Feature: Trauma and deprivation linked to opioid use

People who’ve experienced trauma in their lives are more at risk of problematic opioid use, according to drug and alcohol charity Addaction.

For Grace*, who had struggled with anxiety and depression throughout her life, her opioid addiction started with a knee injury which, following four operations, was still causing her pain.

She said she was prescribed Tramadol by her GP which she said suddenly made her ‘feel beautiful’ after a life of struggling with anxiety and depression.

But within a matter of months, her tolerance had increased and she was having to take more to receive the same level of calm. 10 years later she had gone from taking eight tablets a day to 90 and was supplementing her prescription illicitly. She said she didn’t care about her life at that point, she just ‘wanted to feel calm’.

According to Dr Barry Miller, the chair of the Medicines Advisory Group for the Faculty of Pain Medicine at the Royal College of Anaesthetists, this is a worryingly common story.

He said opioids are very effective for short term pain, particularly following an operation, or if the pain is related to cancer, but when prescribed in the long term, are not proven to work on chronic pain, such as backache, and can lead to addiction and in some cases, accidental overdoses and death.

The Office for Nation Statistics reported that the number of opioid-related deaths in the UK has risen to around 2,208, up by 41% from a decade ago. The report said that since 2006 more than half of all drug poisoning deaths each year have involved opioids, with more than 1,336 drug poisoning deaths in 2018 being attributed to heroin or morphine, what’s more, according to UKAT four in five heroin users starting out on prescription painkillers, just like Grace.

While a review into dependence on prescription medicines by Public Health England found that one in four adults had been prescribed at least one of these classes of medicines in 2018. And that half of those adults had been continuously prescribed for at least the previous 12 months, while 32% had been receiving a prescription for the previous three years.

Papering over the cracks

Dr Rachel Britton, director of pharmacy at Addaction, said long term opioid use is a way of ‘papering over the cracks’ of much deeper, more complex emotional problems. She said:

‘The people most at risk of problematic opioid use are people who’ve experienced some kind of trauma in their life. This could be anything from sexual abuse to being bullied at school, or simply just not feeling loved growing up. People are hardwired to seek pleasure and avoid pain and opioids are extremely good at relieving psychological pain in the short term.

‘Substitution therapy such as methadone or buprenorphine can help break the cycle of seeking and finding the drug, giving people the time and space to address the deeper cause behind their addiction.

‘But, like all drug treatment, it’s about working with someone without judgment to help them come to terms with what has happened in their life.’

Dr Miller said: ‘We know that the number and strength of prescriptions increased significantly from 1998-2016, although the figures have been reducing over the last two years.

‘The number of deaths associated with opioids has also risen significantly, but it is not always clear where this is prescribed and when it is illegally obtained/non-prescription usage. Nonetheless, there are clearly a lot of people on prescribed high dose opioids who would be better off either without them or on significantly lower doses.

‘The excessive and inappropriate prescription and administration of opioid painkillers are issues of serious concern. Opioids can, and do, play an important role in the management of complex pain problems, particularly cancer-related, as well as during the short-term recovery phase of other diseases, injury or surgery and pain relief during labour.

‘However, all healthcare staff prescribing these medicines need to ensure they are not doing more harm than good. Safe prescribing of opioids depends on careful assessment of the patient, their pain and their wider medical needs and should only be prescribed in accordance with fundamental best practice principles laid down by healthcare professional regulatory bodies.

‘When prescribed appropriately and taken as directed, the risk of harm with opioid painkillers is minimised.’

The North-South pain divide

Dr Miller also highlighted the correlation between deprivation and opioid prescriptions, which has been backed up by a study published in the International Journal of Drug Policy that found that three out of the highest five GP areas for opioid prescribing are based in the North West of England. With GPs in NHS Blackpool CCG and NHS St Helens CCG prescribe the highest levels of opioids in England.

It also found that when English areas were ranked into 10 levels of deprivation, the average use of morphine increase 100 mg per 1000 patients per day when going from wealthy to poor by just 1 level. Lead researcher Dr Li-Chia Chen, said:

‘Chronic pain is difficult to manage and unfortunately, because their workload pressures are so stringent, GPs have limited capacity to counsel patients with persistent pain. This might explain why drug therapy is the main way GPs manage pain.

‘There’s no guarantee that long term use of opioid analgesics can resolve chronic pain. Indeed the risk of opioids’ side-effects such as dependency, respiratory depression and immunosuppression may sometimes outweigh the potential benefits.

‘Social prescribing such meditation and acupuncture may be helpful, but little is available on the NHS.

‘We also feel it is essential to integrate pain management services with an interdisciplinary team approach. pharmacists could also play a vital role in pain management and, in our view, are an underused resource.’

For Grace, help came in the form of Addaction. She reached out to the addiction charity for support but had to be taken to hospital during her first support session after collapsing. Grace said the incident was the wake-up call she needed and went back to finish her assessment the next day.

She was prescribed the opioid substitute buprenorphine to reduce her withdrawal symptoms alongside person centred psychological support. She no longer takes Tramadol.

Visit the Addaction website to speak with one of the charity’s trained advisors.

Photo Credit – Pixabay

*Grace is not her real name.