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PRESCRIPTION painkillers containing opioids will soon come with a warning in the UK: “can cause addiction”. The decision, announced last month, is part of a range of measures the UK is taking in reaction to the opioid crisis gripping the US.

As medical use of these painkillers in the US has risen, so has the number of people getting hooked on them and graduating to illegal opioids such as heroin. Deaths from opioid overdoses have lowered the country’s life expectancy.

But pain specialists warn that restricting opioid use too much also has risks, as some people have a real need for these powerful medicines. Will the UK be able to avoid following the US down the road to a new addiction epidemic, without leaving people in unnecessary pain?

Opioids have always been our most potent pain relievers. They are excellent for helping people in severe but short-lasting pain, such as from broken bones or surgery. Because of the potential for addiction, though, doctors tended to be cautious about prescribing them outside hospital, apart from for people with terminal cancer.

“Being on opioids for long enough changes brain chemistry so you need more for the same effect”

Attitudes started changing in the 1990s. Pressure was building among doctors to do more to keep people free from pain. Several US medical bodies said it should become the “fifth vital sign”, along with pulse, temperature, breathing and blood pressure.

At the same time, US pharmaceutical companies began creating new formulations of existing drugs, and heavily promoting these to doctors. The best known is OxyContin, a slow-release opioid the manufacturer claimed had less than a 1 per cent risk of addiction. “The message was that if you’re enlightened, you’re going to be different from those stingy, puritanical doctors in the past,” says Andrew Kolodny of Brandeis University in Boston.

Doctors began prescribing more opioids after surgery and upped the use of these drugs outside hospital for conditions such as arthritis, back pain or nerve damage from diabetes.

When someone is on opioids for long enough, their brain chemistry changes and they need to take more to get the same effect. If they try to cut back, the pain amplifies. At higher doses, opioids also cause sedation and feelings of pleasure, so people in withdrawal feel highly agitated.

As a result, many in the US began asking their doctor for ever-higher doses. If they reached one doctor’s limit, they might try other clinicians or topping up from illicit sources. More liberal prescribing meant people had spare pills to sell, fuelling the black market. “It was in everybody’s medicine chest,” says Kolodny. Deaths from opioid overdoses started to climb.

Once people are buying pills illegally, there can be a temptation to switch to heroin because it is cheaper. Making things worse, there has recently been an influx of newer synthetic opioids such as fentanyl, which are much more potent and easier to overdose on. Drug dealers began spiking their heroin with fentanyl to make it go further. “It has led to a public health catastrophe,” says Kolodny.

There have been similar trends in Canada and, to some extent, Australia. But the picture is very different in the UK and most other European countries. That is partly down to culture. In North America, people have more control over their medical care. The US is also one of the few nations where drug firms can advertise prescription medicines directly to the public.

The way the UK’s National Health Service is set up has helped. Everyone registers with a single primary care physician who acts as gatekeeper, so people can’t juggle multiple prescriptions. “You don’t doctor shop,” says Clare Gerada, a family doctor in London who specialises in addiction.

There has been a rise in opioid use in the UK: in England, prescriptions have more than doubled since 2000. But doctors seem to have taken heed of what is happening across the Atlantic. In both 2017 and 2018, there was a slight fall in the number of prescriptions.

Now, though, the UK risks running into the opposite problem: of doctors being too reluctant to give opioids, says Cathy Stannard, a pain specialist at the NHS Gloucestershire Clinical Commissioning Group. For people in long-term pain, there are no simple alternatives to opioids. For a while, it seemed the answer was a newer class of painkillers such as pregabalin, but then people began getting addicted to those too.

This means opioids can be valuable for people who can take a low dose for a long time without developing a tolerance, says Stannard. “There are a small number of people for whom these drugs are life-transforming.” The proportion of people like this is unclear, but Stannard estimates it to be about 10 per cent.

Yet some doctors are so alarmed at the prospect of the UK having its own addiction epidemic that they try to stop opioids for such individuals, says Lesley Colvin at the University of Dundee, UK. “Everyone’s saying you must not use opioids for chronic pain, [but] there is a group of people where they work reasonably well.”

Even people on too high a dose shouldn’t be made to quit unduly fast or they will get withdrawal, says Colvin. “If you’re in horrible pain, that’s fairly terrifying.”

The risk is that people in pain turn to illegal drugs. When some US states clamped down on opioid prescribing, fatal heroin overdoses surged. “The prescribing was just stopped,” says Colvin. “There was no additional support.”

Stannard, who advises clinicians on pain management, says a few family doctors have tried to ban long-term opioid use. “I’ve had people saying to me: ‘We are going to take everyone off opioids’.”

Emma Scott-Smith, an artist in Stirling, UK, who is on opioid painkillers for spinal pain, experienced this when she saw a different doctor to her usual one a few years ago. He told her she needed to come off medication because she was an addict, she says. “I was fearful because I knew my life depended on it.” Without painkillers, she says, “just moving is almost unbearable”.

She was referred to a specialist who overruled her doctor and she is now on a long-term programme to slowly lower her dose, although she believes she will always need some painkillers to be able to get out of her house and go to work.

Stannard has also had to talk hospital doctors out of ditching opioids for pain after surgery. “That’s a ridiculous, knee-jerk response,” she says. “Opioids are absolutely the best thing for post-operative pain.” She says these drugs can be used safely after surgery, as long as people get just a few days’ supply and are told how to reduce the dose over that time.

UK doctors will soon get more help to tread the fine line between being too strict and too liberal with these medicines because various UK bodies are working on inquiries or guidelines on opioid use. A report from Public Health England is due out in a couple of months, while a spokesperson for the UK’s Medicines and Healthcare products Regulatory Agency says it is considering further moves “to minimise the risk of inappropriate use while ensuring these medicines are available for those who need them”, but declined to give specific details.

Kolodny says Europe should learn lessons about opioids from the US. “We have known for millennia that these are highly addictive, so it makes sense to be as cautious as possible,” he says. “You need to tread very carefully to avoid following in our footsteps. For us the genie’s out of the bottle.”