People in Blackpool are twice as likely as the inhabitants of Wokingham to die before they are 70. A recent paper which measured the distribution of opioids not by the number of prescriptions, but in equivalent units of morphine, found that NHS prescriptions of opioid painkillers have been generally rising in England and Wales, but have risen most in the north of England and more in poorer areas. Blackpool, again, tops the list. In part this is because poverty is correlated with chronic physical pain: both men and women in the lowest income quartile report suffering chronic pain at rates much higher than those in the top quartile. That, in turn, reflects that fact that hard physical labour and unemployment are both bad for health in the long term.
But the prevalence of pain can’t entirely account for the pattern of prescription. Many forms of chronic pain do not respond well to opioids. For lower back pain the Nice recommendation is not to treat it at all, except perhaps with ibuprofen, exercise and massage. It will go away on its own, or it will not. Figures suggest that only one opioid prescription in eight was written out for cancer pain in 2014. The others were written for conditions where is it much less obvious that they are the best possible treatment.
Other social factors are important. Poverty is in itself bad for health, and also bad for the quality of healthcare. Doctors in deprived areas are not any less dedicated than those in prosperous ones; they may well be more dedicated and even harder working. But they are stretched much more thinly across a more demanding population and they have less in the way of backup services available.
Their patients turn up at the surgery with possibly more complex problems, which are aggravated by their social situation. It is all very well to recommend meditation or acupuncture to relieve stress, but even where these are available, they wouldn’t be nearly as effective for many patients as would be the simple confidence that they can pay the bills. Unfortunately for such patients, the NHS cannot prescribe money. A patient who leaves the surgery with a prescription for pills will at least feel that the doctor has done something for them, and will at least no longer be prevented by pain – and the exhaustion that pain brings – from taking other measures which may help with their immediate problems. But an unnecessary prescription is still an inadequate and potentially dangerous solution.
Britain is a long way from an opioid crisis on the US scale, and this is a tribute to the superiority of single-payer healthcare. The NHS is stretched and imperfect, but its mere existence has prevented the abuses which produced the US crisis. NHS doctors cannot profit directly from the prescriptions they write. In the US there is a strong correlation between the number of doctors in an area and the number of opioid prescriptions written. Our national system also means that the collection of statistics is possible, so that worrying trends can be spotted and nipped in the bud if necessary.
But it should be possible to do much more. The fact that prolonged pain does not respond well to opioids does not mean it should go untreated. The study’s authors suggest that multi-disciplinary teams could help patients where simple prescriptions are no use. Where such teams are unavailable, it should at least be possible to keep a record of patients who are on prolonged high doses of opioid painkillers. Those people – and they are an increasing number – need help, and they are not getting it.
