybarite48/18200667470/">Daniel Jolivet/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Codeine is a synthetic drug derived from morphine. It was first discovered in 1832 by Pierre Robiquet, a French chemist. Small amounts of codeine are actually found in the opium poppy from which morphine is extracted, although modern formulations make codeine from pharmaceutical-grade morphine.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/127500/original/image-20160621-13039-1gmh5hy.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/127500/original/image-20160621-13039-1gmh5hy.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=841&fit=crop&dpr=1 600w, https://images.theconversation.com/files/127500/original/image-20160621-13039-1gmh5hy.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=841&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/127500/original/image-20160621-13039-1gmh5hy.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=841&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/127500/original/image-20160621-13039-1gmh5hy.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1057&fit=crop&dpr=1 754w, https://images.theconversation.com/files/127500/original/image-20160621-13039-1gmh5hy.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1057&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/127500/original/image-20160621-13039-1gmh5hy.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1057&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<h2>How does it work?</h2>
<p>The drug works by interacting with opiate receptors in the brain, reducing the sensation of pain in the same way as morphine and the related (illicit) drug <a href="https://theconversation.com/weekly-dose-treating-heroin-dependence-with-heroin-58424">heroin</a>. This is why drugs related to morphine and codeine are known as opiates.</p>
<p>Codeine is a much weaker narcotic analgesic than morphine – approximately one-tenth the potency.</p>
<h2>It doesn’t work for everyone</h2>
<p>About 8% of the population is unable to metabolise codeine to its active metabolite, morphine, leading to a poor response to codeine. This is not in itself dangerous (these people just have to change analgesics), but there are also a small number of people (about 5%) who metabolise codeine to morphine at a much larger extent. </p>
<p>These people are at an increased risk of toxicity caused by the increased amounts of morphine produced.</p>
<h2>Availability</h2>
<p>In Australia, codeine is available over the counter by itself or in combination with a range of other drugs in low-dose formulations (8mg, 15mg) such as with the anti-inflammatory drug ibuprofen. Stronger tablets (30mg) are only available by prescription.</p>
<p>Its main use is to relieve pain and to treat minor aches, including headaches, but only for a short term. Doctors can prescribe a higher-dose form (forte formulations containing 30mg codeine) for more significant aches and pains. </p>
<p>Low-dose forms are also used to treat coughs (antitussive), often available as syrup or linctus. Codeine can also help reduce the effects of nausea and diarrhoea without causing significant side effects.</p>
<h2>Cost</h2>
<p>Codeine is the most widely and commonly used prescription opiate in the world. It is relatively cheap when obtained over-the-counter, often for less than A$10 for low-dose packs. </p>
<p>Higher costs are associated with combination tablets and larger pack sizes. Prescribed codeine phosphate 30mg is available in a pack size of 20 tablets costing a maximum of A$25.23 under the PBS.</p>
<h2>Doses</h2>
<p>It is taken orally with doses ranging from 15-60mg but may range up to 240mg daily. Once consumed this drug will act for approximately three to six hours.</p>
<p>Codeine is available in combination preparations such as Nurofen Plus, which also contains the anti-inflammatory drug ibuprofen; and in cold and flu preparations with paracetamol and decongestants. Codeine is also found in combination with paracetamol and doxylamine (for example Mersyndol). This is recommended for the treatment of tension headache, migraine, and it may be useful in controlling fever.</p>
<p>The drug should not be used for prolonged periods, particularly without supervision and control by a medical practitioner. The main risk is the development of dependence (addiction) and tolerance that can lead to use of higher doses, particularly in patients whose pain is not well managed. </p>
<p>Codeine may not be the best treatment for a given condition; hence medical supervision is always warranted when longer-term use is sought. Risks are also associated with products that combine codeine with other drugs. Prolonged use of high-dose codeine/ibuprofen combinations has been linked with gastrointestinal disorders and renal failure. Combinations with paracetamol can also lead to liver damage.</p>
<h2>Side effects</h2>
<p>Codeine may cause red, itchy skin rashes, difficulty breathing, faintness, constipation, hayfever, and swelling of the face or throat. </p>
<p>Serious side effects include unusual sleepiness, confusion, and difficult and noisy breathing. The drug can suppress the cough reflex and create breathing difficulties, particularly when asleep.</p>
<h2>Adverse drug combinations</h2>
<p>Alcohol (other than low doses), other analgesics, benzodiazepines (Valium, Temaze, Serepax), other sedatives and sleeping tablets, and some antidepressants interact with codeine and should be avoided since they may enhance the sedative actions.</p>
<p>Use of codeine is not advised in people who have had recent biliary tract surgery (unblocking of the bile ducts), have suffered a recent head injury or conditions that raise the pressure within the head, or are suffering from diarrhoea caused by poisoning or antibiotics.</p><img src="https://counter.theconversation.com/content/58067/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Olaf Drummer does not receive current funding from overnment-funded, foundation or research council grants.</span></em></p>About 8% of the population is unable to metabolise codeine, and a small number metabolise it at a much larger extent.Olaf Drummer, Professor, Forensic Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/579432016-06-03T00:50:51Z2016-06-03T00:50:51ZWhat is chronic pain and why is it hard to treat?<figure><img src="https://images.theconversation.com/files/124195/original/image-20160526-22080-1hnaidv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It hurts.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-392626384.html?src=download_history">Back pain image via www.shutterstock.com.</a></span></figcaption></figure><p>A recent study by the <a href="http://dx.doi.org/10.1016/j.jpain.2015.05.002">National Institutes of Health</a> found that more than one in three people in the United States have experienced pain of some sort in the previous three months. Of these, approximately 50 million suffer from chronic or severe pain. </p>
<p>To put these numbers in perspective, <a href="http://www.diabetes.org/diabetes-basics/statistics/">21 million people have been diagnosed with diabetes</a>, <a href="http://www.cancer.org/cancer/cancerbasics/cancer-prevalence">14 million have cancer</a> (this is all types of cancer combined) and <a href="http://www.cdc.gov/nchs/fastats/heart-disease.htm">28 million have been diagnosed with heart disease</a> in the U.S. In this light, the number of pain sufferers is stunning and indicates that it is a major epidemic. </p>
<p>But unlike treatments for diabetes, cancer and heart disease, therapies for pain have not really improved for hundreds of years. Our main therapies are non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or aspirin, which are just modern versions of chewing on willow bark; and opioids, which are derivatives of opium. </p>
<p>In 2012 <a href="http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm">259 million prescriptions for opioids</a> were filled in the United States. It is not clear how many of these prescriptions were for chronic pain. And indeed, <a href="http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf">new CDC guidelines</a> on the use of opioids to treat noncancer chronic pain caution physicians to consider the risks and benefits of using opioids when prescribing them to patients. </p>
<p>The fact is, however, that opioids are used to treat chronic pain not because they are the ideal treatment, but because for some patients, despite their drawbacks, they are the most effective treatment available at the moment. </p>
<p>The problem, as I see it, is this: we are not investing enough in researching and teaching what causes pain and how to treat it.</p>
<h2>Pain can have a purpose</h2>
<p>I study the processes that trigger and maintain chronic pain. One of the first things I teach my students is that pain is a biological process that is critical for life. Pain protects our bodies from injury and by reminding us that tissue is damaged and needs to be protected it also aids in repairing the injuries we do acquire. </p>
<p>This is graphically illustrated by individuals who are congenitally incapable of <a href="https://ghr.nlm.nih.gov/condition/congenital-insensitivity-to-pain">feeling pain</a>. People with these conditions typically succumb to infections or organ failure at a young age due to multiple injuries that go unattended. Because they cannot feel pain, they never learn to avoid hazards, or how to protect still-healing injuries. </p>
<p>For the most part, physicians and scientists are not particularly concerned with pain from everyday bumps, bruises and cuts. This type of acute pain typically does not require treatment or can be treated with over-the-counter medication. It will resolve itself when the tissue heals. </p>
<p>What concerns those of us who treat and study pain, however, is chronic pain. This <a href="http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm#What_is">type of pain</a> – that can last for weeks, months or even years – serves no useful purpose for survival and is actually detrimental to our health. </p>
<p>There isn’t one type of chronic pain. </p>
<p>In many cases chronic pain persists after an injury has healed. This happens relatively often with <a href="http://www.ncbi.nlm.nih.gov/pubmed/20104399">wounded veterans</a>, car accident victims and others who have suffered violent trauma.</p>
<p>Chronic pain from arthritis is telling the person about the damage in their body. In this respect it is similar to acute pain and, presumably, if the body healed the pain would subside. But, at the moment, there is no treatment or intervention to induce that healing so the pain becomes the most troubling aspect of the disease. </p>
<p>Chronic pain can also arise from conditions, like <a href="http://www.niams.nih.gov/health_info/fibromyalgia/">fibromyalgia</a>, which have an unknown cause. These conditions are often misdiagnosed and the pain they produce may be dismissed by health care professionals as psychological or as drug-seeking behavior. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/124196/original/image-20160526-22060-ctbt03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/124196/original/image-20160526-22060-ctbt03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=357&fit=crop&dpr=1 600w, https://images.theconversation.com/files/124196/original/image-20160526-22060-ctbt03.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=357&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/124196/original/image-20160526-22060-ctbt03.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=357&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/124196/original/image-20160526-22060-ctbt03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=449&fit=crop&dpr=1 754w, https://images.theconversation.com/files/124196/original/image-20160526-22060-ctbt03.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=449&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/124196/original/image-20160526-22060-ctbt03.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=449&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">How does the brain process pain?</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/wellcomeimages/16765237052/in/photolist-rxudTf-khquvW-9RPWDj-pUMbMm-qAAbSS-rg1jHu-pJKfTp-bGTZ8M-pEurqE-pWSMJH-9RPW2G-khnPbt-p66rbs-khnEji-rxzDXr-9RPW61-bPTEPp-9RM2RZ-9RM3SB-bBzyC7-9RQtvj-bQuf4v-wsfgQn-9RQtwf-GgbgLV-v7xRxC-FR4PY3-wGqd6G-wsfgYZ-Gp9WmY-ushSEP-v7FzRk-us8483-us84gj-a86X4e-ws7WZj-vGhbnc-vKwyJC-vMHGfE-ws7XuN-vMSe2x-wKeCrV-v7xUe9-vKwyKE-wJ2fsf-ws7XEs-wGqd9s-wJJTG6-ws7X6w-EpAGfH">Wellcome Images</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<h2>How do we experience pain?</h2>
<p>The human pain experience can be divided into three dimensions: what pain researchers call the sensory-discriminative, the affective-motivational and the cognitive-evaluative. In acute pain there is a balance between each of these dimensions that allows us to accurately evaluate the pain and the threat it may pose to our survival. In chronic pain these dimensions are disrupted. </p>
<p>The sensory-discriminative dimension refers to the actual detection, location and intensity of the pain. This dimension is the result of a direct nerve pathway from the body to the spinal cord and up into the brain’s cortex. This is how we are aware of the location on our bodies of a potential injury and how much damage may be associated with the injury. </p>
<p>Knowing where it hurts is only part of experiencing pain. Is your injury life-threatening? Do you need to run away or fight back? This is where the affective-emotional dimension comes in. It arises from the pain circuitry interacting with the limbic system (the emotional centers of the brain). This adds an emotional flavor to the incoming pain signal and is part of the fight-or-flight response. This pathway evokes the anger or fear associated with the possibility of physical harm. It also provokes learning so that in the future we avoid the circumstances leading to the injury. </p>
<p>The third dimension, the cognitive-evaluative, is the conscious interpretation of the pain signal, combined with other sensory information. This dimension draws on the different aspects of pain processing allowing us to determine the location and potential severity of an injury and to come up with survival strategies based on all available information.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/124197/original/image-20160526-22068-19svmb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/124197/original/image-20160526-22068-19svmb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=371&fit=crop&dpr=1 600w, https://images.theconversation.com/files/124197/original/image-20160526-22068-19svmb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=371&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/124197/original/image-20160526-22068-19svmb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=371&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/124197/original/image-20160526-22068-19svmb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=467&fit=crop&dpr=1 754w, https://images.theconversation.com/files/124197/original/image-20160526-22068-19svmb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=467&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/124197/original/image-20160526-22068-19svmb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=467&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">When pain is the disease.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-178383632/stock-photo-senior-hands-suffering-from-pain-and-rheumatism.html?src=tD6LkwLNTEMhMfUawwBxAw-1-55">Hands images via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>When it always hurts</h2>
<p>The pain sensory system is designed for survival. If a pain signal persists, the default programming is that the threat to survival remains an urgent concern. Thus, the goal of the pain system is to get you out of harm’s way by ramping up the intensity and unpleasantness of the pain signal. </p>
<p>To increase the urgency of the pain signal, the sensory-discriminative dimension of pain becomes less distinct, leading to a more diffuse, less localized, pain. This pathway also amplifies the pain signal by rewiring spinal cord circuits that carry the signal to the brain, making the pain feel more intense.</p>
<p>If there is a threat to survival, the increasing intensity and unpleasantness of pain serves a purpose. But if the pain signal persists from, let’s say, arthritis or an old injury, the increased intensity and unpleasantness is unwarranted. This is what we define as chronic pain. </p>
<p>In chronic pain, as compared to acute pain, the affective-motivational dimension becomes dominant, leading to psychological consequences. Thus suffering and depression are much worse for chronic pain patients than it would be for an individual with an equivalent acute injury. </p>
<p>The multifaceted nature of pain is why opioids are often the most effective agents for both moderate to severe acute and chronic pain. </p>
<p>Opioids act at all levels of the pain neural circuitry. They suppress incoming pain signals from the peripheral nerves in the body, but importantly for chronic pain patients, they also inhibit the amplification of the signals in the spinal cord and improve the emotional state of the patient. </p>
<p>Unfortunately, patients rapidly develop tolerance to opioids, which significantly reduces their effectiveness for chronic therapy. Because of this as well as their addictive nature, potential for abuse and overdose, and side effects such as constipation, opioids are less than ideal agents for treating chronic pain. It is critical that we find alternatives. But that’s easier said than done. </p>
<h2>Funding for pain research lags</h2>
<p>In 2015 the National Institutes of Health spent US$854 million on <a href="https://report.nih.gov/categorical_spending.aspx">pain research</a>, compared to more than $6 billion for cancer. It is no wonder that pain patients muddle through with what amounts to centuries-old therapies.</p>
<p>The competition for funding for pain researchers is intense. In fact, many of my friends and colleagues, all highly experienced midcareer scientists, are leaving research because they cannot sustain the funding necessary to make any significant progress in finding treatments for pain. I, myself, spend up to 30 hours per week preparing and writing research proposals for funding agencies. Yet, less than one in 10 of these proposals are funded. The dearth of funding is also discouraging young scientists from doing pain research. With tenure at major universities becoming more and more difficult to attain, they can little afford to spend all of their time writing research proposals that do not get funded. </p>
<p>In addition, many medical and dental programs in the United States devote as little as one hour in their curriculum to teaching <a href="http://www.ncbi.nlm.nih.gov/pubmed/21945594">pain mechanisms and pain management</a>. Thus, most of our health professionals are poorly prepared to diagnose and treat chronic pain, which contributes to both the under treatment of pain and the abuse of opioids. </p>
<p>Unrelieved pain contributes more to human suffering than any other disease. It is time to invest in research to find safe effective therapies and on training health care providers to appropriately diagnose and treat pain.</p><img src="https://counter.theconversation.com/content/57943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Caudle receives funding from the National Institutes of Health and the Facial Pain Foundation. He is also a partner in Velocity Laboratories, LLC. Velocity Laboratories, LLC is a contract research organization.</span></em></p>Unrelieved pain contributes more to human suffering than any other disease.Robert Caudle, Professor of Oral and Maxillofacial Surgery, Neuroscience Division, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/562052016-03-25T09:40:38Z2016-03-25T09:40:38ZThe other opioid crisis – people in poor countries can’t get the pain medication they need<figure><img src="https://images.theconversation.com/files/116393/original/image-20160324-17840-1018h1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hard to get. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-244226398/stock-photo-morphine-sulfate-pills-with-bottle-and-prescription.html?src=6k1Q_GIQBxQ8258IRKLelw-1-3">Morphine pills image via www.shutterstock.com.</a></span></figcaption></figure><p>There are two opioid crises in the world today. One is the epidemic of abuse and misuse, present in many countries but rising at an <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">alarming rate in the United States</a>. The other crisis is older and affects many more people around the world each year: too few opioids. </p>
<p>Hospitals in the U.S. and Europe routinely prescribe opioids for chronic cancer pain, end-of-life palliative care and some forms of acute pain, like bone fractures, sickle cell crises and burns. But patients with these conditions in much of Asia, Africa and Latin America often receive painkillers <a href="http://www.nytimes.com/2007/09/09/world/africa/09iht-pain.4.7440327.html?_r=0">no stronger than acetaminophen</a>.</p>
<p>Many factors play into this crisis, but I would argue that the International Narcotics Control Board (<a href="https://www.incb.org/">INCB</a>), an independent monitoring agency established by the U.N., <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=10232633&fulltextType=RA&fileId=S089803061600004X">is a fundamental cause</a> of untreated pain in Asia, Africa and Latin America.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A worker handles medicine in the Pharmacie de la Sante Publique warehouse in Abidjan, Ivory Coast. Opioid painkillers can be difficult to access in many parts of Africa.</span>
<span class="attribution"><span class="source">Thierry Gouegnon/Reuters</span></span>
</figcaption>
</figure>
<h2>Just how vast is the gap in pain relief?</h2>
<p>In 2009, the U.S., Canada and Europe accounted for 18 percent of global population, but <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">90 percent</a> of global morphine consumption.</p>
<p><a href="https://ppsg.medicine.wisc.edu/">The global gap in access to opioids has been growing</a> for a long time. In the U.S., consumption of morphine in 2013 was 32 times higher than in 1964 (increasing from 2.3 mg per person to 79.9 mg per person). In the same time period, morphine consumption in Tanzania only doubled to 0.15 mg person. In India in 2013, this figure was only 0.11 mg per person.</p>
<p>Per capita medicinal opioid consumption in Asia, Central America, the Caribbean and Africa <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">is far below</a> the INCB’s own minimum global standard. In countries and regions below this benchmark (set at 200 daily doses per million inhabitants per day), we can be certain that patients who need opioids for legitimate medical reasons do not receive them.</p>
<p>The INCB argues that poor countries have too few opioids because they <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">cannot afford them</a>. While there is a correlation between national income and national consumption of opioids, cost isn’t the principal issue. </p>
<p>Generic opioids are cheap. A generic 10mg immediate-release morphine sulfate tablet costs roughly <a href="http://journals.lww.com/anesthesia-analgesia/Abstract/2007/07000/Pain_Management__A_Fundamental_Human_Right.37.aspx">US$0.01 to produce</a>.</p>
<p>The main problem, <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=10232633&fulltextType=RA&fileId=S089803061600004X">I would argue</a>, is a policy based on the fear that increased use of opioids will inevitably lead to abuse and trafficking. Palliative care physician and ethicist Eric Krakauer calls this fear “<a href="https://dx.doi.org/10.3109/15360288.2010.501852">opiophobia</a>.” </p>
<p>The work of the INCB has been crucial in increasing this fear of opioids and promoting restrictive policies that continue to keep millions of patients in unnecessary pain.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Morphine has legitimate medical uses.</span>
<span class="attribution"><span class="source">Vaprotan, via Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Fear of abuse drives ‘opiophobic’ policies</h2>
<p>The International Narcotics Control Board has two purposes: to prevent addiction and to ensure the availability of opioids for legitimate medical use. But since its founding in 1968, the INCB has focused almost entirely on combating drug abuse, while ignoring access to pain relief.</p>
<p>One way the INCB tried to prevent addiction was by writing so-called “model laws” that it encouraged countries to enact. One such <a href="https://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_1969-01-01_2_page002.html">law</a>, written in 1969, set controls on opioid prescription and distribution that were manageable for wealthier countries, but that would prove onerous in poor countries, particularly those with few doctors.</p>
<p>The Model Law stated, for instance, that opioids could be supplied only by doctors. This provision did not affect access to opioids in the United States or in other wealthy nations with many physicians. But many poorer countries, where doctors were scarce, relied on nurses and other kinds of practitioners to prescribe drugs. The model law made no allowance for this.</p>
<p>In addition, the Model Law stated that physicians who prescribed opioids inappropriately or who failed to keep full records should be subject to “the same prison sentences and fines as are inflicted under the Penal Code for housebreaking.”</p>
<p>INCB laws were promoted by the United Nations Fund for Drug Abuse Control (<a href="https://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_1971-01-01_2_page002.html">UNFDAC</a>), which was founded in 1970. The UNFDAC conducted training sessions for national drug-control administrators and law enforcement to stress the dangers of abuse. But, as I found in my research, the sessions rarely mentioned the importance of access to pain relief.</p>
<p>The model laws and training sessions helped inspire countries in Latin America, Asia and Africa to pass <a href="http://dx.doi.org/10.1017/S089803061600004X">new, more restrictive laws</a> during the 1970s and ‘80s. </p>
<p>For instance, in India, a 1985 law required hospitals to obtain so many licenses before each shipment of morphine that many stopped using the drug at all. Medicinal morphine consumption in India fell by 97 percent between 1985 and 1997. </p>
<p>In Panama, nurses were barred from prescribing opioids. Paraguay and Guinea-Bissau mandated long prison sentences for any doctor who could not produce documentation justifying every single pill prescribed over years of practice. Fearing these punishments, doctors avoided prescribing opioids, even when they were medically necessary.</p>
<h2>Countries underestimate opioid needs in response to INCB pressure</h2>
<p>The INCB also tried to prevent opioids prescribed to treat pain from being diverted into illegal markets by requiring every country to provide annual estimates of projected opioid needs for medical and scientific purposes. The INCB was responsible for approving these annual estimates, and tried to ensure that countries imported no more than the approved quantities. </p>
<p>Between the 1960s and the 1980s, <a href="https://books.google.com/books/about/Estimated_World_Requirements_of_Narcotic.html?id=O_8tAQAAIAAJ">INCB reports</a> chastised many nations in Africa, Asia and Latin America for making estimates that it considered too high.</p>
<p>A country that imported more opioids than the INCB had approved risked a costly stain on its international reputation. The INCB could even <a href="http://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_1962-01-01_1_page007.html">recommend that countries impose trade embargoes</a> on nations that produced or imported more opioids than it had deemed necessary. As a result, countries low-balled their estimates of future medicinal opioid requirements.</p>
<p>But the INCB didn’t judge these estimates based on actual medical need. Rather, <a href="https://books.google.com/books/about/Estimated_World_Requirements_of_Narcotic.html?id=O_8tAQAAIAAJ">it insisted</a> estimates should be based on the number of physicians in a country, a potentially misleading piece of data in parts of the world were doctors are in short supply, and nurses and other health care professionals fill the gaps and prescribe medicine. </p>
<p>The INCB worried that too many opioid prescriptions could lead to abuse. Indeed, this is a major cause of the current addiction crisis in the United States. But, in the countries where the INCB exerted the greatest influence, the bigger problem was that too few (rather than too many) opioids were being prescribed.</p>
<p>A 1989 report from the INCB and World Health Organization revealed that national estimates of future opioid need were often calculated based <a href="https://www.ncjrs.gov/pdffiles1/Digitization/141719NCJRS.pdf">on nothing more than previous years’ imports</a>. That report also quantified the extent of untreated cancer pain, estimating that “at least 3.5 million cancer patients” worldwide “suffer needlessly from pain.” </p>
<h2>The INCB is starting to change, slowly</h2>
<p>For many years, the only thing most countries heard from the INCB was that their estimates were too high. But in 1999, <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">the INCB announced</a> it would begin to contact governments that submitted “particularly low estimates” to encourage them to increase their imports.</p>
<p>And in 2010, the INCB agreed that countries with few doctors should <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">allow nurses to prescribe morphine</a>, a reversal from previous policy recommendations. </p>
<p>But these small steps have not been enough to overcome the fear of opioids spread by decades of model laws and training sessions. The INCB’s recommendations continue to focus almost entirely on abuse.</p>
<p>For instance, a 2012 INCB <a href="https://www.incb.org/documents/Narcotic-Drugs/Guidelines/estimating_requirements/NAR_Guide_on_Estimating_EN_Ebook.pdf">report</a> stated that national requests to import opioids sufficient to address existing need might be denied if such imports might raise “the possibility of diversion or abuse.” </p>
<p>International meetings, especially the <a href="http://www.unodc.org/ungass2016/">United Nations Special Session on the World Drug Problem</a> in April 2016, should pay far more attention to untreated pain than they have in the past. </p>
<p>More recent estimates from the World Health Organization suggest that each year <a href="http://www.who.int/medicines/areas/quality_safety/ACMP_BrNote_Genrl_EN_Apr2012.pdf">5.5 million terminal cancer patients</a> and 1 million end-stage HIV/AIDS patients around the globe don’t get enough treatment, or any treatment at all, for their moderate to severe pain. The WHO estimates that tens of millions of people are denied medically necessary pain treatment every year.</p>
<p>Pain is universal, but its relief is still a function of geography.</p><img src="https://counter.theconversation.com/content/56205/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Luke Messac does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Why are so many people in dire need of pain relief unable to access the powerful painkillers that are so commonly prescribed in the United States?Luke Messac, M.D./Ph.D. student in History, University of PennsylvaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/503442015-11-25T05:06:39Z2015-11-25T05:06:39ZFrom the clinic to the street: How the explosion in prescription painkillers has created more heroin users<p>In the early years of my clinical practice as a psychologist treating heroin users, I commonly saw adolescents and young adults using heroin as their first drug. A typical client was a male in his mid-teens, perhaps a runaway or living in foster care, or someone who had been in and out of juvenile detention, or dropped out of school and who was court-ordered into treatment. When we saw older heroin users in treatment, it was considered unusual. That’s not the case anymore.</p>
<p>According to a new study, 50-59-year-olds are the <a href="http://dx.doi.org/10.3109/10826084.2015.1027929">largest age group</a> in opioid treatment programs. Another recent study found that drug overdoses were a factor in the <a href="http://dx.doi.org/10.1073/pnas.1518393112">rising mortality</a> rate for non-Hispanic white middle-aged Americans. </p>
<p>According to <a href="https://dx.doi.org/10.1001/jama.2014.7404">reports</a> in the Journal of the American Medical Association, the new generation of heroin users is older, predominantly white and living outside of inner-city urban neighborhoods. And the average age of first heroin use <a href="http://dx.doi.org/10.1001/jamapsychiatry.2014.366">has increased</a> from age 16 to over 23 and from equal numbers of white and nonwhite users to about 90 percent white. </p>
<p>Why have the demographics of heroin use changed so much? For that, we can look to dramatic increase in prescriptions for opioid painkillers, such as Oxycontin or Vicodin. These medications can treat acute and chronic pain, but can also lead to addiction. And when people can’t access pills anymore, heroin can provide a cheaper and more powerful alternative.</p>
<h2>Overdose deaths are up</h2>
<p>The incidence of drug overdoses is five times higher today than 35 years ago. In 2009, drug overdose deaths <a href="http://www.cdc.gov/HomeandRecreationalSafety/pdf/HHS_Prescription_Drug_Abuse_Report_09.2013.pdf">passed</a> motor vehicle deaths for the first time. And prescription pain medications, specifically opioids, have increasingly accounted for the majority of drug overdose deaths. </p>
<p>From 1999 to 2010, drug overdose deaths from opioid pain medications increased from about 30 percent to over 60 percent, and in 2010, the most recent year that statistics are available, deaths from opioids <a href="http://www.cdc.gov/HomeandRecreationalSafety/pdf/HHS_Prescription_Drug_Abuse_Report_09.2013.pdf">far exceeded deaths</a> from any other legal or illegal drug class.</p>
<p>In large part, this increase stems from a change in how doctors treated pain that began in the 1990s. At that time, I was working in a large, urban hospital system, and both researchers and clinicians were advocating aggressive and proactive treatment for pain. Restrictions on prescribing opioids were lessened, and physicians were <a href="http://dx.doi.org/10.3122/jabfm.2014.05.130311">being encouraged</a> to more adequately treat their patients’ pain. </p>
<p>And prescriptions for opioids have gone up dramatically. The Centers for Disease Control and Prevention (CDC) <a href="http://www.cdc.gov/drugoverdose/prescribing/guideline.html">reports</a> that as recently as 2012, over 250 million prescriptions for pain relievers were written in the United States per year, representing a 300 percent increase in the previous 13 years. </p>
<p>Unfortunately, with the increased use of prescription opioids, there was a <a href="http://dx.doi.org/10.3122/jabfm.2014.05.130311">commensurate increase</a> in overdoses. </p>
<h2>Why are more older people becoming addicted to painkillers?</h2>
<p>The National Institutes of Health <a href="http://www.ncbi.nlm.nih.gov/pubmed/16215337">reports</a> that chronic pain patients tend to be older, that their pain is of longer duration, more often accompanied by other conditions and more likely to be treated. For patients in severe pain, opioids are often the only effective treatment. </p>
<p>There are three primary effects of opioid use: analgesia (pain relief), sedation and euphoria. Patients experience the three differently, depending on their reasons for using the drug. Some people may become dependent on opioids, and some will become addicted – and they <a href="http://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug-addiction/section-iii-action-heroin-morphine/10-addiction-vs-dependence">are not the same</a> thing. </p>
<p>Dependence is defined as having withdrawal symptoms when the drug is stopped, while addiction is the compulsive use of the drug for a state (euphoria) other than pain relief. The compulsion becomes so consuming that the addict’s life centers around seeking and obtaining the drug, using it, withdrawing from it and seeking it again, to the neglect of all other aspects of life.</p>
<p>While opioids carry the risk of addiction, not all patients will become addicted. For example, patients being treated with opioid medications after surgery are not likely <a href="http://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug-addiction/section-iii-action-heroin-morphine/10-addiction-vs-dependence">to become addicted</a>, regardless of the dose. That is because for the post-surgical patient, the sedative and analgesic effects of the medication override the euphoric effect. </p>
<p>On the other hand, individuals who focus on the state of euphoria (the “high”) are the ones more likely <a href="http://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug-addiction/section-iii-action-heroin-morphine/10-addiction-vs-dependence">to become addicted</a>. </p>
<h2>How does abuse start?</h2>
<p>As clinical psychologist working with pain patients over the years, I was able to observe distinct patterns of use. Some people were able to stop the pain relievers with relative ease after recovery. Others might start taking opioids for nonmedical reasons. </p>
<p>Here’s a typical example: A patient who had been prescribed Vicodin after back surgery might need fewer pills after a while to manage their pain, but was afraid to tell the doctor (“What if the pain comes back?”), so the prescriptions continued. By the time recovery was complete, the patient had a stockpile of pills. One day after work, this patient came home with a headache from a stressful day. In the medicine cabinet were the leftover Vicodin. A couple of pills, and the patient experienced relief not only from the headache but from the stress of the day. The next time, taking the pills was easier, until before long, the patient was addicted and seeking more. This patient, like many who become addicted, did not intend to start abusing the drug.</p>
<p>Eventually, the prescriptions stopped, but the addiction did not, and many of these patients either began to doctor-shop, a term that describes frequent changes in doctors or having multiple doctors in order to obtain prescriptions, or they turned to illegally obtained drugs, prescription or street drugs such as heroin. </p>
<p>Heroin is cheap. A single 80mg OxyContin pill can cost between US$60 and $100 on the street, <a href="http://www.usatoday.com/story/news/nation/2013/04/15/heroin-crackdown-oxycodone-hydrocodone/1963123/">compared</a> to $45-$60 for a single purchase of multiple doses of heroin. Heroin also has a larger effect, depending on the purity and method of ingestion, and doesn’t have the ceiling effect that controlled prescriptions have. </p>
<p>Data from Substance Abuse and Mental Health Services Administration (SAMHSA) back that up. SAMHSA <a href="http://dx.doi.org/10.1001/jama.2013.278861">reports</a> that nearly 80 percent of heroin users report having become addicted to prescription pain medications first, while just 3.6 percent had a history of heroin use before beginning prescription pain medications. Heroin is now rapidly replacing Vicodin, Oxycodone and other prescription opioid painkillers as the drug of choice for nonmedical use by a <a href="http://dx.doi.org/10.1001/jamapsychiatry.2014.366">growing population of users</a>. </p>
<p>And there are reports that drug dealers may <a href="http://dx.doi.org/10.1001/jama.2013.278861">encourage drug seekers to use heroin</a>, if they cannot afford prescription medicines. As more older people become addicted to opioids, more may turn to heroin.</p>
<p>A study of heroin users conducted by researchers at Washington University in St Louis, Missouri reported that typical heroin users in their study were white, middle-aged and equally divided among males and females.</p>
<p>When asked about switching from prescription pain medications to heroin, many reported that they felt <a href="https://dx.doi.org/10.1001/jama.2014.7404">forced</a> to switch because of lack of availability of the prescription drugs.</p>
<h2>Can policy fixes turn the tide?</h2>
<p>In an effort to curb the rising rates of addiction to prescription opioids and the associated costs in lives, the U.S. Drug Enforcement Administration (DEA) has imposed restrictions on the prescribing of hydrocodone combination product, like Vicodin. </p>
<p>These <a href="http://blogs.fda.gov/fdavoice/index.php/2014/10/re-scheduling-prescription-hydrocodone-combination-drug-products-an-important-step-toward-controlling-misuse-and-abuse/">include</a> strength, number of doses, frequency of prescription and method of delivering new prescriptions. </p>
<p>While attempting to curb the nonmedical use of the opioids, these policies are also limiting access to pain treatments for the legitimate pain patient. However well-meaning these new laws are, it remains to be seen whether or not they will force increased numbers of pain patients to the streets and street drugs for relief.</p>
<p>In the meantime, physicians would do well to learn about opioid use as well as engage in drug screening and monitoring, pill counting and the use of other pain management protocols such as behavioral counseling. That would be an important beginning of the end of the drug addiction cycle.</p><img src="https://counter.theconversation.com/content/50344/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeannie D. DiClementi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Why have the demographics of heroin use changed so much? For that, we can look to dramatic increase in prescriptions for opioid painkillers, such as Oxycontin or Vicodin.Jeannie D. DiClementi, Associate Professor of Psychology, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/493482015-10-18T15:00:34Z2015-10-18T15:00:34ZPrescription drugs in sport: kill the pain, not the player<figure><img src="https://images.theconversation.com/files/98754/original/image-20151018-25142-wmogl1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">NRL players Aaron Gray and Dylan Walker suffered a life-threatening reaction to a combination of controlled drugs.</span> <span class="attribution"><span class="source">AAP/David Moir</span></span></figcaption></figure><p>The use of prescription-only painkillers by athletes is hardly new, but debate about their (ab)use in Australia has recently been brought into focus by the emergency hospitalisation of South Sydney NRL players Aaron Gray and Dylan Walker, both of whom suffered a <a href="http://www.smh.com.au/rugby-league/south-sydney-rabbitohs/aaron-gray-and-dylan-walkers-families-told-it-was-5050-after-drug-overdose-20150922-gjsri6.html">life-threatening reaction</a> to a combination of controlled drugs. These athletes were recovering from post-season surgery to address injuries, with painkillers prescribed by their surgeons to assist with post-operative discomfort. </p>
<p>According to a <a href="http://www.smh.com.au/rugby-league/south-sydney-rabbitohs/dylan-walker-and-aaron-gray-released-from-hospital-after-sever-reaction-to-prescribed-painkillers-20150925-gjv13i.html">Fairfax report</a>, Gray and Walker had been prescribed the painkiller Targin, which they took. Inexplicably, they also consumed another painkiller, known as Tramadol. Thankfully, the athletes have recovered from their acute care, taking the time to <a href="http://www.smh.com.au/rugby-league/south-sydney-rabbitohs/dylan-walker-and-aaron-gray-released-from-hospital-after-sever-reaction-to-prescribed-painkillers-20150925-gjv13i.html">publicly thank medical staff</a> and to apologise for inadvertently causing the emergency. </p>
<p>Just why the players took both drugs is the subject of an inquiry by the NRL Integrity Unit. This episode has certainly raised some confronting questions about the use and abuse of prescription drugs in the NRL.</p>
<p>Sport and society are not separate. It is therefore crucial to note that the Australian Medical Association has described the misuse or abuse of prescription drugs as a “national emergency”. As an <a href="http://fisherdore.com.au/blog/index.php/category/criminal-defence-and-procedure/drug-offences/">example</a>:</p>
<blockquote>
<p>Of the 384 overdose deaths investigated by the Victorian coroner’s court in 2014, 82% of the deaths involved prescription drugs. </p>
</blockquote>
<p>This is not an attempt to discount medication (ab)use challenges in sport, but rather to emphasise that there are multi-faceted society-wide problems in terms of prescription drugs.</p>
<h2>Responding to crisis</h2>
<p>While a case of n=1 hardly amounts to a league-wide catastrophe, NRL stakeholders and commentators have been polarised in the wake of the Gray-Walker episode. Some have suggested that there is a prescription drugs “crisis” in rugby league, while others refute such accusations as baseless in fact.</p>
<p>Although anecdote is no antidote to methodical research, the media was soon replete with stories by either current or former players and coaches about “widespread” abuse of prescription medications. </p>
<p>The problems varied: over-reliance on painkillers – even <a href="http://www.foxsports.com.au/nrl/mark-geyer-reveals-painkiller-addiction-with-rabbitohs-duo-dylan-walker-aaron-gray-hospitalised/story-e6frf3ou-1227540215923">addiction</a>; the misuse of prescription drugs for <a href="http://www.news-mail.com.au/news/alarm-bells-ring-after-close-call/2785130/">“recreational” purposes</a> (such as by mixing them with alcohol); and players turning to medically approved substances because they were warned off alcohol in-season as well as being <a href="http://thenewdaily.com.au/sport/2015/09/23/prescription-drugs-sport-abuse-coming-sure/">subject to testing for illicit substances</a> like marijuana, ecstacy and cocaine. </p>
<p>Sensationally, one journalist even suggested that players were <a href="http://www.foxsports.com.au/nrl/nrl-premiership/nrl-360-host-paul-kent-says-nrl-players-are-stockpiling-prescription-painkillers-issued-by-club-doctors/story-fn2mcuj6-1227541083908">“stockpiling” painkillers</a>, then either handing them over to team-mates or selling them – either of which is illegal.</p>
<p>As a counter to these alarming narratives, there was calm within the sport’s hierarchy. The Rugby League Players’ Association (RLPA) pointed to internal testing conducted on <a href="http://www.smh.com.au/rugby-league/league-news/players-union-says-prescription-drug-abuse-not-major-issue-in-nrl-20150922-gjsbls.html">behalf of the NRL</a>, with its findings having indicated no significant problems in terms of the drugs screened for: prescription relaxants – benzodiazepines, and prescription sleeping pills – zolpidems. </p>
<p>This was also the position of NRL CEO Dave Smith, who <a href="http://www.heraldsun.com.au/sport/nrl/nrl-ceo-dave-smith-denies-code-has-problem-with-prescription-drugs/story-fni3fbgt-1227542521693?sv=e8e50d2e98c18265ad903c67e7000753">said</a>:</p>
<blockquote>
<p>The [NRL testing] data does not suggest a widespread problem in rugby league.</p>
</blockquote>
<p>The glaring problem with both arguments is that the NRL tests – and therefore the associated data – do not include opioid analgesics, such as Targin and Tramadol. Both the RLPA and Smith were therefore asserting faith in a test that was not being conducted. </p>
<p>Little wonder that the NRL soon <a href="http://m.theaustralian.com.au/sport/nrl/nrl-may-add-oxycodone-to-drugs-for-which-players-are-tested/story-fnca0von-1227541061230?sv=65eac597f88026a97d63d72aa380b154">announced that</a> “other [prescription] drugs could now be included in the [testing] process”, namely opioid analgesics.</p>
<h2>The hair apparent</h2>
<p>The NRL had performed a backflip with triple pike. Not only would they now test for opioid analgesics, they were going to adopt a new methodology for the biochemical surveillance of all prescription drugs – <a href="https://www.researchgate.net/publication/257462720_Validation_of_a_method_for_the_targeted_analysis_of_96_drugs_in_hair_by_UPLC-MSMS">hair testing</a>.</p>
<p>Screening for drugs by strands of hair typically has the advantage of a <a href="http://www.aic.gov.au/publications/current%20series/rpp/21-40/rpp25.html">longer diagnostic period</a> – up to 90 days prior to the collection of a follicle. According to Nick Weeks, the head of the NRL’s Integrity Unit, this was all part of a grand plan. He <a href="http://www.nrl.com/prescription-drug-testing/tabid/10874/newsid/90123/default.aspx">said</a> that:</p>
<blockquote>
<p>The prospect of [prescription drug] hair testing has been the subject of discussion between the NRL and RLPA for several months. </p>
</blockquote>
<p>That was convenient to say the least. During the Gray-Walker episode both the league and the RLPA waxed lyrical about the existing testing regime.</p>
<p><a href="http://www.theguardian.com/money/work-blog/2013/jan/31/mandatory-drug-tests-workplace">Employers testing employees for drugs</a> is controversial from a civil liberties perspective, especially when there is no obvious risk to public safety, such as in the <a href="http://www.dailytelegraph.com.au/news/fifty-qantas-and-virgin-airline-and-alcohol-drug-testing/story-fni0cx4q-1226800199631">aviation</a> and <a href="http://www.afr.com/business/mining/coal/bhp-coal-mine-attacks-ice-scourge-with-new-drug-testing-regime-20150608-ghj2fq">mining</a> industries. According to the NRL, though, this is not intended to be a <a href="http://www.smh.com.au/rugby-league/league-news/nrl-to-test-players-for-prescription-drugs-20140214-32qq0.html">punitive approach</a>, for the league’s Prescription Drug Policy, which began in 2014, has the <a href="http://wwos.ninemsn.com.au/article.aspx?id=8799920">“health and wellbeing of players”</a> at its core. </p>
<p>No surprise, then, that the South Sydney Football Club, for whom Gray and Walker play, have <a href="http://www.triplem.com.au/sydney/sport/nrl/news/2015/9/nrl-to-try-out-hair-testing-for-presciption-drugs/">volunteered to pilot</a> the hair testing program for the NRL.</p>
<h2>Athlete safety: beyond the NRL bubble</h2>
<p>In the midst of the Gray-Walker emergency, a casual observer might have formed a view that rugby league is the only sport where prescription drug (ab)use might be problematic. However, even a cursory glance at the literature abroad suggests the use and abuse of <a href="http://journals.humankinetics.com/ssj-back-issues/ssj-volume-31-issue-3-september/when-is-a-drug-not-a-drug-troubling-silences-and-unsettling-painkillers-in-the-national-football-league">painkillers</a> (including <a href="http://journals.lww.com/lbjnewsletter/Citation/2002/01000/Anesthetic_Injections_in_Football__What_Should.1.aspx">anaesthetics</a>) in elite competitions. </p>
<p>While there is similar concern about player misuse of drugs, there is an emerging awareness of policy silences within sport that may compromise athlete safety.</p>
<p>According to a <a href="http://www.nhs.uk/news/2012/06june/Pages/most-footballers-at-international-cup-tournament-took-painkillers.aspx">study</a> published by the British Journal of Sports Medicine:</p>
<blockquote>
<p>39% of players at the 2010 World Cup took pain medication before every game to help them play with an existing injury. </p>
</blockquote>
<p>The drugs may have killed the pain, but what of the status of the injury post-game? When the authors looked at the <a href="http://bmjopen.bmj.com/content/5/9/e007608.full">2014 World Cup</a>, the volume of painkillers and local anaesthetics had increased.</p>
<p>Similarly in the NFL, although the major talking point about player safety is concussion, there is growing realisation of the potential for painkillers to compromise the <a href="http://espn.go.com/nfl/story/_/id/10975522/excerpt-painkillers-abuse-nfl-king-sports-gregg-easterbrook">long-term well-being of athletes</a>. Some <a href="http://www.cbc.ca/fifth/m/episodes/2014-2015/the-pain-game-drugs-doctors-and-pro-sports">team doctors</a>, critics allege, are part of the problem because they over-prescribe in the interests of getting a player back on the field quickly. </p>
<p>This is also said to be evident in US amateur sport. In <a href="http://kdvr.com/2015/05/13/masking-the-pain-toradol-in-college-sports/">college football</a>:</p>
<blockquote>
<p>A vast arsenal of numbing agents, narcotics, and other painkillers [are] given to students-athletes in the training room.</p>
</blockquote>
<p>Although the NCAA <a href="http://www.deseretnews.com/article/695222184/Painkillers-the-dark-side-of-sports.html?pg=all">conducts</a> “a periodic survey of drug use among college athletes”, prescription narcotics – that is, opioid analgesics – are not listed.</p>
<p>This takes us full circle back to the NRL. For although the league and the RLPA wax lyrical about player welfare, what is their position on athletes being given local anaesthetics in order to take to the field? Precisely the same as that of the World Anti-Doping Agency, which has <a href="http://www.usada.org/substances/wada-ncaa-differences/">no objection to medically approved local anaesthetics</a> – whether on game day or between matches. </p>
<p>The case of Boyd Cordner is therefore interesting. Suffering a hip point injury in the lead-up to the finals, the Daily Telegraph <a href="http://m.dailytelegraph.com.au/sport/nrl/nrl-casualty-ward-cordner-needs-needle/story-fnp0lyn3-1227525266411">reported</a> that the NRL backrower would “play out [the] season with painkilling injections”. </p>
<p>So he did. And without any outcry from pundits that he might be putting his <a href="http://emedicine.medscape.com/article/87322-treatment">body at risk</a> of <a href="http://www.sciencedirect.com/science/article/pii/S027859191200110X">aggravating the injury</a>. As one physician who has worked with the NRL <a href="http://bjsm.bmj.com/content/36/3/209.long">acknowledges</a>:</p>
<blockquote>
<p>… degenerative arthritis of the hip … [is] common in professional football players. </p>
</blockquote>
<p>Is killing the pain <a href="http://cjsmblog.com/2012/01/13/local-anesthetic-use-in-sport-for-early-return-to-play-should-we-be-offering-these-jabs/">sparing the player</a>?</p><img src="https://counter.theconversation.com/content/49348/count.gif" alt="The Conversation" width="1" height="1" />
The use of prescription-only painkillers by athletes is hardly new, but debate about their (ab)use in Australia has recently been brought into focus by the emergency hospitalisation of South Sydney NRL…Daryl Adair, Associate Professor of Sport Management, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/471562015-09-30T19:41:25Z2015-09-30T19:41:25ZDo you need to take some painkillers with food to protect your stomach?<figure><img src="https://images.theconversation.com/files/95315/original/image-20150918-12371-19slt8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There is little hard data on whether taking ibuprofen with food prevents gastric damage.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/jodigreen/7294862082/in/photolist-c7C5mb-8YGBgm-8xGZZf-sNQyEc-c29559-c7C5gu-6jQM1g-c7C5c5-81dyMa-6FpGRK-8Z7zem-a8mUbD-8vHMU-hNn9e-MJTqQ-2mRMyP-jgPugB-qVt7gW-7Rc4k-dQtU8f-ecBUvW-fvQEvL-qQ6Yy1-51cFx5-ov5T3e-q1k9H6-4iKaQh-9ovudD-9ovsFK-9ovvUg-3sBKG-9oyx3E-82vrM-tsSM3-4YzWZ2-4ZfkcN-7auKWr-8Z6NkM-3gRnw5-zmbBo-9bpCS-HAHBB-4wgEuR-beaF4-5mEBMu-dRsLkh-84DMvo-8sQ6Gv-cwEfdL-hM3GFy">Jodi Green/Flickr</a></span></figcaption></figure><p>Medical media recently <a href="http://www.6minutes.com.au/news/latest-news/ibuprofen-ok-on-an-empty-stomach">reported</a> that a clinicians’ reference handbook had changed advice on how to take the painkiller <a href="http://www.nps.org.au/medicines/muscles-bones-and-joints/anti-inflammatory-medicines-nsaids/ibuprofen">ibuprofen</a> - commonly sold under the brand names Nurofen and Advil. </p>
<p>While the <a href="https://amhonline.amh.net.au/">Australian Medicines Handbook</a> previously advised this drug must be taken with food, the <a href="https://amhonline.amh.net.au/chapters/chap-15/musculoskeletal-conditions-other/nsaids/ibuprofen">updated version says</a>:</p>
<blockquote>
<p>Take oral doses with a glass of water. It may be taken without food but if this upsets your stomach, try taking it with a meal.</p>
</blockquote>
<p>The change isn’t particularly remarkable. Minor adjustments are often made to how we dose drugs as our knowledge improves. And yet a few medical media outlets considered it interesting enough to be <a href="https://ajp.com.au/news/ibuprofen-safe-to-take-with-water-alone-new-advice/">a story</a>. So why the kerfuffle? </p>
<p>Ibuprofen, together with drugs such as <a href="http://www.nps.org.au/medicines/pain-relief/simple-pain-reliever-and-fever-medicines/aspirin">aspirin</a> and <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcmed.nsf/cmipages/CMI11358">diclofenac</a> (Voltaren), belongs to a class of medicines called <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Medications_non-steroidal_anti-inflammatory_drugs">non-steroidal anti-inflammatory drugs</a> (NSAIDs). Chronic use of these can <a href="http://pmj.bmj.com/content/77/904/82.full#ref-1">damage</a> the stomach lining, leading to gastritis and <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/stomach_ulcer">ulcers</a>. </p>
<p>Until recently, medical advice in Australia and Europe (but not the <a href="http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm125225.htm">United States</a>) to take the painkillers with food was based on the assumption that it reduced the risk of stomach damage. Does the change in advice mean the assumption has also changed? And are we risking stomach damage when taking anti-inflamatories without food?</p>
<h2>Gastric damage</h2>
<p>Our stomach walls (made of protein) need protection from stomach fluid, which is highly acidic and full of enzymes dedicated to breaking down proteins in food. On an empty stomach, gastric fluid acidity ranges from that of battery acid to lemon juice.</p>
<p>To protect itself, the stomach secrets a layer of mucus, which can control the amount of stomach acid and neutralise it. When one or both of these mechanisms go awry, stomach lining damage and ulceration can occur.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=448&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=448&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=448&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=563&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=563&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96587/original/image-20150929-30964-166zcvo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=563&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Typical over-the-counter doses of ibuprofen are up to 1200mg per day and can be taken for up to three days.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/jeepersmedia/15026174567/in/photolist-oTP5ci-oTNs9u-p9ggXW-p9ggPE-pbijWz-pbghEb-oTP2ru-oTP2hm-pbghqy-oTMWXT-oTP23U-p9gg3u-p9gg2C-pbggRC-pb2AAi-oTP1sA-pb2AqD-oTMW2e-oTMVVT-oTMVTP-62aNWn-7xLez8-bncpSZ-jNEwz-r9m85P-6kK9Qm-5F7o6e-6MxNr1-6MUwJN-4aEptY-7KQRvq-9LpQnC-9vFvsd-9vFBqd-9vCtsr-9vCtzi-9vCtht-9vCsAM-3KxyJp-9vFzch-9vFwt9-9vFwfq-6D6TBx-moAj6d-aS78wg-5rQf5B-4WWEEN-6MuQ7d-e7Z8DD-bzXNH8">Max Mozart/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Ironically, due to their pain-relieving properties, NSAIDs can cause <a href="http://physrev.physiology.org/content/88/4/1547">serious damage to stomach lining</a>. This is because they decrease pain and inflammation by inhibiting production of <a href="https://en.wikipedia.org/wiki/Prostaglandin">prostaglandins</a>, a group of fatty acids that promote inflammation and increase pain perception.</p>
<p>But prostaglandins also protect the stomach lining from acid, by decreasing acid production and increasing mucus secretion and its neutralising properties. So inhibiting prostaglandins also reduces their protective functions. </p>
<p>NSAIDs are commonly used to manage the pain and inflammation of arthritis and musculoskeletal disorders. People also take them for short-term pain relief: for headaches, migraines and period pain, as well as to reduce fever. There’s an important difference between the risk to long-term users compared to someone who takes them for the occasional headache.</p>
<p>Gastric ulceration, where irritation to the stomach erodes its surface, can be severe. Symptoms include internal bleeding, indigestion, nausea, vomiting and weight loss. Studies show that, in relation to NSAIDs, ulceration is <a href="http://www.ncbi.nlm.nih.gov/pubmed/18335848">time- and dose-dependent</a>. </p>
<p>Typical over-the-counter doses of ibuprofen are up to 1200mg per day and can be taken for up to three days. There is <a href="http://www.ncbi.nlm.nih.gov/pubmed/22420652">either no or minimal gastric damage</a> at doses of less than 1600mg a day over three days. But people who take prescription doses for a month or more have a <a href="http://jama.jamanetwork.com/article.aspx?articleid=193062">2% to 4% chance of developing ulcers</a>.</p>
<p>It has long been thought that <a href="http://www.sciencealert.com/why-do-we-take-some-medications-with-food">food “cushions” the stomach</a> from acidity. But, surprisingly, there is <a href="http://www.ncbi.nlm.nih.gov/pubmed/22420652">very little hard data</a> to support that it can <a href="http://www.ncbi.nlm.nih.gov/pubmed/23163547">protect the stomach from NSAID damage</a>.</p>
<h2>NSAIDs with food</h2>
<p>Food does reduce stomach acid, from around battery acid levels to somewhere around that of tomato juice or black coffee. </p>
<p>NSAIDs are better absorbed from acidic, rather than neutral, solutions. So an acidic stomach environment, after a night of fasting for instance, means NSAIDs will reach a higher blood concentration than after a meal. But a less acidic environment created by food will <a href="http://onlinelibrary.wiley.com/doi/10.1111/bcp.12628/epdf">slow NSAID absorption</a>.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=545&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=545&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=545&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=685&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=685&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96566/original/image-20150929-30964-1cpf3jy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=685&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Stomach ulcers can cause vomiting and weight loss.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>In studies where <a href="http://www.ncbi.nlm.nih.gov/pubmed/7084604">animals were given high levels of NSAIDs</a> after 24 to 48 hours of fasting, they developed ulcers in the stomach. On the other hand, animals that had been fed got ulcers in their intestine instead of their stomach. That is, ulcers developed in both circumstances - they were just found in different locations.</p>
<p>However, whether these effects are applicable to humans, especially with the typical doses used for pain relief, and whether different food components play a role in this shift from stomach to intestine ulceration, is unclear. </p>
<p>Pain relief is related to the <a href="http://onlinelibrary.wiley.com/doi/10.1111/bcp.12628/epdf">concentrations</a> of painkillers in the blood. There’s <a href="http://www.ncbi.nlm.nih.gov/pubmed/15460211">reasonable evidence</a> that faster ibuprofen, or other NSAID absorption, will lead to faster pain relief.</p>
<p>Peak concentrations of ibuprofen in blood occur between <a href="http://www.medsafe.govt.nz/profs/datasheet/i/IbuprofenArrowcaretab.pdf">1.5 to three hours after a 200mg dose</a> in people who take it with a meal. For those who take it with just water, the maximum concentration is reached after 45 minutes. </p>
<p>So taking ibuprofen with water is likely to result in better pain control and also <a href="http://www.ncbi.nlm.nih.gov/pubmed/23969325">reduce the need</a> to take more. Having to take fewer doses in turn reduces the likelihood of gastrointestinal effects. Also, people who put off taking ibuprofen until they eat will suffer pain for longer than necessary. </p>
<p>Overall, changing from taking NSAIDs like ibuprofen with food to just water - unless there is stomach upset - may improve pain relief and is very unlikely to harm people who take the drug occasionally and as directed. Those who use ibuprofen and other NSAIDs for chronic pain relief, however, should consult their doctor about how best to take it.</p><img src="https://counter.theconversation.com/content/47156/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Musgrave receives funding from the National Health and Medical Research Council to study adulterants and contaminants of herbal medicines, and has received past funding from the Australian Research Council to study nutracueticals and amyloid toxicity. </span></em></p>It’s long been thought anti-inflammatory painkillers need to be taken with food to protect the stomach. But a handbook for doctors has recently moved away from this advice.Ian Musgrave, Senior lecturer in Pharmacology, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.