Episode 5: Medicines and surgeries are not often the answer

Hello, and welcome to Episode 5 of the Flippin’ Pain Formula Podcast. The key message that we are going to cover in this session is that medicines and surgeries are often not the answer.

But before we start talking about that, I would like to ask how you got on with your homework: or did your dog eat it? Try to spend just five minutes looking back on your list of DIMS and SIMS. Now that you have had time to reflect on it, has it changed? Is there anything you would like to alter? Do you think that you could address some of these DIMS? Are you addressing them right now just by listening to these podcasts?

OK, now the homework is over, let’s move onto this session’s key message: medicines and surgeries are often not the answer. Many drugs and surgeries that have previously been used to treat persistent pain are now known to be ineffective, carry significant risk and can sometimes cause more harm than good.

Let’s begin with a quick task. I would like you to ask yourself two quick questions and write the answers down. If you don’t have persistent pain, try to put yourself in the shoes of someone who does.

Question 1: If you were offered surgery for your persistent pain tomorrow, how likely is it that you would take it on a 0 to 10 scale (with 0 being “absolutely no way”, and 10 being “absolutely yes way!”)?

Question 2: If you were on opioids for your pain since it started two years ago, and your pain levels were still really high, how likely is it that you would be willing to come off those tablets? Rank this on a 0 to 10 scale (with 0 being “absolutely no way”, and 10 being “absolutely yes way!”).

Over the past 20 to 30 years, clinical guidelines for treating persistent pain have changed a lot. They have moved away from medical treatments such as surgery and potent pain medications, and towards more holistic treatments like education and exercise. There are a number of reasons for this.

Firstly, we know that everything matters when it comes to pain, not just the biological but also psychological and social factors. And surgery and pain medications only treat the biology. Secondly, the scientific evidence to support the use of many of these biomedical treatments just doesn’t add up. Thirdly, these biomedical treatments often come with a number of really bad side effects. In contrast to this, the more holistic treatments like exercise have solid evidence behind them and few side-effects.

Let’s start by taking a closer look at surgery. Let’s take back pain as our first example. The National Institute for Health and Care Excellence (or NICE, as it is known), which is based here in the UK (but respected right around the world), does not provide a ringing endorsement for spinal surgery. I know what you are thinking: surely, some surgeries are beneficial? Well, of the three broad surgical categories (spinal fusions, disc replacements and spinal decompression), the NICE guidelines clearly state: do not do spinal fusions or disc replacements clinically. Of the third, spinal decompression, there is evidence that this type of surgery can be helpful in certain cases, and the guidelines say it should be considered when conservative treatment has not led to an improvement. However, evidence would suggest that long-term outcomes are similar to those achieved through conservative treatments.

Worryingly, in stark contrast to these guidelines, the number of spinal surgeries in England has actually doubled over the past 15 years or so.

Of those people who do receive spinal surgery, about 60% go on to require some sort of additional care for their pain, whether that is more surgery or long-term pain medication. It is so alluring to think that surgery will provide a permanent solution to pain, especially if we think the issue is in the tissues and that some structure is damaged and needs fixing. So, it is often a really tempting option for people in pain, their families, and indeed health care professionals to opt for or to offer surgery. Unfortunately, it is not this straightforward, and surgery does not usually result in an end to the pain.

What about surgical approaches for other conditions, such as keyhole surgery for knee pain? Again, we see a similar pattern, with clinical guidelines saying not to do them, while surgery rates have risen by 69% in England over the past decade.

To explain why keyhole surgery for knee pain is usually not a good idea, I want to tell you about one of my favourite clinical trials of all time. In this trial, a surgeon in the USA recruited participants with knee osteoarthritis and randomly assigned them to three different groups. Group one received a surgery called ‘lavage’, where the joint was washed out with saline fluid to get rid of any loose bodies and debris. Group two received a surgery called ‘debridement’, where the surfaces of the body are smoothed before the joint is washed out with saline fluid. Group three received a placebo surgery, where they received anaesthetic and an incision but nothing else was done. All the participants knew there was a chance they could get a placebo surgery, but none of them knew which group they were in.

Patients were followed up a number of times over two years. So what happened? You guessed it: there was no significant difference between any of the three groups at any time point. If anything, in the first few months, the placebo group looked to do a little better. This amazing study tells us a couple of important things. Firstly, people will volunteer for some crazy things: I don’t know about you, but I am not sure I would volunteer for a study that meant I could get a placebo surgery. Secondly, for knee pain, keyhole surgery is no better than placebo. Thirdly, on average all three groups improved by about 20%, even those where their only treatment was a flesh wound!

I have another task for you. I would like you to take a couple of minutes to think about the results from this study. Why do you think all three groups got better? Do you think it was because the tissues in the knee were fixed? Or do you think it was something else? If you think it was something else, try and explain what it was. Think back to our previous sessions about how everything matters when it comes to pain. Please spend the next five to ten minutes doing this task.

So, what did you come up with? Here are my thoughts: let’s see how they compare with yours.

The improvement seen in all three groups cannot have been due to fixing the tissues in the knee, because if this was the case, how come the placebo group improved when those tissues were untouched? I believe that each participant’s Assumpta had a big part to play, that is, the subconscious part of the alarm system that weighs up the balance between safety and danger.

Prior to the surgery, Assumpta was receiving a variety of messages to say that the knee was in danger, she wanted to draw attention to this and get something done about it to keep the person safe. So, she gave pain, because the purpose of pain is protection. After the surgery, Assumpta received a variety of new messages, including being told by the surgeon (someone knowledgeable and trustworthy) that the surgery was successful, and the problem was fixed. This will have influenced Assumpta’s scales, increasing the ‘safety in me’ (SIM) side, making her believe the knee was in less danger. Believing the knee was in less danger, she didn’t need to draw attention to it as much and there was less need to do something about it. She believed the knee needed less protection and thus she created less pain by opening up the drug cabinet in the brain. Did you come to a similar conclusion, or did you come up with a different possibility?

Let’s move on now to talk about medicines. Let’s start by thanking the stars for the invention of pain-relieving medication. Pain medication has transformed healthcare and can be so effective in a variety of acute situations, be that in the immediate aftermath of a road traffic accident, to immediately post-surgery, or during labour: these are just a few examples. However, when we move away from immediately or shortly after the event, it is a very different story.

Unfortunately, when the pain goes on for a long time, as is the case in persistent pain, evidence shows these medications are not very effective and can actually start contributing to the problem. 

In particular, I want to talk about strong pain medication like opioids, gabapentin and pregabalin. In the case of these medications, we seem to see a similar pattern to that of surgery, with guidelines saying to use them less and clinical practice actually prescribing more.

NICE guidelines state that there is little evidence that opioids are helpful for people with persistent pain. But surely opioids can be helpful in some cases? Yes, indeed, a small proportion of people may obtain good pain relief with opioids in the long-term, if the dose can be kept low and use is intermittent, but it is difficult to identify these people at the start of treatment. If useful relief with opioids has not occurred within two to four weeks, then it is unlikely that it will occur with longer use.

We must also remember the risks associated with these strong pain medications, especially at higher doses. At one end of the scale, opioids can lead to nausea, constipation, vomiting and drowsiness. On the other end of the scale, they can lead to addiction and even death.

You probably knew all that, but did you know this? One of the most bizarre and frustrating side effects of the long-term use of opioids is, would you believe it, increased sensitivity to pain. So not only are they not reducing pain levels, but in some people, opioids can increase pain levels. What a kick in the teeth! The exact reason for this is unknown, but it seems that opioids can interfere with the drug cabinet in our brain, making our internal pain-relieving system less effective. So NICE guidelines recommend that opioids should be discontinued if the person is still in pain despite their use, even if no other treatment is available, as it could be making things worse and could result in significant side effects.

Now, let’s look at what is actually happening in practice here in the UK. Would you believe, in stark contrast to guidelines, that opioid prescriptions have gone up by 127% in the past 20 years? So why is there such a difference between guidelines and practice? Why is the use of surgeries and opioids increasing for the treatment of persistent pain when all the evidence says they should be decreasing?

If I could answer that I would be a millionaire! You probably have some of your own ideas, and this is something that we will touch on again in the next session. For my part, I think it is because nothing motivates us as a species more strongly than pain. It cries out for immediate action, and in doing so, it can often drown out all other voices, including that of evidence based guidelines.

People want the pain to go away, and health care professionals desperately want to help. And so, leaping into action can seem like the best and maybe the only way forward at that point in time. But it is not: there is another way, a more evidence-based way.

This way is not quick, but it might be quicker than you think. This way is not easy, but it might be easier than you think. You have already started to take the first tentative steps by starting to learn more about your pain, putting you in a good place to make more informed choices about your future.

Before we finish up this session, remember at the beginning of this section I asked you the following questions?

Question 1: If you were offered surgery for your persistent pain tomorrow, how likely is it that you would take it on a 0 to 10 scale (with 0 being “absolutely no way”, and 10 being “absolutely yes way!”)?

Question 2: If you were on opioids for your pain since it started two years ago, and your pain levels were still really high, how likely is it that you would be willing to come off those tablets? Rank this on a 0 to 10 scale (with 0 being “absolutely no way”, and 10 being “absolutely yes way!”).

Can you answer these questions again now please? Have you done it? Now compare it with what you wrote down at the start: have you answered the same or differently?

If your answer has changed, please note down why you think it has changed. If it has not changed, please note down why you think it hasn’t. As always, discuss it with friends and family, and weigh up the potential pros and cons. Take five minutes now to do this task.

Let’s finish off by reminding ourselves of the key message from this episode. Medicines and surgery are often not the answer, but that is not to say that they do not have an important place in some cases. However, when it comes to persistent pain, they are rarely the best way forward.

Thanks for listening. I look forward to speaking to you again in Episode 6.