Jo, a 34-year-old living in London, was first prescribed co-codamol after suddenly developing back pain. Her doctor insisted she must have hurt herself in some way and so she was given a short prescription for 30 500mg tablets, the dose prescribed for moderate to severe pain, and sent on her way.
"That was around five years ago now and the pain has never truly subsided," she tells R29. She was able to order the prescription on repeat and have it on hand on the occasions it was needed. Finally, in 2020, she brought up her pain with a different doctor who actually listened. "He ordered tests but his first priority was to lower my pain levels so he upped the amount of co-codamol I could order to packs of 100s, alongside additional prescriptions for naproxen and gabapentin. The tests resulted in a referral to a rheumatologist and then a diagnosis of fibromyalgia in early 2021."
Prescription painkillers, particularly opioids like co-codamol and tramadol, play an important role in healthcare, especially for cancer pain, end of life care and what is defined as 'acute' pain (lasting for less than six months). They are also used by people with different forms of chronic pain, for various reasons: in cases where the pain is not properly investigated and identified, like Jo’s; for conditions we know little about; or when the patient has no other options. But the efficacy of their long-term use has long been called into question and there are concerns about the rate at which they are being prescribed, to whom and for how long.
The prescription of painkillers for non-cancer pain has grown significantly since 2006, with one in six patients with prescriptions for non-cancer pain becoming long-term opioid users within a year of taking them for the first time.
The past few years have only exacerbated this. According to The Guardian in 2021, women in England are almost twice as likely as men to be prescribed opiate painkillers. This was echoed in data collected by Refinery29 UK from a Freedom of Information (FoI) request to the NHS Business Services Authority, which found that on average, between 2016 and 2021, women in England were prescribed co-codamol 63% more frequently than men and tramadol 50% more frequently than men.
On average, between 2016 and 2021, women were prescribed co-codamol 63% more frequently than men and tramadol 50% more frequently than men.
There are several theories as to why prescriptions are higher among women. Dr Barry Miller from the Faculty of Pain Medicine tells R29 that these theories range from perception to access to the nature of the pain.
"We have good evidence that men and women seem to perceive pain differently, with women probably perceiving it more intensively than men," he explains. "Additionally, women tend to attend healthcare settings more commonly than men. Normally in chronic pain clinics we see far more women than men." The reason for this is unclear but by accessing healthcare you’re more likely to be prescribed something, irrespective of any other factor.
Additionally, there are conditions that affect women and people with wombs more. Ian Semmons, chairman of Action On Pain (AOP), tells R29: "AOP has operated for 25 years during which the ratio of male/female using our services is 8% to 92%. There has been no change nor do we anticipate one. We feel there are more health conditions in women that would merit the use of opiates than men. Examples would be severe period pain and having a section during childbirth where short-term use of opiates could be beneficial."
The pandemic also has a role to play in the increase of prescriptions, Barry says. "The most obvious reason is that people who would otherwise have been investigated and treated for some problem now have a much longer journey," he explains. In the meantime, you’re likely to be prescribed painkillers. The other reason is that any pain investigation was hampered by social distancing. As Barry puts it: "The number of options available to healthcare professionals was largely down to a prescription pad." This meant that medication of all sorts, particularly opioids, was prescribed as a stopgap.
This can be a cause for concern due to the addictive nature of opioids, which emerges when the pills are taken for prolonged periods of time.
"The longer you use opioids, the less effective they become," Barry explains. "They're really good in the short term but if the problem is chronic they often are only effective to begin with, then their efficacy tends to wane." Essentially, people get used to them and their effects diminish. As time goes on you have to take more and more for the same or even less effect.
Long-term usage carries other health risks, too. Opioid withdrawal, whether from prescription versions or illegal drugs, is terrible and the path off them follows the same pattern as coming off something like heroin. Barry explains that people who rely on opioids in the long term can also develop hyperalgesia (a hypersensitivity to normal levels of pain) and points to associations with mood disorders and accidents.
This is why, Barry says, you should be on opioids for a good reason and be properly supervised by someone who regularly reviews their usage. Many public bodies echo his position. The Royal College of Anaesthetists says there is little evidence that opioids help with long-term chronic pain, although they work for acute pain and end-of-life care. Similarly, Ian says: "We feel that opiates have a role to play in pain management usually on a short-term basis. The key is that at all times the patient is monitored and fully aware of potential side effects." However, he adds, this "sadly is often not the case".
The longer you use opioids, the less effective they become.
Dr Barry Miller
As Ian’s comments reflect, this caution presses up against the reality that prescriptions are rising among women and access to proper monitoring is limited.
To some this indicates that women’s pain is not being treated properly, either because we know so little about chronic pain conditions like fibromyalgia, endometriosis and Ehlers-Danlos Syndrome (EDS) which are more likely to (or solely) affect women, or because that pain is not being adequately investigated. As Jo puts it: "It makes me wonder what sort of investigation is done to diagnose the root causes of pain, and whether opiates are being used as a sticking plaster for most complex issues."
Emma is in her 20s and has been on tramadol for about five years to manage the widespread chronic pain that comes from having both Ehlers-Danlos Syndrome and fibromyalgia. "I’m allergic to codeine, which means tramadol is the perfect medium-strength painkiller. I have also been prescribed morphine for worse days but I often think of tramadol as the equivalent of most people using ibuprofen – I have higher pain levels so need something a bit stronger to do the job. I find it really works and am so grateful for it!"
Despite this, Emma doesn’t feel that her pain is taken seriously. "While I’ve been referred to specialist pain clinics and seen multiple doctors over the years, no one has ever taken the problem seriously and I’ve learned to deal with it myself or pay to see private health specialists. I’ve never felt like my pain is valid and often felt gaslit by professionals who’ve repeatedly told me it’s in my mind."
There is a lack of alternatives for treating many forms of chronic pain, particularly when the pain is caused by an underlying condition like ulcerative colitis, EDS or fibromyalgia. Then there are the reasons why those diagnoses can get delayed, from pain being dismissed to lack of available services. If diagnosis is delayed and no clear cause of the pain is identified, it is classed not as secondary chronic pain but as primary chronic pain (persistent pain over three months without a clear cause).
This is a problem. In an attempt to curb the overprescription of opioids, the National Institute for Health and Care Excellence (NICE) recently published guidelines saying that people with chronic pain which has no known cause should not be prescribed painkillers. Instead they should be offered therapies including exercise programmes, acupuncture and antidepressants. There is "little or no evidence" that treating chronic primary pain – which affects 1-6% of people in England – with commonly used painkillers actually makes a difference to people’s quality of life, pain or psychological distress, NICE said.
Wariness around the medication’s addictive qualities is sensible but it leaves those with chronic pain (both primary and secondary) facing the fact that right now there aren’t many suitable alternatives.
Emma explains that doctors have denied her repeat tramadol prescriptions "because they’re addictive but have failed to suggest any alternative solution". She understands the risks but feels that she is not being given the space to explain herself and therefore explore other options. "I’m offered painkillers, which help, but when doctors decide they’re no longer safe to use I’m left in the lurch, still in pain, with nothing to help it."
This is not helped by the fact you’re not guaranteed any clear guidance on how to stop using medications. It is not taught in medical school and the pressures on the NHS mean that general practitioners and primary care services do not have the time or resources to properly investigate pain, guide individuals out of using painkillers, or offer alternatives.
I'm offered painkillers, which help, but when doctors decide they're no longer safe to use I'm left in the lurch, still in pain, with nothing to help it.
The solution to the question of opioid painkillers is vast: it requires better, less fragmented care, more understanding and time with patients – especially when there are no other options – further research and improved monitoring of painkiller use.
For now those changes remain out of reach and in the meantime people either have to rely on the pills or live with the pain.
"In the past five years I've had no management of my painkillers, other than upping the dose," Jo explains. "Having done a little of my own research over the years, it seems like the best management of painkillers would involve everything that's lacking in the NHS: time, money and continuity of care. Pain is biological but it's also psychological and social. Painkillers are a super important component in helping people live full lives but they're not a cure, and they're not without potentially life-altering side effects."