Doctors are still dishing out millions of NHS prescriptions for powerful opioid painkillers – five years after stark warnings that Britain was heading for a US-style addiction crisis.
Numbers taking high-strength pills such as codeine, tramadol, and oxycodone increased during lockdown, according to the latest data, while the death toll in England and Wales from the potent pills has almost doubled over the past decade to 700 a year.
The alarming news comes just months after Public Health England revealed 13 percent of the population – roughly seven million people – are currently taking prescription pain medications, and more than 500,000 have been on them for three or more years, despite guidelines recommending a few weeks at most.
Addiction specialists say opioids are routinely being prescribed for chronic pain, even though studies show they are not particularly effective and can even make things worse.
Millions more may be hooked on over-the-counter versions containing codeine, an opioid linked to more than 200 fatal overdoses in the UK last year, according to the Office for National Statistics.
Experts have long argued for an outright ban on high street chemists selling products such as Nurofen Plus, Solpadeine Plus, Migraleve, and Paramol.
Now the worry is a year of lockdowns may have prompted more people to use powerful painkillers to help cope with the loneliness and mental strain of Covid-enforced isolation.
'Five or so years ago there was a big push to reduce opiate prescribing, and there was a drop,' says Dr. Barry Miller, chairman of the medicines advisory group at the faculty of pain medicine of the Royal College of Anaesthetists.
'But with lockdown, the figures have gone up again, and that's a cause for concern. People are being prescribed the drugs where they ought not to be.'
And addiction expert Professor Ian Hamilton, a lecturer at the University of York, said: 'We've been warning for years that if prescriptions for opioids continue to be handed out so routinely, we'd face a US-style crisis. Now, in some areas of the country, it's happening.'
In the US, opioid overdoses have caused more than 500,000 deaths over the past two decades alone, outstripping AIDS.
The impact has been so profound that between 2015 and 2017 there was a dip in overall life expectancy in America – something that had not occurred for 100 years.
Nuno Albuquerque, head of treatment at UK Addiction Treatment Centres, who runs eight rehab facilities across the UK, said they had seen a steep increase in inquiries for help with prescription painkiller addiction over the past 18 months.
He said: 'Perhaps people are feeling alone, anxious or frightened. Some turn to drink to cope but others start relying more and more on their prescription painkillers, which numb difficult feelings.'
Opioids are a group of pain-relieving drugs that work by interacting with opioid receptors on nerve cells in the brain, spinal cord, digestive system, and other parts of the body, blocking the transmission of pain messages.
They can be naturally derived – made from the poppy plant, as with morphine and codeine – or synthesized in a laboratory.
In the short term they not only dull pain but cause feelings of calm and drowsiness that some find pleasant. But in higher doses – and when mixed with other drugs or alcohol – they can also suppress breathing and affect the heart, with potentially deadly consequences.
They were traditionally used in palliative care to lessen the agony of end-stage cancer, or after surgery. But in the mid 1980s, doctors in the US began offering them to sufferers of chronic pain conditions, such as arthritis.
It has since emerged that the shift was, at least in part, down to pharmaceutical companies promoting the drugs to doctors, in some cases making unsubstantiated claims about their effectiveness and offering financial incentives to 'high-volume prescribers'.
Among the firms pushing the medications into this new, lucrative market was Purdue, makers of drug OxyContin, the brand name for opioid oxycodone.
In emails dating back to the 1990s unearthed by American news show PBS NewsHour, Purdue boss Richard Sackler suggests telling doctors that because OxyContin was longer-acting than other opioids, it was also less addictive.
At the time, there was no proof to support that claim – and there still isn't.
Doctors who prescribed OxyContin were allegedly also paid six-figure sums by the company.
Purdue filed for bankruptcy in September 2019, facing more than 2,900 lawsuits from aggrieved patients who'd become addicted and seen their lives ruined – or, in many cases where the patient had died, their surviving family members. In August the Sackler family agreed to pay nearly £3.1 billion to resolve the lawsuits.
Despite this long-running and high-profile case, UK doctors have continued to prescribe oxycodone and other opioids for chronic pain. The NHS spent £209 million on 23 million prescriptions for opioid analgesics in the year to January.
Prof Hamilton said: 'Patients addicted to opioids are typically in their 30s and up. We see equal numbers of men and women affected. The easy availability of over-the-counter opioid painkillers and the fact that prescription pills can be bought on the internet has worsened things.
'It's possible to become dependent in a matter of weeks, but because they're medicines people often don't realize what they're doing is harmful until it's too late.'
One patient hooked on oxycodone for more than a decade is 73-year-old Kathleen McManus, from North London, who for more than 20 years has suffered with complex regional pain syndrome – a nerve condition that causes intense, burning pain, usually in the limbs.
'The pain in my legs was constant,' said Kathleen. 'It was worst when I tried to walk but the burning was always there. I couldn't get comfortable and I couldn't sleep.
'I tried normal painkillers but nothing worked.'
After her diagnosis, Kathleen became unable to work and her relationship broke down.
Ten years ago, with her condition worsening, she was referred to a hospital pain clinic and was prescribed a 'cocktail' of strong drugs, including the antidepressant amitriptyline and anti-seizure medicine gabapentin – both of which are also used for pain – as well a sleeping tablet called zopiclone, and oxycodone.
Kathleen said: 'I felt a bit drowsy but it did help. I was able to see friends, go to the shops, or take the dog for a walk.
'At my regular check-ups, the doctor would ask how my pain was and I told him I felt better, although the sleeping tablets stopped working so well so he doubled the dose.
'Then one day I turned up and was told the clinic was closing.'
For the next few years, Kathleen's repeat prescription continued to be filled by her GP.
She added: 'Eventually I started getting odd symptoms, like an itchy rash all over my body and tinnitus, like the sound of bees in my head. The pain began getting worse again, too.'
She was referred to another pain clinic which advised her to cut down her tablets gradually. 'I managed to stop the gabapentin and the doctor swapped me from zopiclone to diazepam [also known by brand name Valium].
'I've halved my dose of oxycodone, but if I take any less than that it's horrendous – the pain comes back and I'm doubled up with cramps, sweating, and vomiting. The first time it happened, I thought I was going to die.'
But cutting back on oxycodone also led to seizures.
'She'd begin shaking uncontrollably and then sort of slump and become unresponsive,' said Kathleen's daughter Julie, 42, a PR consultant who gave up full-time work to care for her mother,
'We'd call an ambulance and they'd take her to hospital then discharge her. Mum went back to her pain clinic, saying she was concerned, but they told her other people were on higher doses of oxycodone so she didn't need to worry.
'We've had to move her into sheltered accommodation with a warden on-site, and emergency pull cords, as her health is so precarious.'
Kathleen said: 'I can't go out, or do anything. I can't even concentrate to watch TV. My life feels like it's been destroyed and I'm desperate to stop taking these pills.
'No one seems to know what to do and the worst part is I've now read I shouldn't ever have been put on medicines like these in the long term.'
Father-of-two Matthew Colton, a 42-year-old carpenter from Guildford, Surrey, has faced a similar battle. He was first prescribed the opioid oramorph – a form of morphine – followed by tramadol, for lower back pain.
Matthew, who also has two stepchildren with his partner, said: 'The oramorph worked and my pain went away, but I think I was probably also using it for the wrong reasons.
'It's a liquid and the bottle comes with a little measuring cap, but eventually I was just swigging from the bottle. I think the doctor twigged I was taking too much, and so I was switched to tramadol.'
Matthew was told to take no more than eight tramadol pills a day. He admitted: 'At my worst, I was on about 40. I liked the way it made me feel – sort of mellow and a bit like you're floating. But if I didn't take enough I'd get horrible shakes, sweats and my heart would race. I'd feel sick.'
In August 2019, Matthew was at a playground with his children when he suffered a seizure.
'Doctors said I was lucky I didn't die. I suppose I'd been in denial as I'd been prescribed them by a doctor.'
With his GP's support, Matthew gradually reduced his tramadol dose. But last year, as lockdown hit and as his back pain began to return, he 'stumbled across' over-the-counter codeine-containing painkiller Nurofen Plus.
He recalled: 'I thought, they must be safe if you can buy them in Boots and you don't even need to speak to a doctor.
'But I quickly found I wanted to take more and more of them, too, and was eventually getting through a box of 32 a day. If I took less, I'd get withdrawal symptoms – just like last time.'
Pharmacists are instructed to sell codeine-containing painkillers only if other options have proved ineffective – and advise that they are to be used for no more than three days.
Guidelines also require them to ensure that tablets 'are not intended for abuse or misuse', so many will limit how much they sell to a single customer. However, Matthew found a simple work-around. 'I'd visit different chemists every day and come up with all sorts of stories.'
Nurofen Plus also contains the anti-inflammatory ibuprofen, which can damage the stomach lining if used in high doses over a long period – and Matthew's habit did trigger an ulcer.
He signed up to a recovery program and Help Me Stop, a new private addiction service that provides day rehab services in person and online. 'I'm not taking anything now but it's difficult because I know how easy drugs are to get hold of,' said Matthew.
So what is the solution?
Experts agree the easy availability of addictive painkillers in high street stores needs to be examined, but Prof Hamilton said GPs also need specialist training to help opioid addicts quit, because many are taken off them too fast.
And a big problem is that because the pills don't come in smaller doses, they have to be cut up, making it harder to regulate how much patients are taking.
Nuno Albuquerque added: 'We need to change the way doctors deal with pain. GPs should be able to offer acupuncture, yoga, or other ways to help manage the problem. And, right now, addiction treatment is mainly a private service, so less-well-off people can't access it.'
For Kathleen, all of this is little comfort: 'Doctors have said coming off the pills at my age could trigger a heart attack. It feels like they've given up on me.
'I just keep thinking, how did my life end up this way?'
Matt Birnholz, MDPeer