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Monday 14 January 2019

Britain’s everyday drug problem

Prescriptions of opioids – powerful and addictive painkillers – have been on the rise across England. But one coastal stretch shows how they are being dispensed to treat something other than pain

By Paul Caruana Galizia and Tom Goulding

If you rank local authority areas in England by the rate at which they prescribe painkillers, nine of the top ten are in the North-East. In some of the old steel-making, shipbuilding and mining towns – Gateshead and Sunderland, Redcar and Stockton – opioids are dished out at a rate of one item – a single supply of the drug on a prescription form – per year for every man, woman and child who lives there.

Even allowing for the effects of deprivation and an elderly population – two factors associated with higher prescriptions – 95 per cent of authorities in the rest of the country don’t reach even half the level of such prescriptions issued in the 12 local authorities in the North-East. The stretch of barely more than 100km from Northumberland down to Darlington and Middlesbrough is in a league of its own.

The regions of the North-East are by no means homogenous. There’s relative prosperity in Durham and Northumberland alongside deprivation where the old industries have fallen away. Enterprise zones with growing biotechnology and computer start-ups scramble for a toe-hold among the manufacturers that remain.

Nor do these regions seem economically unique in the UK. Industries like the ones that have died here have collapsed in other parts of the country too. Its politics are not exceptional.  In June 2016 the response to de-industrialisation found a voice that echoed in other similarly afflicted areas as great swathes of the North-East voted to leave the EU. On the night of the vote, the people of Sunderland were among the first to make themselves heard.  Millions of others said the same.

Measuring opioid prescription rates is not straightforward. Prescriptions are officially classified as “items”, and items vary. They can have different quantities of tablets, and the amount of the opioid within each tablet also varies. But new academic research shows that even after adjusting for these differences, England’s stark geographical pattern in opioid prescriptions remains.

As reporters, this isn’t where we started – or expected to end up. The question in our minds last summer when we began looking at painkiller prescription was whether the scandal of opioid addiction in the US had echoes in the UK. But the numbers pointed to a different cycle of medication, a pattern of prescription in which drugs designed to treat severe pain are being dispensed for something else entirely.

So what particular pain is the North-East trying to cure?

Is there more pain in North-East than elsewhere?

The North-East, simply put, has health problems. It has bigger health problems than any other region in England. Life expectancy is lower, and currently falling. In the most deprived areas in the North-East, men’s healthy life expectancy is almost five years lower than in similarly deprived areas in other parts of the country.

Moreover, the rate of chronic pain in the North-East (43 per cent) was 7.5 percentage points higher than the national average according to a study last year. More pain, more opioids? It isn’t quite that simple – the study also showed that those with severe chronic pain in the North-East were more likely to be prescribed opioids for their pain than patients in chronic pain living elsewhere.

Does social trauma explain the North-East’s problem?

While the North-East is not significantly more deprived than other areas, it is significantly different in one respect: it suffers from a much higher rate of social trauma, resulting from  domestic violence, abuse and adverse childhood experiences. And pain consultants find that this history of trauma is the single factor most likely to lead to problematic use of opioids.

Looked at through this lens, the North-East suddenly seems like a place apart. There are 65 per cent more domestic abuse incidents per capita here than in any other area of the UK, 30 per cent more child protection cases, and 62 per cent more child sexual abuse cases.

These events have a long-term effect on the nervous system. The body’s use of natural opioids, such as endorphins, is overactivated by the need to deal with “toxic stress” from the abuse. This disruption of the body’s internal reward and punishment system for pain means “you tend to subtly live your life in a subtle withdrawal state, because your body is always trying to catch up”, says Cathy Stannard, an NHS pain specialist. The patient perennially craves to be placated by external opioids, despite a higher tolerance of typical doses.

“You might have some event that is likely to be painful,” says Stannard, such as undergoing surgery or suffering an industrial injury, but for people who have undergone trauma, “the pain becomes out of control, because your nervous system is waiting to [implode]”.

Overworked clinicians see opioids as a ready fix. NHS doctors’ workload has gone up 16 per cent since 2011, with a decline in resources in real terms, which in poorer areas like the North-East causes increasingly full waiting rooms of distressed patients, some of whom come in demanding opioids. “Doctors find it really difficult to say, ‘this is not something medicine can treat’,” says Stannard. “Distress is something we just can’t cope with not treating, as healthcare professionals.”

However, alternative treatments are typically difficult to access. “The wait for a physiotherapy appointment [for chronic pain] or a counselling session on the NHS could take six weeks,” says Harry Shapiro, director of DrugWise, a charity that aims to provide information about drugs, tobacco and alcohol. Meanwhile Shapiro, who campaigns for restricted opioid prescribing, estimates that “a prescription for tramadol takes three minutes”.

A world of pain

Around 20 million people in Britain live with chronic pain, which is pain that has lasted more than three months, often a lot longer, originating from conditions such as arthritis, knee operations or lower back problems. For probably seven million of this group, their pain significantly limits their daily activities.

And since the 1990s, doctors across the UK have turned increasingly to opioids.

Painkillers such as tramadol, oxycodone and fentanyl, as well as the more historically familiar morphine and codeine, can be effective against cancer pain or short-term pain after operations. But the surge in opioid prescription rates nationwide in the past 15 years has all been for non-cancer pain, despite the fact that the drugs have no proven long-term effectiveness for these conditions. They relieve pain for around six weeks, and then patients develop a tolerance; to stay pain-free, they need higher doses. Coming off the drugs would yield crushing withdrawal symptoms. Tens of thousands, probably more, have become stuck in the opioid trap.

From 2000 to 2010, the number of non-cancer-pain patients put on opioids on the NHS increased seven-fold. Around 23.8 million opioid items were prescribed in 2017 – such that one in 20 adults has at some point been prescribed one. Institutional protections within the NHS against the power of big pharma have prevented an epidemic of opioid abuse on the scale of the United States. But after the first and only death from tramadol in 1996, there are now regularly hundreds of fatalities each year, making prescribed opioids the second leading cause of drug deaths in the UK, behind only heroin and its substitutes, morphine and methadone.

What makes pain lead to painkiller?

We tend to think of pain as one of the simple, unpleasant facts of life, and an equaliser: my injury will hurt more or less the same as yours. But we have each evolved a system that can vary the intensity of pain in response to an injury to a remarkable degree. Understanding how to treat pain requires a recognition that it is a complex sensory experience, an expression of both physiological and emotional well-being, not just a body part gone bad.

This complexity means that patients in areas of high deprivation who encounter neglect, insecurity and ill-health will feel that their pain is amplified, whether it originates in broken physical tissue or not. “Life can be pain-tolerable,” says Jonathon Tomlinson, a GP who runs one of the lowest opioid-prescribing clinics in the country in Hackney, east London. “But when people are deprived of social security, meaningful relationships and a liveable environment,” this no longer holds. What we might call deprivation disease amplifies pain compared to those who have the good fortune to live in different circumstances.

Some blame careless doctors for dishing out dangerously addictive pills at will to an unsuspecting population. But “it takes two people to end up with a prescription,” says Stannard; if a patient in pain is hell-bent on receiving a painkiller, they are likely to be successful. And being confronted by patients in anguish is immensely difficult in a healing profession. “Distress is something we just can’t cope with as clinicians,” says Stannard. “We find it extremely difficult to say: ‘Tough, this is not something medicine can treat.’”

The prescription, in this case, is certainly not the cure. The North-East’s opioid problem is, underneath it all, more about trauma than pain.

Paul Caruana Galizia

Tom Goulding

Top picture by Andrew Testa / Panos 

Photographs by Tom Pilston

“My problems started when I was a very young boy”

For Malcolm, 17 years of repeat opioid prescriptions carried him to a desperate place. Four years ago he was 44, “on eight tramadol a day, eight codeine-phosphate a day, diagnosed with depression, taking paracetamol for the pain”. He was also prescribed amitriptyline – an antidepressant that works on nerve damage. It took six months of therapy and a deep understanding of the impact of events in his childhood for him to change course.

He was first prescribed opioids after shattering his knee cap while playing rugby. No one told him that they are only effective against pain for a matter of weeks. Almost two decades later, and recognising that he had been addicted, he checked into the Oaktrees Rehabilitation Centre.

It was during counselling at Oaktrees, he says, “that I knew there was something wrong mentally. My problems started when I was a very young boy. That’s when I learnt to put a mask on – what my counsellor called a ‘survival mechanism’.”

In the North-East, Malcolm continued, “you keep your chin up. You just get on with it. You don’t talk.” You especially don’t talk “about things that happened in childhood”.

At Oaktrees, where Malcolm spent a total of 24 weeks, he said that nearly everybody had a history of sexual or physical abuse. They were asked to tell their life stories in the third week, which they did in a “matter-of-fact way”. They are stories of “what took you to addiction”.

“Finally,” he says, “I could talk to someone. I experienced a lot of physical violence from an early age,” he says. His mother left home when he was two years old, giving him abandoned child syndrome. In later life, Malcolm would jump in and out of relationships. “I was looking for the mother I never had,” he says. His father was an alcoholic, a “rogue”, who “didn’t know how to bring up children”.

The problems started when he was eight years old. “There was sexual abuse, but predominantly violence.” There were hospital visits, he says, “and I’m not talking about scratches or bruises or anything like that, but broken bones.”

Malcolm is one of three sons and each left home when they turned 16. They remain very close and are in touch every day. Like all their aunties and uncles, their father died a long time ago from substance abuse; alcoholism, in his case. “He was from a different age,” Malcolm says about his father. “He could have done better, but I can’t live with anger all my life.”

Malcolm now takes only fluoxetine, most commonly known as Prozac, for his mood. His mood disorder emerged after he was prescribed opioids. The shock of being told that he couldn’t play rugby or work, as a pipe-fitter, was dulled by the opioids to the point where “pretty quickly I realised that I didn’t care about work any more, didn’t care about the rugby either”.

Far from continuing to live with anger, Malcolm has turned his life around. He volunteers two days a week with PROPS, a North East-based support service for people living with substance misuse. He also works with Changing Lives, a charity that supports vulnerable people. During his voluntary work, Malcolm says that “every household I visit has a story of abuse”.

There’s a widespread problem of child abuse in the North-East , he says, but “people block out what happened in their childhood”. People “are afraid of social workers, the police”, he says. “They keep their problems in the family, which are often centres of abuse. You’ve got to reach out. If you don’t, you’ll stay in the same place.”

Addaction is one of the UK’s leading mental health, drug and alcohol charities: 020 7251 5860 or 01429 285000. PROPS North East is a support service for individuals, families and carers of those living with alcohol and substance misuse: 0191 226 3440.

The language of pain

  • Opioids: a class of drugs made from the opium poppy plant or in labs by scientists. Opioids are mostly prescribed for moderate to severe pain. They can make people feel deeply relaxed and high, which is why they are used recreationally and are highly addictive. They work by blocking pain signals from travelling along the nerves to the brain. Heroin is an opioid, but is illegal.
  • Chronic pain: pain that has lasted more than three months, often a lot longer, seemingly originating from conditions like arthritis, knee operations or lower back problems. There isn’t always a clear cause. Other health problems like fatigue, sleep disturbance and mood changes can often accompany chronic pain. It can limit a person’s movements, strength and stamina, leading to physical disability and emotional distress.
  • Prescription item: the most commonly used measure of prescriptions in the UK. A prescription item is “a single supply of a medicine, dressing or appliance prescribed on a prescription form”, according to NHS England. If a prescription includes three medicines it will be counted as three items. Data on prescription items don’t indicate the length of treatment or quantity of medicine (eg, three months of three pills a day).
  • Social trauma: trauma, such as domestic violence, abuse and adverse childhood experiences, where the trauma legacy of violence is common in entire groups and/or areas.

Prescription opioids

  • Tramadol: prescribed for moderate to severe pain, say after an operation or a serious injury. Tramadol is a popular opioid in NHS England. Its strength is 10 per cent that of morphine, but became the most common prescribed opioid cited in drug deaths by the 2010s. Brand names include: Invodol, Larapam, Mabron, Maneo, Marol, Maxitram, Oldaram, Tilodol, Tradorec, Tramquel, Tramulief, Zamadol, Zeridame and Zydol.
  • Oxycodone: prescribed for moderate to severe pain. Its strength is 150 per cent that of morphine. Brand names include: Percodan, Endodan, Roxiprin, Percocet, Endocet, Roxicet and OxyContin, which is produced by the Sackler family and is at the heart of the US opioid crisis.
  • Codeine: prescribed for moderate pain, say as a cough medicine and for diarrhoea or following an injury or operation. Lower-strength codeine can be bought from a pharmacy in England. Its strength is 15 per cent that of morphine. Brand names include: Aspalgin, Codral Cold & Flu Original, Nurofen Plus, Panadeine Forte, Panamax Co, Mersyndol and Panalgesic.
  • Fentanyl: prescribed for chronic and severe pain as a result of cancer, nerve damage, and major trauma and surgeries. It is 80 to 100 times stronger than morphine, and the illicit use and production of fentanyl is growing, with a 29 per cent rise in fentanyl deaths in the UK in 2017. It is a popular street drug, especially in the north of England, as its potency makes it ideal to mix with heroin or cocaine. It is used as a lethal injection to execute inmates in Nebraska, while Russian authorities were reported to have used a related opioid, carfentanyl, which is 100 times stronger than fentanyl and up to 10,000 times stronger than morphine, in the 2002 Moscow theatre hostage crisis in which 130 people died. Rodrigo Duterte, the Philippines president who’s reported to have ordered extra-judicial executions of alleged drug dealers, once said that he went over his required dose of fentanyl because it made him feel like he’s “on cloud nine”. Brand names include: Abstral, Actiq, Duragesic, Ionsys and Sublimaze.
  • Morphine: prescribed for severe chronic and acute pain, say after surgery or a serious injury, or cancer pain or pain from a heart attack. Most of the world’s morphine is used to make other opioids, including oxymorphone and heroin. Morphine’s strength is the benchmark against which the strength of other painkillers and analgesics is measured. Brand names include: MST, Zomorph, Sevredol, Morphgesic, MXL and Oramorph.

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