Doctors have expressed concern over the increasing use of analgesics for the management of chronic pain, as well as the potential harms associated with these medicines and the lack of access to adequate pain relief at the end of life.
At the BMA’s 2015 ARM (annual representative meeting) members passed a resolution highlighting the rising use of opioid analgesics for chronic non-cancer pain across the UK, calling for the BMA to identify and explore factors that might support safer prescribing of these medicines.
There are separate and distinct concerns surrounding the lack of access to adequate pain relief at the end of life, highlighted as part of a recent BMA research project on end-of-life care.
The BMA board of science has produced two briefing papers which explore ways of supporting improvements in analgesic use in these settings. These papers were produced with support and guidance from the Faculty of Pain Medicine of the Royal College of Anaesthetists.
The briefings follow a BMA board of science seminar, initiated by Baroness Ilora Finlay (BMA president 2014-15), which explored problems facing clinicians when prescribing opioids in palliative care and for chronic pain.
Read more about the issues, our recommendations and download the briefing papers below.
The management of patients with chronic pain can present significant challenges, and the substantial public health harms in relation to prescription analgesics seen in the United States and elsewhere has prompted renewed efforts to assess the role of these medicines in pain management.
Complementing the BMA’s work on prescribed drugs associated with dependence and withdrawal, this briefing paper explores ways of supporting the safer prescribing of analgesics; aiming to help ensure that patients are only prescribed medicines from which they derive benefit and to limit medication associated harms.
- There were nearly 2,000 opioid-related deaths in England and Wales in 2015, an increase from 1500 from 2011 (including misuse of non-prescription opioids).
- Over recent years there have been significant increases in opioid prescribing for chronic pain, and the annual cost opioid prescribing in the UK has risen to over £330 million.
- Chronic pain is complex: An estimated 49% of patients in the UK suffering from chronic pain also suffer from depression.
- Pain management is best delivered by multidisciplinary teams, yet there is high variation in access to specialist pain management services across the UK.
Pain at end of life
'When talking about their hopes and fears about the end of life during the public events, pain was mentioned more than any other issue; the most frequent hope was that death would be quick and “pain-free”. As a corollary, being in pain was frequently mentioned as the primary fear about dying. Amongst participants who had experienced a recent bereavement, the presence or absence of pain played a key role in their memory of the death and whether or not it was deemed to have been a “good death”.
Throughout 2015 the BMA conducted a series of dialogue events across the UK, hearing from over 500 doctors and members of the public on a range of issues related to end-of-life care. The BMA’s research identified pain as a leading concern to both members of the public and doctors, when asked to consider fears about the end of life and dying.
Building on our previous work, this briefing paper explores in more detail ways of supporting improvements in pain management at the end of life, highlighting that:
- the number of people needing end-of-life care expected to rise over the next 15 years
- access to round the clock pain relief provided by specialist palliative care teams is patchy across the UK
- patients with non-cancer terminal illnesses are likely to experience poorer access to adequate pain relief than cancer patients, and are less likely to receive palliative care.
Chronic pain: supporting safer prescribing of analgesics
Download the briefing paper
Summary of recommendations
Developing the evidence base
- To better inform clinical practice more research is required into the effects of long-term prescribing of opioids for pain relief, including their efficacy & safety for periods longer than six months.
- Consideration should be given to the range of support that is required for doctors and patients during the process of assessment, trial and review of opioid treatment for chronic pain. This should include support for stopping opioid treatment that is not working.
- Sufficient investment and resources for primary care, including longer consultation times, are required to support improvements in analgesic prescribing for patients with chronic pain.
- All relevant commissioning and provider organisations – including CCGs in England, health boards in Scotland and Wales, and the Health and Social Care Board in Northern Ireland – should ensure that multidisciplinary pain management services are available for patients in their area and that these are commissioned according to available guidance. These organisations should also work to ensure timely access to pain management programmes, to support early intervention and comprehensive rehabilitation for patients with chronic pain.
- All healthcare providers that are responsible for the management of patients with chronic pain should be familiar with the range of non-pharmacological interventions that may be effective for the management of chronic pain - including physical and psychological therapies. Healthcare professionals should also be aware of the local availability of these services.
Training and education
- Pain competencies should be included in the curricula of all medical schools and be assessed in graduation examinations.
- Medical schools should ensure that existing resources - such as the IASP’s curriculum outline on pain and the FPM’s EPM-lite programme – are used effectively to ensure sufficient high quality undergraduate teaching on the basics of pain management.
- Existing guidance on the management of chronic pain and the appropriate prescribing of analgesics needs to be promoted, and consideration given how it can be maximised to support more appropriate use of analgesics, including amongst clinicians who are not specialists in pain medicine.
Improving analgesic use to support pain management at the end of life
Download the briefing paper
Summary of recommendations
- Steps should be taken to understand the barriers to prescribing opioids in palliative care and ensure that access to appropriate pain relief in palliative care is not affected by a patient’s age.
- Existing guidance on the appropriate prescribing of analgesics in palliative care needs to be promoted, this should include reviewing the impact of existing prescribing guidance and how this can be maximised to support more appropriate use of analgesics in different settings.
Access to services
- Organisations responsible for commissioning and providing palliative care services should ensure that specialist palliative care services are available to all patients with palliative care needs, including in their own homes, hospices, care homes and elsewhere in the community.
- Comprehensive guidance should be provided so that doctors are better able to identify and refer patients with non-cancer terminal illness to specialist palliative care services. This should be supported by nationally agreed criteria for accessing specialist palliative care services.
- More research should be conducted to specifically assess the access to pain relief for patients with non-cancer terminal illnesses.
- Systems need to be in place, in all areas, to ensure appropriate and timely availability of medication and equipment, particularly for those being cared for in the community.
- To support the provision of pain relief specialist palliative care services tailored to the needs of children should be readily accessible to people living in all parts of the UK.
Supporting healthcare professionals
- Anxiety amongst healthcare professionals about administering high, but appropriate, levels of strong analgesics and sedatives, to patients at the end of life should be addressed.
- Generalists responsible for treating pain at the end of life should have access to advice and support from specialists.
- Health departments across the UK should ensure that specialist palliative care advice is available whenever and wherever the need arises.
Education and training
- Those responsible for medical education and training should ensure that the importance of pain control is appropriately included in relevant training, as part of university undergraduate and postgraduate medical curricula.
- Additional specific training in palliative care should be provided as a core part of specialty training programmes, to support improvements in analgesic use.
- All healthcare professionals and carers who are likely to come into contact with patients who may be unable to communicate pain should be trained in recognising the signs or have access to the advice and tools that can support their work.
Please note: this list of publications is intended for further information only. The BMA is not responsible for the content or accuracy of external websites, nor does it endorse or otherwise guarantee the veracity of statements made in non-BMA publications.
Supporting individuals affected by prescribed drugs associated with dependence and withdrawal, British Medical Association
End-of-life care and physician-assisted dying, Vol’s 1-3 (2016) British Medical Association
Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain, hosted by the Faculty of Pain Medicine
Core Standards for Pain Management Services in the UK, Faculty of Pain Medicine
The hidden suffering of chronic pain, The Chronic Pain Policy Coalition
Pain Management Services: Planning for the future: Guiding clinicians in their engagement with commissioners, Royal College of General Practitioners
National Pain Audit Final Report 2010-2012 (England and Wales)
Guidance on the management of pain in older people (2013), British Geriatrics Society