Horizon (1964–…): Season 51, Episode 1 - Should I Eat Meat? The Big Health Dilemma - full transcript
Michael Mosley investigates the alleged danger in eating red and processed meat, and does a one month test on himself, doubling his meat intake.
Britain is in the grip
of a drug crisis.
Wow.
Each year, more than five million
of us are prescribed opioids.
Painkillers which can be as
powerful as class A drugs.
You know that it is related
to morphine and heroin?
No.
In America, a prescription opioid
epidemic accounts for more deaths
than gun crime.
Now, a landmark report suggests
we may also have a problem.
How many of these tablets
were you consuming?
Erm, between 50 and 70...
Wow.
...a day.
I ended up overdosing.
I'm Dr Michael Mosley.
I want to understand just how
worried we should be,
because millions of us get stuck
on these painkillers long term.
The tablets just destroyed
her, really.
When a doctor prescribes
them, you take them -
you take whatever,
whatever you can take.
I want to find out how easy it is
to get hold of these potent drugs.
Pain relief prescriptions,
free UK express delivery.
That's for me.
And discover their potential risks.
We're really heading towards a very
dangerous place
and we need to do something
about it now.
I also want to explore the biology
of pain...
I can feel it beginning to burn now.
...to find out why opioids work
for some...
...but not for others.
They didn't sort the pain out.
What they actually did was turn my
beautiful, lovely,
active wife into a zombie.
I think this is a major public
health issue up there
with heart disease and cancer.
I want to find out what's gone wrong
and whether science can help us
tackle Britain's opioid crisis.
I'm in Hastings, a town that's
on the front line
of Britain's opioid problem.
You don't have to look far to find
evidence that they are now part
of our everyday lives.
Thanks.
This contains codeine, which is
a powerful and effective painkiller.
It is also an opioid which makes
it part of the same family
as morphine and heroin.
And that means it can also
cause addiction.
Now, this stuff absolutely pales
in comparison
to what you can get from your GP.
Your GP can quite legally prescribe
you something which
is 300 times more powerful
than this.
Here in the Hastings area,
around one in seven adults
were prescribed an opioid last year.
But do they know
what they're taking?
So any of you on painkillers? I am.
What are you on? Dihydrocodeine.
You know that it is an opioid,
related to heroin and morphine? No.
Did you know that they are related
to heroin and morphine?
Not really, no.
Would that put you off taking them?
Of course it would, yeah.
What are you on? Oxycodone.
You know that it is an opioid,
related... Yes, I do.
...to morphine and heroin? Yes, I do.
OK, and does that put you off,
at all? No, not at all.
Doesn't turn me off, I still take
my tablets.
It doesn't really, I don't touch
drugs anyway.
They're a life-saver for me,
they get me about.
And do they work?
Erm, they do, but I didn't like
the feeling that I had.
What was that?
I just felt a bit, well, my partner
call them my happy pills,
because I felt a bit spaced out.
So, plenty of familiarity
with opioids in Hastings.
But what of the national picture?
Come on, I'm taking a pound
to clear!
I've invited my new friends
to my stall in the town market
to demonstrate the scale
of our opioid consumption.
OK, ta-da.
Whoo-hoo!
Right, so, imagine this
is the amount of opioids
the good old British public
was consuming 20 years ago.
How much do you think
they're consuming now?
More. More, a lot more?
OK, how much more do we reckon?
I reckon about here. OK.
I think about here.
About here?
I reckon it'll be...
I'm asking people to guess how much
the total amount
of prescription opioids
has increased.
Shout when you think I'm getting
close to it.
Whoa! Lots of lovely opioids
going in, yeah.
More?
A bit more, keep going.
As the years have gone by,
the population's been getting older.
But we certainly haven't been
getting this much sicker.
Keep going, we're going, going,
going, going, going, going, whoa!
Hurrah, that was 2017.
Wow!
So that is a good doubling
in the amount of opioids
that people were consuming
20 years ago.
So that is pretty terrifying,
isn't it?
That is terrifying, yes.
There's no doubt that opioids
have a vital role to play
in cancer pain, end-of-life care,
or to relieve pain after
an operation.
But that doesn't begin to explain
the huge surge in prescribing
we've seen in recent years.
I do think it's important to point
out that opioids in the right
patients can be absolutely
life-changing.
However, a major new report
by Public Health England
has revealed that 5.6 million adults
in England and Wales
are currently on
prescription opioids.
That is an astonishing one
in eight of us.
So what are opioids?
Originally, they came from the sap
of the poppy plant,
which has been used
for thousands of years,
both recreationally
and to treat pain.
It gave the world heroin.
They act on the opioid receptors
in the brain,
blocking pain signals from the rest
of the body.
In fact, they're probably
the greatest tool doctors have
for numbing acute pain,
like a broken bone,
or an infected tooth.
They're often promoted as a safe
and effective way
to treat all manner of pain.
But unfortunately, many
patients are discovering
that this simply isn't true.
Nice cup of coffee.
Thank you.
I was weighing these books up.
And as I turned, sort of, like,
bent slightly sideways to check
the reading, something in my back
just went pop!
It was actually heard throughout
the office.
It was.
My immediate boss was like,
"What the hell was that?"
In 2014, Karen popped a disc
in the middle of her spine.
Almost like having a having
a red-hot poker
put between your vertebrae.
Painful, very painful.
Research suggests there could be
as many as 28 million Brits
like Karen living in chronic pain.
Pain, which is constant or recurring
and has been there for more
than 12 weeks.
Karen's doctor's solution? Opioids.
We got on these opiates,
which initially, I was very
excited about
because I thought, "Yes, she's going
to be pain free."
Sadly, it didn't work out like that.
You got this false sense of illusion
that, "Well, actually,
"they must be doing something,
even though I'm still in pain."
What, if I stopped them, my God,
the pain's going to be horrendous.
Over the course of five years,
Karen was put on increasingly
powerful opioids, starting on
Tramadol and ending up on morphine.
But they didn't sort the pain out.
What they actually did was turn
my beautiful, lovely,
active wife into a zombie.
The curtains were always shut.
The bed was always unmade,
because I was always
in it, sleeping.
It was heartbreaking because
the girls used to say,
"Where's our mum?
"She's not... she's not here any
more."
Yeah, I felt like a drug addict.
Every day was the same.
And it was just sleep, wake, eat...
...toss and turn, get up.
Sleep, eat.
I felt like there was no hope.
You want it to help, do you know
what I mean?
So you kind of...
...tell yourself it's working.
And it's only people around you say,
"Nothing's changed, Karen,
"if anything, now you're mindless."
Long-term opioid use put people
like Karen at risk of constipation,
memory loss, addiction, even
accidental death by overdose.
And perhaps the most startling
finding of the Public Health England
report is that over half a million
people have been on opioids
continuously for more than
three years.
Doctors have over 40 different
opioid painkillers
at their disposal.
Most can be picked up from one
of Britain's 11,000 pharmacies,
like this one in south London.
Akash, here?
Just round there? Lovely, thank you.
Hi there.
Hi, Akash, Michael Mosley, hello.
Nice to meet you.
Akash Patel is a pharmacist who's
agreed to show me
just how powerful opioids can get.
He says all of them are safe
if used correctly,
but dangerous if misused.
That's the weakest, which is
bog-standard co-codamol
that you can buy over the counter.
OK.
The codeine in co-codamol is mixed
with paracetamol.
It can be bought from a pharmacy
without a prescription.
Even at this strength, codeine
can be addictive.
But just how powerful do
opioids get?
Akash has offered to demonstrate,
using pills to show different
opioids' relative strengths.
OK, so that represents one pill.
Yeah.
Yeah, OK, what's next?
Moving on to some codeine, 30
milligrams,
that you can only get on
a prescription. OK.
So this is prescription only? Yeah.
And this is the equivalent of having
four tablets, is that right?
Yeah.
So these pure codeine pills
are far more powerful
than the codeine in co-codamol.
At this strength, you might
experience withdrawal symptoms
if you came off it suddenly
after long-term use.
From here, the opioid drugs doctors
can prescribe
get stronger and stronger.
After this, it's basically
into the cupboard.
Into the cupboard, right, OK.
And then, there you go.
Ooh.
Some morphine. Yeah.
You've got 15 milligrams
of morphine tablets there.
And that's equivalent
to 13 Co-codamols.
Right.
Morphine, the drug Karen was on
for her severe pain,
is a close relation to heroin.
It is highly addictive.
And then you can go up to some
oxycodone. Right?
Which is equivalent
to 75 codeine tablets.
OK.
Oxycodone is one of the most
widely-abused prescription opioids.
In the US, it's been implicated
in thousands of deaths.
I also have some diamorphine. Right.
Which is more commonly
known as heroin.
Heroin? Blimey, no wonder it's
locked away. Yeah.
Heroin, which is around the same
strength as oxycodone,
is also prescribed for pain,
often the end of life care.
But surprisingly, there are opioids
that are even stronger than heroin.
The next one, I don't think we
should take out
of where we got it,
which is the fentanyl.
Which is equivalent
to 338 co-codamol.
Wow.
That, I can see the difference.
I mean, when you see that, then
suddenly it makes sense, doesn't it?
This is a massively greater dose,
in its kind of morphine-like
qualities than something like that.
All of it, one little patch?
One little patch.
Fentanyl is so powerful, it's
usually given to patients
via a slow-release skin patch.
What would happen if I slapped
one of these on, would it kill me?
Probably wouldn't kill you,
but you wouldn't be very well.
You'd probably be in hospital
for a few days.
It is a bewildering selection
and all of these drugs come
with wide-ranging side effects.
Given what we know about
the risks and dangers,
why are doctors so happy
to prescribe them?
Salford has significantly
higher prescribing rates
than the national average.
I'm here to meet one of its
GPs, Dr Nicholas Browne.
Michael? Yeah. Hello, hi.
I've heard one reason opioid
use has soared
is because doctors were encouraged
by established guidelines
to prescribe ever-higher doses
to those in pain.
It's something we commonly
see in most surgeries,
someone experiencing an acute level
of pain, or ongoing chronic pain.
The, you know, the story
we've told, we've almost sold
that we have the ability
to conquer pain.
You are the magicians.
We are, and I think we are
suffering the consequences
of that optimism.
In the 1980s,
The World Health Organisation
came up with something they called
the pain ladder.
If a low dose of painkillers
didn't work, then go up a step,
give something stronger.
The kind of mantra the WHO pain
ladder was find the right drug.
Find the right dose,
and find the right timing.
To find that magic dose
that managed to keep you pain-free.
That's what we would have
been saying,
"We can get you pain-free."
And we would have encouraged you
to take regular doses.
If you came back and said, "Listen,
almost there, but not quite,
"I'm still struggling certain
times of the day, or stopping me
"doing certain things."
Then we would want to probably
increase that further.
We would reassure you that, "Listen,
the side effects are minimal
"when you take it for chronic pain."
There are certainly things
we can do about it.
And what we are aiming for
is pain-free.
So, basically, more and more
medication
and stepping onto opiates
and then more and more opiates?
We would find what dose
was right for you,
and if that required us to go up,
that is what would be necessary.
Opioids are now so common, it's easy
to forget how powerful they are.
Particularly when mixed with drink.
People who have been on it for many
years become accustomed to it.
Everyone feels very confident. And, "Well,
you've been on it. What harm can it do?"
And people are found dead.
Why is this? Alcohol.
You know, you might go to a party, have slightly
more to drink than you would normally do,
and you're taking high-dose opiates.
And then we're adding in more medication
that interacts with this medication.
20 years ago, there were 47
drug-poisoning deaths in England and Wales
involving just two drugs -
codeine or tramadol.
Last year, it was nearly 400.
Even if that's far from US levels,
it is still a worrying trend.
So in America, we've seen
an absolute crisis
with, you know,
huge numbers of deaths.
Can you imagine the same thing
happening in the UK?
Yes, I can. And it is something
that's very much on my mind
and very much of a concern
and a worry
that we're already seeing signs
that that's happening.
And I can see it very easily
slipping into that.
Over the not-too-distant future, the
medium term, the next five years,
that we will start
seeing a progressively-increasing
accidental overdose rate.
It was quite chilling, the fact
that he does think it is possible
that things could get as bad here
as they have got in the States.
And it was also quite disturbing when
you realised how we got into the situation.
It was all the best of intentions.
It would be easy to blame
our doctors for overprescribing,
but, of course, they're only doing
what they've been trained to do.
Hi, there.
When I was at medical school
in the 1980s,
we were taught that opioids can be
horribly addictive,
except when patients
are in severe pain.
Then it's OK to increase the dose
because they won't get hooked.
We now know that advice
was hopelessly misguided.
I'm in Oxford to find out
what went wrong.
Hi, there. Hello.
This is Dr Jane Quinlan,
a consultant in pain management.
So, how do you think we got into the
situation where so many people are on opiates?
Yeah, it all goes back to the 1980s,
where two things happened.
One of them was that evidence
came from palliative care,
looking at patients at end of life
and who had pain,
to say that actually, giving
patients like that high-dose morphine,
high-dose opioids was safe.
People didn't get addicted.
And you could just increase the dose
as much as you needed to
to make sure someone was
comfortable.
Which is really important
when someone is dying of cancer. Mm.
Equally, at the same time, there was
a letter that was published
in the New England
Journal of Medicine,
that was a five-sentence letter
looking at about 11,000 patients
who were in hospital
and given opioids
just for a short time.
And this letter said,
"None of our patients got addicted".
The big headline, Addiction Is Rare
In Patients Treated With Narcotics -
we now call these opioids. Yes.
And so, this headline message
has then been repeated
over 600 times.
But this 100-word letter
isn't peer-reviewed research,
it's simply an observation.
And yet it was referenced
time and time and time again
in science journals.
And some took the letter's
tentative conclusions much too far.
This suited big pharmaceutical
companies very well indeed.
And they not only helped fund
much pain research,
but began aggressively promoting
opioid use.
Some patients may be afraid
of taking opioids
because they're perceived as
too strong, or addictive.
But that is far from actual fact.
Four out of five heroin users
in the USA
started out by misusing
prescription opioids,
an epidemic which has now claimed
more than 200,000 American lives.
In 2017, the co-author
of the original letter,
Dr Hershel Jick, wrote -
Things aren't nearly as bad
in Britain,
but I suspect the way
this research was deployed
helped drive the overprescribing
we've seen here.
Oxycodone, also known by
the brand name OxyContin,
was implicated in 79 deaths
in England in 2018.
NHS doctors are closely regulated,
so it's unlikely opioids
will ever be dispensed
as freely here as in America.
But Dr Quinlan is still concerned
about the high levels
some people are on.
Some evidence has just come out
to say if you're on more than
100 milligrams of morphine
equivalent per day,
your risk of death
is nine times higher
than someone on 20 milligrams
or less.
And that's huge.
That is absolutely vast, isn't it?
Aren't patients aware of the risks
they're running?
No, I don't think they've got
any idea at all.
And again, they've been assured
all these years
when they've been prescribed
these drugs
that these are safe drugs to take.
So often, having that conversation
at our first consultation
is actually quite difficult for them
because they were unaware of
the risks they're running
by being on these high doses,
that they've been taking
in good faith,
and they assumed were
appropriate doses.
Because they were obviously
prescribed them in the first place.
Exactly. Exactly.
If you're one of the many people
on high-strength opioids,
please don't just stop taking them.
Your chances of dying
from an accidental overdose
remain incredibly small.
Nevertheless, as the Public Health
England report reveals,
too many people are on opioids
that are too strong for too long.
And that increases risk.
Which begs the question - why aren't
we urgently getting people off them?
Unfortunately, it's not as simple
as that.
Do you find the swaying helps? Yeah.
OK. Why? I don't know.
I think because if you...
I am beginning to sway with you,
I have to say!
Yeah. Yeah. I don't... I don't know.
It just does? Yeah. Yeah.
This is Brenda, at home in Salford
with her husband, Roger.
Brenda has been taking high-strength
morphine for 15 years to cope
with an injury which was sustained
while working at her local hospital.
We were transferring
a young stroke patient
and I sort of twisted
and went down, but...
And was it very painful?
Excruciating. Yeah.
Out of 10? Er... 20.
Yeah.
It was horrendous.
Brenda has been left
in constant pain.
In fact, her days seem
quite unbearable.
I wouldn't wish it
on my worst enemy.
It's horrendous.
You've given birth to two kids.
How does it compare to that?
Um... giving birth, easy-peasy.
Brenda's story is remarkably similar
to Karen's, the first patient I met.
But while Karen's opioids
turned her into a zombie,
Brenda swears by them.
And what's the morphine
actually done?
It's just magic.
It is for me, anyway.
It really is.
Do you think you could get by
without it? No.
And what would you say
if someone tried to take it away?
Why?
And what are you giving me
that's as good as that?
I couldn't imagine being without it.
There'd have to be a backup to it.
Oh, it would be horrendous,
I know it would.
Does it affect your brain at all?
Does it fog you up at all? No.
Have you had any obvious
side-effects from it? None at all.
You're taking it without any significant
side-effects, as far as you can see?
Yeah, I think so. And it's
bringing the pain down? Yeah.
So, for you, it's working
really well? Yeah, definitely.
That's... There we go. Are you up?
Are you up?
Oof! Are you going to do
a bit more swaying?
Yeah, I'm going in there, swaying.
Thank you very much.
Thank you very much. Thank you.
You're welcome. Mwah!
I can say I've kissed
a famous person!
I really feel for Brenda.
She's obviously in a bad state
and believes the thing that makes
her life tolerable is morphine.
But is she right?
There are hundreds of thousands
of people like Brenda
who are taking opioids,
but are still in pain.
So, how much are these drugs
actually helping?
I need to learn more about
the science of pain.
I'm back in Oxford to meet one of
the world's foremost pain experts,
Dr Irene Tracey.
To help me get to grips
with the subject,
I'm going to take part
in a little experiment.
I'm assured it won't be too painful.
OK.
What we're going to start with here
is some chilli-pepper cream
that we've had specially made up
by a pharmacy. OK.
And we're going to just put a little
area of your skin with it on. OK.
And we're going to let that cook
for about 30 minutes. OK.
This chilli is going to burn my skin
and trigger a complex network
of pain sensors in the body.
Rub that in, make sure
it's really soaking in for you.
Starting to feel... I can feel
it beginning to burn now. Yeah.
You've got these things...
Your fibres out there in your arm,
that are going to send the signals
in. They then hit your,
sort of, spinal cord.
It's at the back there.
Then they enter the brain
and the brain puts it together.
But again, the brain's got
a capacity to change
how those signals are processed.
It also can change and talk,
down to that point where
those signals are first coming into
your spinal cord... Right.
...and turn it up and turn it down.
The sensation I'm feeling now
is acute pain.
It's triggered by the nerve fibres
in my skin
that are being burnt by the chilli.
What is the key difference between
acute and chronic pain?
Chronic pain is just something
very different to acute.
The definition of chronic pain
is a pain that's still there
beyond normal tissue healing times,
so three to four months.
Historically, we thought
it was just a continuation,
it was just an ongoing symptom,
an ongoing acute pain.
Now we know that in that transition
from acute to chronic,
it's a whole new biology
has established itself.
There's been changes in your cells
and your genetics, your wiring.
It is a, sort of, disease
in its own right. Yeah.
And it's not just a continuation
of the acute pain symptom.
It is something different now.
This remarkable discovery,
that acute and chronic pain
are fundamentally different,
is being modelled right now
on my increasingly sore arm.
If I brush you... Yeah.
..that normal touch is now painful.
Yeah, indeed.
And it's not because that part
of the skin is injured,
it's because this injured bit
has sent signals in
for the past 30 minutes,
it's set off those amplifiers
we spoke about, the spinal cord
and the brain. Yeah.
So now, when those signals go in...
Sorry!
...they are being amplified,
literally like a volume button.
More goes into your brain,
it hurts more. Right.
That is a really important mechanism
in chronic pain. Yeah.
With my pain system now
in overdrive, I'm experiencing
burning where there's
no chilli cream.
And that's what happens
in chronic pain -
you feel it even when there's
no longer a physical injury.
I might have this off now.
Shall we have this off?
I think we'll have this off, yes.
OK, so I'll just peel that off.
Hopefully that won't hurt too much.
Not at all.
So, I get that in acute pain,
you have the pain and it has
a purpose... Yeah.
...to teach you to avoid stuff
and to protect yourself.
But why do you get these things
which switch on and stay on?
Yeah, it's...
Well, it doesn't have a purpose.
I think, again, we thought, chronic
pain, there was a purpose for it.
There just isn't. It's a system
gone wrong. Right.
There's no doubt that opioids
are one of the best tools
in our armoury for numbing
acute pain.
But this experiment raises
an important question -
if chronic and acute pain
are different conditions,
is the same treatment - opioids -
likely to be just as effective
in both?
It is a critical question,
because the majority of opioid
prescriptions handed out in Britain
are for chronic pain.
I'm heading to the Royal College
of Physicians in London
to meet Dr Cathy Stannard.
She's one of the world's leading
experts on pain medicine.
I want to find out just how useful
she thinks opioids are
at tackling chronic pain.
Chronic pain is very difficult
to treat.
Probably fewer than one in ten
people given opioids
for long-term pain will get
a useful...
...clinically useful result from
them.
Shockingly, that suggests
that in 90% of chronic pain cases,
opioids really aren't helping.
But as I've learned, if the opioids
aren't numbing the pain,
doctors have been trained
to give more.
So if I give you a drug for blood
pressure and your blood pressure
stays high, nobody would argue
that it's not working.
But if I give you a painkiller
and you come back and say,
"I'm still in pain." What do we do?
We double it.
And you come back and say, "I'm
still in pain." And we double it.
If you give it and it doesn't work,
stop it.
You know, that's what you would do
with any other drug.
But why don't we do that?
That was a pretty amazing statistic,
that less than one in ten people
who go on opioids
get any benefit from it.
And that does suggest that there
are an awful lot of people
out there on high-dose opioids
with horrible side effects
who are actually getting
no pain relief at all.
And it makes you wonder,
why are they on it?
Why ARE they on it?
Who is responsible for so many
being put on life-altering,
addictive, potentially
dangerous opioids,
especially when it seems
in the majority of cases,
they don't actually work?
Hi, there. Hello.
Helen Stokes-Lampard
is the country's most senior GP.
I believe GPs have always
tried to do their best
for their patients, and if patients
have come to see them in pain,
they've used whatever materials
they have at their disposal.
Years gone by, there weren't many
options, and opioids were high
on the list of what
we were encouraged to use.
If now, we are part of a system
where people are hooked on things,
we need to do all we can to help
de-prescribe for those patients.
But GPs, fundamentally,
are trying to do what's right.
But why are they put on it in the
first place, if they're useless?
Myriad reasons, because they started
with acute pain.
Anything that becomes long-term
started as a new problem
once upon a time.
So you start somewhere... And they
were stuck on them, presumably,
with not a great deal of evidence
that they were going to work,
because I've looked back through
the data, and there really
was never any great evidence
that they would work.
But there was clear guidance that
that's what we should use. Right.
The difficulty is, as a GP,
the patient sitting in front of you,
we often don't know which ones are
benefiting and which ones aren't,
until you wean them off
the medication.
But the reality is, there are
half a million people out there...
There are... who have been
identified as being prescribed
too much of this stuff for too long.
That's a lot of people.
There are a significant proportion
of those who would benefit
from being weaned down.
I totally agree.
But it's not just about weaning down
the medication, Michael,
we need to give these people
something to help them
with their pain. 100%. Because
to them, their pain is very real.
We weren't having this conversation
a couple of years ago.
We're now talking about this,
the public are talking about it.
I've had patients
come in to me and say,
"Dr Helen, I think I might
be addicted to my painkillers."
Wow. We didn't have that
a few years ago.
We can't change the past,
but we absolutely can work
on this for the future.
It's clear that the message about
opioids is starting to get through
to doctors and their patients.
But that's not the whole picture
because, of course,
you don't need to see a doctor
to get your hands on an opioid.
Which of these are you actually
the most worried about?
Surprisingly, this one,
the co-codamol.
The one that you can buy
over the counter.
It can cause addiction.
It's not restricted.
You're only allowed to buy
one box at a time - however,
what's stopping you from going
to multiple pharmacies and buying
multiple boxes throughout the day?
Co-codamol is just one
of the many opioid-based drugs
you can buy at a chemist.
And like prescription drugs,
we have no idea how many
are being sold nationally.
And Akash worries
these over-the-counter drugs
are being abused.
What sort of things are you supposed
to ask me before you're dispensing?
So we have a little way of
doing it, which is called WWHAM.
So you start off with,
who, what, how long, action taken,
and any medication.
OK, so that's WWHAM?
That's the basic...
So I should get WWHAM'd?
You should get WWHAM'd, yeah.
In every pharmacy I go to. Yeah, OK.
Thanks a lot.
It's been very enlightening.
Pharmacists WWHAM customers
to make sure the painkillers
they're selling won't be misused.
So how effective is WWHAM
in limiting
the number of pills I can get?
Hello, yes, can I get some
Solpadeine Max, please?
There wasn't any kind of
conversation about why I wanted it
or what I was going to do
with it or anything like that.
So, failed WWHAM test, I'm afraid.
Do you have any Nurofen Plus
or Solpadeine Max, please?
She was much more thorough,
I have to say.
I got my 12.9 milligrams,
again, of codeine.
She did look deeply suspicious,
I have to say.
She asked me what it's for.
She asked me if I'd tried
other things.
Basically, she passed.
That was, kind of, the shortest
conversation of them all so far.
Essentially, "Yeah, sure."
The only conversation
I had about it was whether it had
caffeine in it or not.
Well...
So that guy gave me
absolutely no conversation,
he said nothing at all.
So I just asked for another one,
since I was in there.
And if I had asked for three,
he might have given it to me,
I don't know.
No warnings, no why do you want it,
nothing.
And he really, really failed
the WWHAM test, by a long way.
One, two, three, four, five,
six, seven, eight
boxes of the stuff.
So, yeah, I've been going 40 minutes
and I've got eight boxes
of the stuff,
at 30 tablets a time,
is around 240 tablets,
I have scored.
And to be honest, really,
only two people asked me
all the questions
you're supposed to ask.
So I guess it just shows you
how easy it is
to get these over-the-counter
drugs, if you really want to.
In a few minutes,
I bought enough codeine,
at least in theory,
to give me an opioid hit
stronger than the incredibly
powerful fentanyl patch
Akash showed me earlier.
The thing is, pills like this
not only contain codeine,
but other painkillers like ibuprofen
and paracetamol,
which make them even
more dangerous in large quantities.
And of course, some people
buy codeine for reasons
that have nothing
to do with pain relief.
People who will use these medicines
quite reasonably
to self-manage their pain
will do what they can,
go to the chemist
and buy a painkiller.
Now, where the problem arises is,
you might quite like the sensation
that these medicines give you,
so that is what the driver is
for continuing to take
these drugs
after your acute pain
has settled. Right.
Because it makes it easier
to get through the day.
"It makes it easier to get
through the day".
That seems far removed
from managing pain.
It's a big, unrecognised problem
because people just do not seek
advice,
I think largely
because of the stigma.
Do you have any idea of the scale?
We don't.
I mean, that's the problem.
But what I would say is that
it's interesting that I have seen
so few people
who are addicted to these medicines.
And when I have seen them,
they are all very high-achieving
people in busy jobs,
busy lives, coping well,
coping well
despite their addictions,
so a masked addiction,
high-functioning, if you like.
With the pharmacies, it
would be a case of finding out
what time they opened.
Could I get there before
I started my shift at work?
Could I get there after?
Could I get there in my lunch break?
And it was all very calculated,
especially with the chemists
that were surrounding at work.
This is Vicky.
For years, she held down a steady
office job
while secretly relying
on over-the-counter codeine
to get her through the day.
Initially, it was pain relief.
I came out of hospital
with kidney stones,
so they gave me codeine
for pain relief.
The more I took, the better I felt.
It gives you like a warm,
fuzzy feeling
and a feeling that you can conquer
the world, if you like.
So that's how I found that
the more I took, the better I felt.
What does it do? What does it
feel like?
It feels like...
You know when you're really,
really thirsty, for example,
and you have that refreshing drink
and you just go,
"Oh, wow, I really needed that".
That's how it feels.
If I had a job interview, I'd take
them because if I was nervous,
they would make me feel a lot better
and more confident in myself
and the warm buzz that you get,
it's like a quilt, almost,
around you.
It's nice. It's a nice feeling.
I'm not going to lie.
I can't sit here and lie and say
it's not.
It is, it's a nice feeling.
At your peak, how many of these
tablets were you consuming?
Between 50 and 70.
Wow. A day.
50 tablets contain 25g of
paracetamol,
enough to put you in hospital.
I ended up overdosing in
November.
I did, you know, the treatment
where they literally just flush your
kidneys
and make sure everything's OK.
And I decided that it was now
time to go into detox,
which was the scariest
but most epic time ever.
People were in there for heroin,
crack, alcoholism,
loads of different stuff.
And you were there
for over-the-counter drugs.
I was there for over-the-counter
drugs, yeah.
And they were looking at me going,
"Why are you even here?"
Like, you know, why?
In the end, it was because codeine
is a part of the heroin family.
So it's an addiction.
It doesn't matter what addiction.
It's addiction.
And it was hard.
Vicky has been off codeine
for three months now,
but she'll always be battling
her addiction.
I'm pleased she's on the mend.
But I also wonder how many codeine
addicts are out there.
These days if you want opioids,
you don't have to go to the chemist
to get them.
You can now buy far stronger
prescription opioids on the web.
So how easy is it to buy
codeine online?
Well, I'm in a cafe, got my laptop
and I also have my own
favourite psychoactive drug.
That's caffeine.
And here we go.
Right. We're online.
There we go.
OK. That came up pretty fast.
Pain relief prescriptions,
free UK express delivery.
That's for me.
Discretion and confidentiality,
100% all guaranteed.
Of course, you can buy almost
anything on the internet.
And there's no shortage
of sites offering me codeine.
But I won't be advertising the name
of this particular vendor.
It's dispensed by registered
UK pharmacies, it says.
That looks good.
And then it says,
"Start consultation". OK.
"Are you registered with a GP
practice in the UK?" Yes.
"Do you give us consent to write
to your GP for approval?" No.
I don't want my GP to know.
No problem, it seems.
Instead, 12 hours later, they
approve my form themselves.
Right.
Final thing is, I've got to register
myself.
I think I might go with
a fake name, James Reid.
That sounds plausible.
They did do an ID check,
but mine didn't say James Reid.
Let's see if that bothers them.
It does not. That's marvellous. OK.
So finally, let's buy.
There we go.
And now, really, let's see
if it actually comes through.
Will they deliver?
And deliver they do.
So here we go, two packages in the
name of the fictional James Reid.
And I have to say, they have come
very promptly,
because I only ordered
them two days ago.
OK, so this is the one which comes
from a properly regulated British
company based here in the UK.
Here we go.
Codeine phosphate tablets.
That shouldn't have happened.
And I got really enthusiastic,
and I wanted to see whether I could
also order it from online services
which are not based in the UK.
And I decided to go for some
really high-dose codeine.
And yeah, here it is,
two packets of 20 tablets each.
That's 40 tablets of codeine.
Now, this stuff is really serious.
It is pure codeine,
and that means it is a class B drug.
And in the UK,
that means that simply possessing it
without a proper prescription
means that I could go to jail
for up to five years.
Time, I think, to go and talk
to the regulator
about how easy
it is to get hold of this stuff.
All Britain's chemists are regulated
by the General
Pharmaceutical Council.
So what do they make
of my online shopping?
I'm sitting here and I've got
codeine phosphate
and this is a class B drug,
isn't it, in terms of codeine?
It's not something
that people should be flogging over
the internet.
Absolutely not. As a controlled
drug,
there are important restrictions
in place
which are there to protect people.
It took me about 15 minutes
to buy the stuff, though.
I really shouldn't be allowed
to do that, should I? No.
It's important that there are
checks on identity...
They were pretty pathetic at that!
...that the patient or consumer
is asked for consent
so that the GP can be...
Indeed, they just said, "Do
you want us to contact your GP?
I said no. And they said, "Fine".
Ethically... That's not fine,
of course.
That is not acceptable practice,
which is why we're taking
action to tackle it.
There's a physical pharmacy
behind that website
which is registered with us.
We have a team of inspectors
who are pharmacy professionals
who will go and visit that building.
It's serious stuff.
And you're rightly highlighting
an important issue,
which we are working
on with all the effort
that you would expect of us.
And what of the foreign opioids
that I bought just as easily?
If people are using a pharmacy
service
that's not registered with us in
this country,
then they are really
in a very dangerous situation.
We would absolutely discourage
anybody from accessing medicines
through an overseas website.
You never know
what you're going to get.
Well, you don't know in terms
of counterfeit, in terms of safety.
You don't know
what the product is.
The danger is, if people are
desperate, they'll do it anyway.
It is dangerous.
That is for sure.
The regulator did indeed
take action a week later.
The UK-registered pharmacy I'd used
was banned from selling opioids.
The overwhelming majority
of other UK licensed sites I tried
refused to sell me them.
I suppose at this stage
of my journey, one thing is clear.
We have been well and truly warned
of our national opioid predicament.
We may not know the scale
of illicit purchasing from abroad
or of over-the-counter meds abuse,
but at least we recognise
there is a problem.
What's more, the Public Health
England report
identifies in meticulous detail the
risks of overprescribing.
But identifying the problems
doesn't solve them.
I'm back in Salford where,
in 2018,
one in six adults
were prescribed an opioid.
So how do you persuade patients
who've been stuck on opioids
for years to come off them?
Local GP Tom Hodson is wrestling
with this challenge.
Three years ago, he was signing
off repeat prescriptions
at his new practice when something
caught his attention.
There was a prescription for some
morphine
that I had a bit of a look at
and the dose seemed to be a little
bit higher than I would expect.
We didn't really know
if that was just a one-off
or there was lots of other patients
that had an issue like that.
So we worked with our pharmacist
to search the whole surgery,
go through all of our patients
and just find anyone that was taking
a dose
higher than we thought
was effective.
We were expecting maybe
two or three patients.
We ended up finding
that it was about 30.
So it was a surprise
that the problem was as big
as it was at our surgery.
Dr Hodson called the patients
in for a chat.
So how did the conversation go?
How does it go? So I come in,
I've been on massive doses.
I've still got terrible back pain.
My back pain is terrible.
And then you go...?
We've got to take your painkillers
away, yes.
So it was about saying...
we obviously needed
longer appointments
because you can't drop a bombshell
like that in ten minutes
and let them leave. No.
Sometimes you needed more
than two appointments.
Sometimes you'd start
this conversation,
patients would be upset.
They'd go away, have a think
and come back.
But most of the patients,
when you show them the evidence
and you show them the risks
and you say, you know,
"This probably isn't doing very much
for you,"
were willing to give it a go.
Once we started the reduction
and some of the patients didn't see
any increase in their pain,
you know, they were
actually quite motivated to do it.
And by the end, the majority
of people that did this
by the end
were quite positive about it.
People on high-strength opioids
can develop a physical dependency
on them.
Coming off quickly results
in an unpleasant withdrawal,
or cold turkey.
So Dr Hodson spends months slowly
reducing each patient's dose,
managing their withdrawal.
This is basically a record of
the prescribing at the surgery.
So this is all the prescriptions
for opioids
at a dose over 120 milligrams.
We started the work about here.
OK.
So that's an impressive decline.
Yes.
Once patients were sort of with us
and wanted to reduce it,
you can see this is the steep curve
once they started to want to reduce
them.
90% of Dr Hodson's high-dose
patients
have now either reduced their opioid
use
or come off them entirely.
And Dr Hodson isn't alone.
Across the country, including back
here in Hastings,
GPs are running de-prescribing
programmes.
Now, after 20 years
of relentless growth,
there is finally some real
grounds for hope.
Opioid prescribing has levelled
off nationally and since 2017,
in most places, it's actually
begun to fall.
But it's not all good news.
The Public Health England report
found that it's people living
in deprived areas
who are more
likely to get prescribed opioids.
And unfortunately, it's these
deprived areas
which have also proved to be
relatively resistant to change.
Hastings is one of the most deprived
towns in the south of England,
so de-prescribing
has been far from easy.
People here tend to have poorer
health and less money to invest
in their wellbeing.
And the grim fact is,
people in more deprived areas tend
to suffer
from more chronic pain.
I can't even get out of the house
unless I really have to, like...
thingy ahead, plan ahead.
Until ten years ago, Malcolm lived
an active, sporty life.
But then he started suffering severe
pain
caused by complications
from an old appendix operation.
The pain goes into my groin,
into my hip and down my right leg.
I would rather be dead than in the
pain that I'm in now.
I split up with my wife.
We sold the house.
I left my job.
It just...
It's a horror.
It's a horror.
If it isn't the injury
that gets you,
it's the mentalness.
By his own admission,
Malcolm is depressed.
He can hardly get out of the
house.
He can't work.
He is caught up in a vicious cycle.
People like him, unable to work,
on low incomes
and in poor mental health,
are much more likely to become
high-dose, long-term opioid users.
Malcolm was on 180 milligrams
of morphine every day
for seven years.
It made your day better.
You was happier with certain things
that you were able to do.
You was happier with...
just everything.
But it was a dangerously high dose.
So the doctors in Hastings
persuaded him
to taper right down to 30
milligrams.
They implanted instead a device
in his spine, a Tens machine,
to help block the pain signals
going to his brain.
It helps me. It helps me so much
with standing up and walking.
It doesn't stop the pain.
It just sort of helps you
deal with the pain.
But even with the Tens machine,
Malcolm finds life without high-dose
morphine almost unbearable.
I've found that I'm suffering more
since reducing the opiates,
so, um...
I would like to increase
my opiates again.
But, um...
The doctor won't do it.
Coming off opioids would be easier
if there were effective
alternatives.
But despite the best efforts
of the pharmaceutical industry,
there's currently no drugs
that can effectively handle
all chronic pain.
There is, however, hope for Malcolm
and thousands like him
thanks to pioneering research
being done in places like Oxford.
When Professor Irene Tracey
isn't burning volunteers
with chilli paste,
she's busy inflicting other kinds
of pain on them
while looking
at their brains in an FMRI scanner,
and one of Irene's experiments
showed that what we feel
affects how much pain we feel.
This is the overview to enable us
to localise more...
Irene's team wanted to see
if changing a volunteer's mood
and making them sad
would change the actual level of
pain they were experiencing.
So she made them listen
to melancholic music
and read depressing phrases.
And the changes they found
were extraordinary.
So if you see here
the orange and yellow,
which is the brain
reacting and being active.
The blue is being suppressed.
You can see a marked increase
in activity when you're sad.
They look very, very different.
Really different.
So if you see here,
this is the same burn. OK.
And that, if I'm honest with you,
I'd have to probably burn them
several degrees more
to drive the brain up that much.
And that's just kind of from
not being really depressed,
just listening to sad music.
Exactly. It proved something
that, without imaging,
is difficult to prove,
that when somebody is sad
or depressed or anxious
and they describe their pain
as more painful,
it's easy to jump
to the conclusion
that they're just exaggerating.
It's the way they describe it.
What you're able to do with,
say, these techniques
is prove that it's physiological.
If you're sad,
the way your brain then processes
those signals is different.
Could that explain why, you know,
you see much higher prescription
rates
for opioids and opiates
in deprived areas?
And presumably there are higher
rates of depression in those areas
and therefore,
that could be driving demand.
Yeah, there's no studies
to prove that.
But it's a sensible hypothesis.
You know, it's always
been a challenge to understand.
Does one cause the other? Yeah.
Do you become depressed
because you're in chronic pain
or is there something underlying
that tips you into one
or the other, or is it just really
actually quite overlapping
physiology and mechanisms?
Dr Tracey's research offers fresh
hope for chronic pain sufferers.
If she's right, then focusing
on ways to improve people's mood
may be more effective
than giving them increasing
doses of painkillers.
This has certainly worked for Karen,
who I met in Hastings at the start
of my journey.
She is now on nothing stronger
than paracetamol.
This is life after opiates.
Before, she wouldn't have even been
out here.
She would have been lying upstairs
on her bed.
When they finally started bringing
her off these tablets,
she... came back to normal.
I had my mum, I could talk to
her again.
We have family times together.
It has affected us.
It's affected all of us right
down to the grandkids,
because they always want to know
where their grandma is.
But, yeah, now it's so much better.
I'm so glad that she's not
on 'em no more.
With help from her family,
Karen has managed to come off
the opioids completely,
using a surprisingly low-tech
intervention...
...group therapy sessions.
Joining different groups
that have different ideas
on how to live with pain
can make a huge difference to where
you go with your pain medication.
I think we've got one more to come,
probably.
The group is run by addiction worker
Rob Ralph to provide pain sufferers
with an alternative to opioids.
This is Michael, everybody.
Hello! Hi, there.
You've managed a massive dose
reduction
from a really dangerous dose of
opiates down to a much safer dose.
I'd rather not take them.
But because we had such a laugh...
Karen has now been off the opioids
for a year,
but she still attends the weekly
group.
And after being recruited by Rob,
Malcolm is also finding
solace at the meetings. I know.
So I'm looking for answers.
I'm looking for anything
that will help me.
I'm going to see you,
going to see the doctors.
They're all things that
could possibly help me.
I go through phases of pain
I can't bear.
And to be in pain like you are,
I know,
cos I've seen it in your face,
I've got to say,
that's a tough one.
I've got a good group of people
that I go to the pain group with.
We share our stories
and comfort each other, really.
And that helps a whole lot.
It's the one thing I do
every week.
I end up being knocked out for five
hours when I come home,
but it's worth doing, you know?
I don't think you ever missed
an appointment with me
or a group at the surgery.
You've never missed a group here.
No, I was late for one.
Well, we'll let you off that.
Rob's programme has been
a great success.
Half the 235 people he's worked
with
have either stopped or significantly
reduced their opioid use.
Imagine if more schemes like this
were rolled out nationwide.
But the sad truth is,
running successful courses like
Rob's
is harder and more expensive
than prescribing opioids
to people like Malcolm.
On this journey,
I've come to realise the true nature
of our opioid crisis,
that too many have been prescribed
opioids
that are too strong for too long,
even though they rarely work
for chronic pain.
I have been shocked
by just how easy it is
to get
opioids over the counter or online.
I do think we need to do
more to tackle the link
between deprivation, mental illness
and opioid prescribing,
and we do desperately need
alternatives to opioids
when it comes
to treating chronic pain.
I think we owe it to the millions
of people
who have got hooked on opioids
through no fault of their own
and who are now
desperately trying to come off.
of a drug crisis.
Wow.
Each year, more than five million
of us are prescribed opioids.
Painkillers which can be as
powerful as class A drugs.
You know that it is related
to morphine and heroin?
No.
In America, a prescription opioid
epidemic accounts for more deaths
than gun crime.
Now, a landmark report suggests
we may also have a problem.
How many of these tablets
were you consuming?
Erm, between 50 and 70...
Wow.
...a day.
I ended up overdosing.
I'm Dr Michael Mosley.
I want to understand just how
worried we should be,
because millions of us get stuck
on these painkillers long term.
The tablets just destroyed
her, really.
When a doctor prescribes
them, you take them -
you take whatever,
whatever you can take.
I want to find out how easy it is
to get hold of these potent drugs.
Pain relief prescriptions,
free UK express delivery.
That's for me.
And discover their potential risks.
We're really heading towards a very
dangerous place
and we need to do something
about it now.
I also want to explore the biology
of pain...
I can feel it beginning to burn now.
...to find out why opioids work
for some...
...but not for others.
They didn't sort the pain out.
What they actually did was turn my
beautiful, lovely,
active wife into a zombie.
I think this is a major public
health issue up there
with heart disease and cancer.
I want to find out what's gone wrong
and whether science can help us
tackle Britain's opioid crisis.
I'm in Hastings, a town that's
on the front line
of Britain's opioid problem.
You don't have to look far to find
evidence that they are now part
of our everyday lives.
Thanks.
This contains codeine, which is
a powerful and effective painkiller.
It is also an opioid which makes
it part of the same family
as morphine and heroin.
And that means it can also
cause addiction.
Now, this stuff absolutely pales
in comparison
to what you can get from your GP.
Your GP can quite legally prescribe
you something which
is 300 times more powerful
than this.
Here in the Hastings area,
around one in seven adults
were prescribed an opioid last year.
But do they know
what they're taking?
So any of you on painkillers? I am.
What are you on? Dihydrocodeine.
You know that it is an opioid,
related to heroin and morphine? No.
Did you know that they are related
to heroin and morphine?
Not really, no.
Would that put you off taking them?
Of course it would, yeah.
What are you on? Oxycodone.
You know that it is an opioid,
related... Yes, I do.
...to morphine and heroin? Yes, I do.
OK, and does that put you off,
at all? No, not at all.
Doesn't turn me off, I still take
my tablets.
It doesn't really, I don't touch
drugs anyway.
They're a life-saver for me,
they get me about.
And do they work?
Erm, they do, but I didn't like
the feeling that I had.
What was that?
I just felt a bit, well, my partner
call them my happy pills,
because I felt a bit spaced out.
So, plenty of familiarity
with opioids in Hastings.
But what of the national picture?
Come on, I'm taking a pound
to clear!
I've invited my new friends
to my stall in the town market
to demonstrate the scale
of our opioid consumption.
OK, ta-da.
Whoo-hoo!
Right, so, imagine this
is the amount of opioids
the good old British public
was consuming 20 years ago.
How much do you think
they're consuming now?
More. More, a lot more?
OK, how much more do we reckon?
I reckon about here. OK.
I think about here.
About here?
I reckon it'll be...
I'm asking people to guess how much
the total amount
of prescription opioids
has increased.
Shout when you think I'm getting
close to it.
Whoa! Lots of lovely opioids
going in, yeah.
More?
A bit more, keep going.
As the years have gone by,
the population's been getting older.
But we certainly haven't been
getting this much sicker.
Keep going, we're going, going,
going, going, going, going, whoa!
Hurrah, that was 2017.
Wow!
So that is a good doubling
in the amount of opioids
that people were consuming
20 years ago.
So that is pretty terrifying,
isn't it?
That is terrifying, yes.
There's no doubt that opioids
have a vital role to play
in cancer pain, end-of-life care,
or to relieve pain after
an operation.
But that doesn't begin to explain
the huge surge in prescribing
we've seen in recent years.
I do think it's important to point
out that opioids in the right
patients can be absolutely
life-changing.
However, a major new report
by Public Health England
has revealed that 5.6 million adults
in England and Wales
are currently on
prescription opioids.
That is an astonishing one
in eight of us.
So what are opioids?
Originally, they came from the sap
of the poppy plant,
which has been used
for thousands of years,
both recreationally
and to treat pain.
It gave the world heroin.
They act on the opioid receptors
in the brain,
blocking pain signals from the rest
of the body.
In fact, they're probably
the greatest tool doctors have
for numbing acute pain,
like a broken bone,
or an infected tooth.
They're often promoted as a safe
and effective way
to treat all manner of pain.
But unfortunately, many
patients are discovering
that this simply isn't true.
Nice cup of coffee.
Thank you.
I was weighing these books up.
And as I turned, sort of, like,
bent slightly sideways to check
the reading, something in my back
just went pop!
It was actually heard throughout
the office.
It was.
My immediate boss was like,
"What the hell was that?"
In 2014, Karen popped a disc
in the middle of her spine.
Almost like having a having
a red-hot poker
put between your vertebrae.
Painful, very painful.
Research suggests there could be
as many as 28 million Brits
like Karen living in chronic pain.
Pain, which is constant or recurring
and has been there for more
than 12 weeks.
Karen's doctor's solution? Opioids.
We got on these opiates,
which initially, I was very
excited about
because I thought, "Yes, she's going
to be pain free."
Sadly, it didn't work out like that.
You got this false sense of illusion
that, "Well, actually,
"they must be doing something,
even though I'm still in pain."
What, if I stopped them, my God,
the pain's going to be horrendous.
Over the course of five years,
Karen was put on increasingly
powerful opioids, starting on
Tramadol and ending up on morphine.
But they didn't sort the pain out.
What they actually did was turn
my beautiful, lovely,
active wife into a zombie.
The curtains were always shut.
The bed was always unmade,
because I was always
in it, sleeping.
It was heartbreaking because
the girls used to say,
"Where's our mum?
"She's not... she's not here any
more."
Yeah, I felt like a drug addict.
Every day was the same.
And it was just sleep, wake, eat...
...toss and turn, get up.
Sleep, eat.
I felt like there was no hope.
You want it to help, do you know
what I mean?
So you kind of...
...tell yourself it's working.
And it's only people around you say,
"Nothing's changed, Karen,
"if anything, now you're mindless."
Long-term opioid use put people
like Karen at risk of constipation,
memory loss, addiction, even
accidental death by overdose.
And perhaps the most startling
finding of the Public Health England
report is that over half a million
people have been on opioids
continuously for more than
three years.
Doctors have over 40 different
opioid painkillers
at their disposal.
Most can be picked up from one
of Britain's 11,000 pharmacies,
like this one in south London.
Akash, here?
Just round there? Lovely, thank you.
Hi there.
Hi, Akash, Michael Mosley, hello.
Nice to meet you.
Akash Patel is a pharmacist who's
agreed to show me
just how powerful opioids can get.
He says all of them are safe
if used correctly,
but dangerous if misused.
That's the weakest, which is
bog-standard co-codamol
that you can buy over the counter.
OK.
The codeine in co-codamol is mixed
with paracetamol.
It can be bought from a pharmacy
without a prescription.
Even at this strength, codeine
can be addictive.
But just how powerful do
opioids get?
Akash has offered to demonstrate,
using pills to show different
opioids' relative strengths.
OK, so that represents one pill.
Yeah.
Yeah, OK, what's next?
Moving on to some codeine, 30
milligrams,
that you can only get on
a prescription. OK.
So this is prescription only? Yeah.
And this is the equivalent of having
four tablets, is that right?
Yeah.
So these pure codeine pills
are far more powerful
than the codeine in co-codamol.
At this strength, you might
experience withdrawal symptoms
if you came off it suddenly
after long-term use.
From here, the opioid drugs doctors
can prescribe
get stronger and stronger.
After this, it's basically
into the cupboard.
Into the cupboard, right, OK.
And then, there you go.
Ooh.
Some morphine. Yeah.
You've got 15 milligrams
of morphine tablets there.
And that's equivalent
to 13 Co-codamols.
Right.
Morphine, the drug Karen was on
for her severe pain,
is a close relation to heroin.
It is highly addictive.
And then you can go up to some
oxycodone. Right?
Which is equivalent
to 75 codeine tablets.
OK.
Oxycodone is one of the most
widely-abused prescription opioids.
In the US, it's been implicated
in thousands of deaths.
I also have some diamorphine. Right.
Which is more commonly
known as heroin.
Heroin? Blimey, no wonder it's
locked away. Yeah.
Heroin, which is around the same
strength as oxycodone,
is also prescribed for pain,
often the end of life care.
But surprisingly, there are opioids
that are even stronger than heroin.
The next one, I don't think we
should take out
of where we got it,
which is the fentanyl.
Which is equivalent
to 338 co-codamol.
Wow.
That, I can see the difference.
I mean, when you see that, then
suddenly it makes sense, doesn't it?
This is a massively greater dose,
in its kind of morphine-like
qualities than something like that.
All of it, one little patch?
One little patch.
Fentanyl is so powerful, it's
usually given to patients
via a slow-release skin patch.
What would happen if I slapped
one of these on, would it kill me?
Probably wouldn't kill you,
but you wouldn't be very well.
You'd probably be in hospital
for a few days.
It is a bewildering selection
and all of these drugs come
with wide-ranging side effects.
Given what we know about
the risks and dangers,
why are doctors so happy
to prescribe them?
Salford has significantly
higher prescribing rates
than the national average.
I'm here to meet one of its
GPs, Dr Nicholas Browne.
Michael? Yeah. Hello, hi.
I've heard one reason opioid
use has soared
is because doctors were encouraged
by established guidelines
to prescribe ever-higher doses
to those in pain.
It's something we commonly
see in most surgeries,
someone experiencing an acute level
of pain, or ongoing chronic pain.
The, you know, the story
we've told, we've almost sold
that we have the ability
to conquer pain.
You are the magicians.
We are, and I think we are
suffering the consequences
of that optimism.
In the 1980s,
The World Health Organisation
came up with something they called
the pain ladder.
If a low dose of painkillers
didn't work, then go up a step,
give something stronger.
The kind of mantra the WHO pain
ladder was find the right drug.
Find the right dose,
and find the right timing.
To find that magic dose
that managed to keep you pain-free.
That's what we would have
been saying,
"We can get you pain-free."
And we would have encouraged you
to take regular doses.
If you came back and said, "Listen,
almost there, but not quite,
"I'm still struggling certain
times of the day, or stopping me
"doing certain things."
Then we would want to probably
increase that further.
We would reassure you that, "Listen,
the side effects are minimal
"when you take it for chronic pain."
There are certainly things
we can do about it.
And what we are aiming for
is pain-free.
So, basically, more and more
medication
and stepping onto opiates
and then more and more opiates?
We would find what dose
was right for you,
and if that required us to go up,
that is what would be necessary.
Opioids are now so common, it's easy
to forget how powerful they are.
Particularly when mixed with drink.
People who have been on it for many
years become accustomed to it.
Everyone feels very confident. And, "Well,
you've been on it. What harm can it do?"
And people are found dead.
Why is this? Alcohol.
You know, you might go to a party, have slightly
more to drink than you would normally do,
and you're taking high-dose opiates.
And then we're adding in more medication
that interacts with this medication.
20 years ago, there were 47
drug-poisoning deaths in England and Wales
involving just two drugs -
codeine or tramadol.
Last year, it was nearly 400.
Even if that's far from US levels,
it is still a worrying trend.
So in America, we've seen
an absolute crisis
with, you know,
huge numbers of deaths.
Can you imagine the same thing
happening in the UK?
Yes, I can. And it is something
that's very much on my mind
and very much of a concern
and a worry
that we're already seeing signs
that that's happening.
And I can see it very easily
slipping into that.
Over the not-too-distant future, the
medium term, the next five years,
that we will start
seeing a progressively-increasing
accidental overdose rate.
It was quite chilling, the fact
that he does think it is possible
that things could get as bad here
as they have got in the States.
And it was also quite disturbing when
you realised how we got into the situation.
It was all the best of intentions.
It would be easy to blame
our doctors for overprescribing,
but, of course, they're only doing
what they've been trained to do.
Hi, there.
When I was at medical school
in the 1980s,
we were taught that opioids can be
horribly addictive,
except when patients
are in severe pain.
Then it's OK to increase the dose
because they won't get hooked.
We now know that advice
was hopelessly misguided.
I'm in Oxford to find out
what went wrong.
Hi, there. Hello.
This is Dr Jane Quinlan,
a consultant in pain management.
So, how do you think we got into the
situation where so many people are on opiates?
Yeah, it all goes back to the 1980s,
where two things happened.
One of them was that evidence
came from palliative care,
looking at patients at end of life
and who had pain,
to say that actually, giving
patients like that high-dose morphine,
high-dose opioids was safe.
People didn't get addicted.
And you could just increase the dose
as much as you needed to
to make sure someone was
comfortable.
Which is really important
when someone is dying of cancer. Mm.
Equally, at the same time, there was
a letter that was published
in the New England
Journal of Medicine,
that was a five-sentence letter
looking at about 11,000 patients
who were in hospital
and given opioids
just for a short time.
And this letter said,
"None of our patients got addicted".
The big headline, Addiction Is Rare
In Patients Treated With Narcotics -
we now call these opioids. Yes.
And so, this headline message
has then been repeated
over 600 times.
But this 100-word letter
isn't peer-reviewed research,
it's simply an observation.
And yet it was referenced
time and time and time again
in science journals.
And some took the letter's
tentative conclusions much too far.
This suited big pharmaceutical
companies very well indeed.
And they not only helped fund
much pain research,
but began aggressively promoting
opioid use.
Some patients may be afraid
of taking opioids
because they're perceived as
too strong, or addictive.
But that is far from actual fact.
Four out of five heroin users
in the USA
started out by misusing
prescription opioids,
an epidemic which has now claimed
more than 200,000 American lives.
In 2017, the co-author
of the original letter,
Dr Hershel Jick, wrote -
Things aren't nearly as bad
in Britain,
but I suspect the way
this research was deployed
helped drive the overprescribing
we've seen here.
Oxycodone, also known by
the brand name OxyContin,
was implicated in 79 deaths
in England in 2018.
NHS doctors are closely regulated,
so it's unlikely opioids
will ever be dispensed
as freely here as in America.
But Dr Quinlan is still concerned
about the high levels
some people are on.
Some evidence has just come out
to say if you're on more than
100 milligrams of morphine
equivalent per day,
your risk of death
is nine times higher
than someone on 20 milligrams
or less.
And that's huge.
That is absolutely vast, isn't it?
Aren't patients aware of the risks
they're running?
No, I don't think they've got
any idea at all.
And again, they've been assured
all these years
when they've been prescribed
these drugs
that these are safe drugs to take.
So often, having that conversation
at our first consultation
is actually quite difficult for them
because they were unaware of
the risks they're running
by being on these high doses,
that they've been taking
in good faith,
and they assumed were
appropriate doses.
Because they were obviously
prescribed them in the first place.
Exactly. Exactly.
If you're one of the many people
on high-strength opioids,
please don't just stop taking them.
Your chances of dying
from an accidental overdose
remain incredibly small.
Nevertheless, as the Public Health
England report reveals,
too many people are on opioids
that are too strong for too long.
And that increases risk.
Which begs the question - why aren't
we urgently getting people off them?
Unfortunately, it's not as simple
as that.
Do you find the swaying helps? Yeah.
OK. Why? I don't know.
I think because if you...
I am beginning to sway with you,
I have to say!
Yeah. Yeah. I don't... I don't know.
It just does? Yeah. Yeah.
This is Brenda, at home in Salford
with her husband, Roger.
Brenda has been taking high-strength
morphine for 15 years to cope
with an injury which was sustained
while working at her local hospital.
We were transferring
a young stroke patient
and I sort of twisted
and went down, but...
And was it very painful?
Excruciating. Yeah.
Out of 10? Er... 20.
Yeah.
It was horrendous.
Brenda has been left
in constant pain.
In fact, her days seem
quite unbearable.
I wouldn't wish it
on my worst enemy.
It's horrendous.
You've given birth to two kids.
How does it compare to that?
Um... giving birth, easy-peasy.
Brenda's story is remarkably similar
to Karen's, the first patient I met.
But while Karen's opioids
turned her into a zombie,
Brenda swears by them.
And what's the morphine
actually done?
It's just magic.
It is for me, anyway.
It really is.
Do you think you could get by
without it? No.
And what would you say
if someone tried to take it away?
Why?
And what are you giving me
that's as good as that?
I couldn't imagine being without it.
There'd have to be a backup to it.
Oh, it would be horrendous,
I know it would.
Does it affect your brain at all?
Does it fog you up at all? No.
Have you had any obvious
side-effects from it? None at all.
You're taking it without any significant
side-effects, as far as you can see?
Yeah, I think so. And it's
bringing the pain down? Yeah.
So, for you, it's working
really well? Yeah, definitely.
That's... There we go. Are you up?
Are you up?
Oof! Are you going to do
a bit more swaying?
Yeah, I'm going in there, swaying.
Thank you very much.
Thank you very much. Thank you.
You're welcome. Mwah!
I can say I've kissed
a famous person!
I really feel for Brenda.
She's obviously in a bad state
and believes the thing that makes
her life tolerable is morphine.
But is she right?
There are hundreds of thousands
of people like Brenda
who are taking opioids,
but are still in pain.
So, how much are these drugs
actually helping?
I need to learn more about
the science of pain.
I'm back in Oxford to meet one of
the world's foremost pain experts,
Dr Irene Tracey.
To help me get to grips
with the subject,
I'm going to take part
in a little experiment.
I'm assured it won't be too painful.
OK.
What we're going to start with here
is some chilli-pepper cream
that we've had specially made up
by a pharmacy. OK.
And we're going to just put a little
area of your skin with it on. OK.
And we're going to let that cook
for about 30 minutes. OK.
This chilli is going to burn my skin
and trigger a complex network
of pain sensors in the body.
Rub that in, make sure
it's really soaking in for you.
Starting to feel... I can feel
it beginning to burn now. Yeah.
You've got these things...
Your fibres out there in your arm,
that are going to send the signals
in. They then hit your,
sort of, spinal cord.
It's at the back there.
Then they enter the brain
and the brain puts it together.
But again, the brain's got
a capacity to change
how those signals are processed.
It also can change and talk,
down to that point where
those signals are first coming into
your spinal cord... Right.
...and turn it up and turn it down.
The sensation I'm feeling now
is acute pain.
It's triggered by the nerve fibres
in my skin
that are being burnt by the chilli.
What is the key difference between
acute and chronic pain?
Chronic pain is just something
very different to acute.
The definition of chronic pain
is a pain that's still there
beyond normal tissue healing times,
so three to four months.
Historically, we thought
it was just a continuation,
it was just an ongoing symptom,
an ongoing acute pain.
Now we know that in that transition
from acute to chronic,
it's a whole new biology
has established itself.
There's been changes in your cells
and your genetics, your wiring.
It is a, sort of, disease
in its own right. Yeah.
And it's not just a continuation
of the acute pain symptom.
It is something different now.
This remarkable discovery,
that acute and chronic pain
are fundamentally different,
is being modelled right now
on my increasingly sore arm.
If I brush you... Yeah.
..that normal touch is now painful.
Yeah, indeed.
And it's not because that part
of the skin is injured,
it's because this injured bit
has sent signals in
for the past 30 minutes,
it's set off those amplifiers
we spoke about, the spinal cord
and the brain. Yeah.
So now, when those signals go in...
Sorry!
...they are being amplified,
literally like a volume button.
More goes into your brain,
it hurts more. Right.
That is a really important mechanism
in chronic pain. Yeah.
With my pain system now
in overdrive, I'm experiencing
burning where there's
no chilli cream.
And that's what happens
in chronic pain -
you feel it even when there's
no longer a physical injury.
I might have this off now.
Shall we have this off?
I think we'll have this off, yes.
OK, so I'll just peel that off.
Hopefully that won't hurt too much.
Not at all.
So, I get that in acute pain,
you have the pain and it has
a purpose... Yeah.
...to teach you to avoid stuff
and to protect yourself.
But why do you get these things
which switch on and stay on?
Yeah, it's...
Well, it doesn't have a purpose.
I think, again, we thought, chronic
pain, there was a purpose for it.
There just isn't. It's a system
gone wrong. Right.
There's no doubt that opioids
are one of the best tools
in our armoury for numbing
acute pain.
But this experiment raises
an important question -
if chronic and acute pain
are different conditions,
is the same treatment - opioids -
likely to be just as effective
in both?
It is a critical question,
because the majority of opioid
prescriptions handed out in Britain
are for chronic pain.
I'm heading to the Royal College
of Physicians in London
to meet Dr Cathy Stannard.
She's one of the world's leading
experts on pain medicine.
I want to find out just how useful
she thinks opioids are
at tackling chronic pain.
Chronic pain is very difficult
to treat.
Probably fewer than one in ten
people given opioids
for long-term pain will get
a useful...
...clinically useful result from
them.
Shockingly, that suggests
that in 90% of chronic pain cases,
opioids really aren't helping.
But as I've learned, if the opioids
aren't numbing the pain,
doctors have been trained
to give more.
So if I give you a drug for blood
pressure and your blood pressure
stays high, nobody would argue
that it's not working.
But if I give you a painkiller
and you come back and say,
"I'm still in pain." What do we do?
We double it.
And you come back and say, "I'm
still in pain." And we double it.
If you give it and it doesn't work,
stop it.
You know, that's what you would do
with any other drug.
But why don't we do that?
That was a pretty amazing statistic,
that less than one in ten people
who go on opioids
get any benefit from it.
And that does suggest that there
are an awful lot of people
out there on high-dose opioids
with horrible side effects
who are actually getting
no pain relief at all.
And it makes you wonder,
why are they on it?
Why ARE they on it?
Who is responsible for so many
being put on life-altering,
addictive, potentially
dangerous opioids,
especially when it seems
in the majority of cases,
they don't actually work?
Hi, there. Hello.
Helen Stokes-Lampard
is the country's most senior GP.
I believe GPs have always
tried to do their best
for their patients, and if patients
have come to see them in pain,
they've used whatever materials
they have at their disposal.
Years gone by, there weren't many
options, and opioids were high
on the list of what
we were encouraged to use.
If now, we are part of a system
where people are hooked on things,
we need to do all we can to help
de-prescribe for those patients.
But GPs, fundamentally,
are trying to do what's right.
But why are they put on it in the
first place, if they're useless?
Myriad reasons, because they started
with acute pain.
Anything that becomes long-term
started as a new problem
once upon a time.
So you start somewhere... And they
were stuck on them, presumably,
with not a great deal of evidence
that they were going to work,
because I've looked back through
the data, and there really
was never any great evidence
that they would work.
But there was clear guidance that
that's what we should use. Right.
The difficulty is, as a GP,
the patient sitting in front of you,
we often don't know which ones are
benefiting and which ones aren't,
until you wean them off
the medication.
But the reality is, there are
half a million people out there...
There are... who have been
identified as being prescribed
too much of this stuff for too long.
That's a lot of people.
There are a significant proportion
of those who would benefit
from being weaned down.
I totally agree.
But it's not just about weaning down
the medication, Michael,
we need to give these people
something to help them
with their pain. 100%. Because
to them, their pain is very real.
We weren't having this conversation
a couple of years ago.
We're now talking about this,
the public are talking about it.
I've had patients
come in to me and say,
"Dr Helen, I think I might
be addicted to my painkillers."
Wow. We didn't have that
a few years ago.
We can't change the past,
but we absolutely can work
on this for the future.
It's clear that the message about
opioids is starting to get through
to doctors and their patients.
But that's not the whole picture
because, of course,
you don't need to see a doctor
to get your hands on an opioid.
Which of these are you actually
the most worried about?
Surprisingly, this one,
the co-codamol.
The one that you can buy
over the counter.
It can cause addiction.
It's not restricted.
You're only allowed to buy
one box at a time - however,
what's stopping you from going
to multiple pharmacies and buying
multiple boxes throughout the day?
Co-codamol is just one
of the many opioid-based drugs
you can buy at a chemist.
And like prescription drugs,
we have no idea how many
are being sold nationally.
And Akash worries
these over-the-counter drugs
are being abused.
What sort of things are you supposed
to ask me before you're dispensing?
So we have a little way of
doing it, which is called WWHAM.
So you start off with,
who, what, how long, action taken,
and any medication.
OK, so that's WWHAM?
That's the basic...
So I should get WWHAM'd?
You should get WWHAM'd, yeah.
In every pharmacy I go to. Yeah, OK.
Thanks a lot.
It's been very enlightening.
Pharmacists WWHAM customers
to make sure the painkillers
they're selling won't be misused.
So how effective is WWHAM
in limiting
the number of pills I can get?
Hello, yes, can I get some
Solpadeine Max, please?
There wasn't any kind of
conversation about why I wanted it
or what I was going to do
with it or anything like that.
So, failed WWHAM test, I'm afraid.
Do you have any Nurofen Plus
or Solpadeine Max, please?
She was much more thorough,
I have to say.
I got my 12.9 milligrams,
again, of codeine.
She did look deeply suspicious,
I have to say.
She asked me what it's for.
She asked me if I'd tried
other things.
Basically, she passed.
That was, kind of, the shortest
conversation of them all so far.
Essentially, "Yeah, sure."
The only conversation
I had about it was whether it had
caffeine in it or not.
Well...
So that guy gave me
absolutely no conversation,
he said nothing at all.
So I just asked for another one,
since I was in there.
And if I had asked for three,
he might have given it to me,
I don't know.
No warnings, no why do you want it,
nothing.
And he really, really failed
the WWHAM test, by a long way.
One, two, three, four, five,
six, seven, eight
boxes of the stuff.
So, yeah, I've been going 40 minutes
and I've got eight boxes
of the stuff,
at 30 tablets a time,
is around 240 tablets,
I have scored.
And to be honest, really,
only two people asked me
all the questions
you're supposed to ask.
So I guess it just shows you
how easy it is
to get these over-the-counter
drugs, if you really want to.
In a few minutes,
I bought enough codeine,
at least in theory,
to give me an opioid hit
stronger than the incredibly
powerful fentanyl patch
Akash showed me earlier.
The thing is, pills like this
not only contain codeine,
but other painkillers like ibuprofen
and paracetamol,
which make them even
more dangerous in large quantities.
And of course, some people
buy codeine for reasons
that have nothing
to do with pain relief.
People who will use these medicines
quite reasonably
to self-manage their pain
will do what they can,
go to the chemist
and buy a painkiller.
Now, where the problem arises is,
you might quite like the sensation
that these medicines give you,
so that is what the driver is
for continuing to take
these drugs
after your acute pain
has settled. Right.
Because it makes it easier
to get through the day.
"It makes it easier to get
through the day".
That seems far removed
from managing pain.
It's a big, unrecognised problem
because people just do not seek
advice,
I think largely
because of the stigma.
Do you have any idea of the scale?
We don't.
I mean, that's the problem.
But what I would say is that
it's interesting that I have seen
so few people
who are addicted to these medicines.
And when I have seen them,
they are all very high-achieving
people in busy jobs,
busy lives, coping well,
coping well
despite their addictions,
so a masked addiction,
high-functioning, if you like.
With the pharmacies, it
would be a case of finding out
what time they opened.
Could I get there before
I started my shift at work?
Could I get there after?
Could I get there in my lunch break?
And it was all very calculated,
especially with the chemists
that were surrounding at work.
This is Vicky.
For years, she held down a steady
office job
while secretly relying
on over-the-counter codeine
to get her through the day.
Initially, it was pain relief.
I came out of hospital
with kidney stones,
so they gave me codeine
for pain relief.
The more I took, the better I felt.
It gives you like a warm,
fuzzy feeling
and a feeling that you can conquer
the world, if you like.
So that's how I found that
the more I took, the better I felt.
What does it do? What does it
feel like?
It feels like...
You know when you're really,
really thirsty, for example,
and you have that refreshing drink
and you just go,
"Oh, wow, I really needed that".
That's how it feels.
If I had a job interview, I'd take
them because if I was nervous,
they would make me feel a lot better
and more confident in myself
and the warm buzz that you get,
it's like a quilt, almost,
around you.
It's nice. It's a nice feeling.
I'm not going to lie.
I can't sit here and lie and say
it's not.
It is, it's a nice feeling.
At your peak, how many of these
tablets were you consuming?
Between 50 and 70.
Wow. A day.
50 tablets contain 25g of
paracetamol,
enough to put you in hospital.
I ended up overdosing in
November.
I did, you know, the treatment
where they literally just flush your
kidneys
and make sure everything's OK.
And I decided that it was now
time to go into detox,
which was the scariest
but most epic time ever.
People were in there for heroin,
crack, alcoholism,
loads of different stuff.
And you were there
for over-the-counter drugs.
I was there for over-the-counter
drugs, yeah.
And they were looking at me going,
"Why are you even here?"
Like, you know, why?
In the end, it was because codeine
is a part of the heroin family.
So it's an addiction.
It doesn't matter what addiction.
It's addiction.
And it was hard.
Vicky has been off codeine
for three months now,
but she'll always be battling
her addiction.
I'm pleased she's on the mend.
But I also wonder how many codeine
addicts are out there.
These days if you want opioids,
you don't have to go to the chemist
to get them.
You can now buy far stronger
prescription opioids on the web.
So how easy is it to buy
codeine online?
Well, I'm in a cafe, got my laptop
and I also have my own
favourite psychoactive drug.
That's caffeine.
And here we go.
Right. We're online.
There we go.
OK. That came up pretty fast.
Pain relief prescriptions,
free UK express delivery.
That's for me.
Discretion and confidentiality,
100% all guaranteed.
Of course, you can buy almost
anything on the internet.
And there's no shortage
of sites offering me codeine.
But I won't be advertising the name
of this particular vendor.
It's dispensed by registered
UK pharmacies, it says.
That looks good.
And then it says,
"Start consultation". OK.
"Are you registered with a GP
practice in the UK?" Yes.
"Do you give us consent to write
to your GP for approval?" No.
I don't want my GP to know.
No problem, it seems.
Instead, 12 hours later, they
approve my form themselves.
Right.
Final thing is, I've got to register
myself.
I think I might go with
a fake name, James Reid.
That sounds plausible.
They did do an ID check,
but mine didn't say James Reid.
Let's see if that bothers them.
It does not. That's marvellous. OK.
So finally, let's buy.
There we go.
And now, really, let's see
if it actually comes through.
Will they deliver?
And deliver they do.
So here we go, two packages in the
name of the fictional James Reid.
And I have to say, they have come
very promptly,
because I only ordered
them two days ago.
OK, so this is the one which comes
from a properly regulated British
company based here in the UK.
Here we go.
Codeine phosphate tablets.
That shouldn't have happened.
And I got really enthusiastic,
and I wanted to see whether I could
also order it from online services
which are not based in the UK.
And I decided to go for some
really high-dose codeine.
And yeah, here it is,
two packets of 20 tablets each.
That's 40 tablets of codeine.
Now, this stuff is really serious.
It is pure codeine,
and that means it is a class B drug.
And in the UK,
that means that simply possessing it
without a proper prescription
means that I could go to jail
for up to five years.
Time, I think, to go and talk
to the regulator
about how easy
it is to get hold of this stuff.
All Britain's chemists are regulated
by the General
Pharmaceutical Council.
So what do they make
of my online shopping?
I'm sitting here and I've got
codeine phosphate
and this is a class B drug,
isn't it, in terms of codeine?
It's not something
that people should be flogging over
the internet.
Absolutely not. As a controlled
drug,
there are important restrictions
in place
which are there to protect people.
It took me about 15 minutes
to buy the stuff, though.
I really shouldn't be allowed
to do that, should I? No.
It's important that there are
checks on identity...
They were pretty pathetic at that!
...that the patient or consumer
is asked for consent
so that the GP can be...
Indeed, they just said, "Do
you want us to contact your GP?
I said no. And they said, "Fine".
Ethically... That's not fine,
of course.
That is not acceptable practice,
which is why we're taking
action to tackle it.
There's a physical pharmacy
behind that website
which is registered with us.
We have a team of inspectors
who are pharmacy professionals
who will go and visit that building.
It's serious stuff.
And you're rightly highlighting
an important issue,
which we are working
on with all the effort
that you would expect of us.
And what of the foreign opioids
that I bought just as easily?
If people are using a pharmacy
service
that's not registered with us in
this country,
then they are really
in a very dangerous situation.
We would absolutely discourage
anybody from accessing medicines
through an overseas website.
You never know
what you're going to get.
Well, you don't know in terms
of counterfeit, in terms of safety.
You don't know
what the product is.
The danger is, if people are
desperate, they'll do it anyway.
It is dangerous.
That is for sure.
The regulator did indeed
take action a week later.
The UK-registered pharmacy I'd used
was banned from selling opioids.
The overwhelming majority
of other UK licensed sites I tried
refused to sell me them.
I suppose at this stage
of my journey, one thing is clear.
We have been well and truly warned
of our national opioid predicament.
We may not know the scale
of illicit purchasing from abroad
or of over-the-counter meds abuse,
but at least we recognise
there is a problem.
What's more, the Public Health
England report
identifies in meticulous detail the
risks of overprescribing.
But identifying the problems
doesn't solve them.
I'm back in Salford where,
in 2018,
one in six adults
were prescribed an opioid.
So how do you persuade patients
who've been stuck on opioids
for years to come off them?
Local GP Tom Hodson is wrestling
with this challenge.
Three years ago, he was signing
off repeat prescriptions
at his new practice when something
caught his attention.
There was a prescription for some
morphine
that I had a bit of a look at
and the dose seemed to be a little
bit higher than I would expect.
We didn't really know
if that was just a one-off
or there was lots of other patients
that had an issue like that.
So we worked with our pharmacist
to search the whole surgery,
go through all of our patients
and just find anyone that was taking
a dose
higher than we thought
was effective.
We were expecting maybe
two or three patients.
We ended up finding
that it was about 30.
So it was a surprise
that the problem was as big
as it was at our surgery.
Dr Hodson called the patients
in for a chat.
So how did the conversation go?
How does it go? So I come in,
I've been on massive doses.
I've still got terrible back pain.
My back pain is terrible.
And then you go...?
We've got to take your painkillers
away, yes.
So it was about saying...
we obviously needed
longer appointments
because you can't drop a bombshell
like that in ten minutes
and let them leave. No.
Sometimes you needed more
than two appointments.
Sometimes you'd start
this conversation,
patients would be upset.
They'd go away, have a think
and come back.
But most of the patients,
when you show them the evidence
and you show them the risks
and you say, you know,
"This probably isn't doing very much
for you,"
were willing to give it a go.
Once we started the reduction
and some of the patients didn't see
any increase in their pain,
you know, they were
actually quite motivated to do it.
And by the end, the majority
of people that did this
by the end
were quite positive about it.
People on high-strength opioids
can develop a physical dependency
on them.
Coming off quickly results
in an unpleasant withdrawal,
or cold turkey.
So Dr Hodson spends months slowly
reducing each patient's dose,
managing their withdrawal.
This is basically a record of
the prescribing at the surgery.
So this is all the prescriptions
for opioids
at a dose over 120 milligrams.
We started the work about here.
OK.
So that's an impressive decline.
Yes.
Once patients were sort of with us
and wanted to reduce it,
you can see this is the steep curve
once they started to want to reduce
them.
90% of Dr Hodson's high-dose
patients
have now either reduced their opioid
use
or come off them entirely.
And Dr Hodson isn't alone.
Across the country, including back
here in Hastings,
GPs are running de-prescribing
programmes.
Now, after 20 years
of relentless growth,
there is finally some real
grounds for hope.
Opioid prescribing has levelled
off nationally and since 2017,
in most places, it's actually
begun to fall.
But it's not all good news.
The Public Health England report
found that it's people living
in deprived areas
who are more
likely to get prescribed opioids.
And unfortunately, it's these
deprived areas
which have also proved to be
relatively resistant to change.
Hastings is one of the most deprived
towns in the south of England,
so de-prescribing
has been far from easy.
People here tend to have poorer
health and less money to invest
in their wellbeing.
And the grim fact is,
people in more deprived areas tend
to suffer
from more chronic pain.
I can't even get out of the house
unless I really have to, like...
thingy ahead, plan ahead.
Until ten years ago, Malcolm lived
an active, sporty life.
But then he started suffering severe
pain
caused by complications
from an old appendix operation.
The pain goes into my groin,
into my hip and down my right leg.
I would rather be dead than in the
pain that I'm in now.
I split up with my wife.
We sold the house.
I left my job.
It just...
It's a horror.
It's a horror.
If it isn't the injury
that gets you,
it's the mentalness.
By his own admission,
Malcolm is depressed.
He can hardly get out of the
house.
He can't work.
He is caught up in a vicious cycle.
People like him, unable to work,
on low incomes
and in poor mental health,
are much more likely to become
high-dose, long-term opioid users.
Malcolm was on 180 milligrams
of morphine every day
for seven years.
It made your day better.
You was happier with certain things
that you were able to do.
You was happier with...
just everything.
But it was a dangerously high dose.
So the doctors in Hastings
persuaded him
to taper right down to 30
milligrams.
They implanted instead a device
in his spine, a Tens machine,
to help block the pain signals
going to his brain.
It helps me. It helps me so much
with standing up and walking.
It doesn't stop the pain.
It just sort of helps you
deal with the pain.
But even with the Tens machine,
Malcolm finds life without high-dose
morphine almost unbearable.
I've found that I'm suffering more
since reducing the opiates,
so, um...
I would like to increase
my opiates again.
But, um...
The doctor won't do it.
Coming off opioids would be easier
if there were effective
alternatives.
But despite the best efforts
of the pharmaceutical industry,
there's currently no drugs
that can effectively handle
all chronic pain.
There is, however, hope for Malcolm
and thousands like him
thanks to pioneering research
being done in places like Oxford.
When Professor Irene Tracey
isn't burning volunteers
with chilli paste,
she's busy inflicting other kinds
of pain on them
while looking
at their brains in an FMRI scanner,
and one of Irene's experiments
showed that what we feel
affects how much pain we feel.
This is the overview to enable us
to localise more...
Irene's team wanted to see
if changing a volunteer's mood
and making them sad
would change the actual level of
pain they were experiencing.
So she made them listen
to melancholic music
and read depressing phrases.
And the changes they found
were extraordinary.
So if you see here
the orange and yellow,
which is the brain
reacting and being active.
The blue is being suppressed.
You can see a marked increase
in activity when you're sad.
They look very, very different.
Really different.
So if you see here,
this is the same burn. OK.
And that, if I'm honest with you,
I'd have to probably burn them
several degrees more
to drive the brain up that much.
And that's just kind of from
not being really depressed,
just listening to sad music.
Exactly. It proved something
that, without imaging,
is difficult to prove,
that when somebody is sad
or depressed or anxious
and they describe their pain
as more painful,
it's easy to jump
to the conclusion
that they're just exaggerating.
It's the way they describe it.
What you're able to do with,
say, these techniques
is prove that it's physiological.
If you're sad,
the way your brain then processes
those signals is different.
Could that explain why, you know,
you see much higher prescription
rates
for opioids and opiates
in deprived areas?
And presumably there are higher
rates of depression in those areas
and therefore,
that could be driving demand.
Yeah, there's no studies
to prove that.
But it's a sensible hypothesis.
You know, it's always
been a challenge to understand.
Does one cause the other? Yeah.
Do you become depressed
because you're in chronic pain
or is there something underlying
that tips you into one
or the other, or is it just really
actually quite overlapping
physiology and mechanisms?
Dr Tracey's research offers fresh
hope for chronic pain sufferers.
If she's right, then focusing
on ways to improve people's mood
may be more effective
than giving them increasing
doses of painkillers.
This has certainly worked for Karen,
who I met in Hastings at the start
of my journey.
She is now on nothing stronger
than paracetamol.
This is life after opiates.
Before, she wouldn't have even been
out here.
She would have been lying upstairs
on her bed.
When they finally started bringing
her off these tablets,
she... came back to normal.
I had my mum, I could talk to
her again.
We have family times together.
It has affected us.
It's affected all of us right
down to the grandkids,
because they always want to know
where their grandma is.
But, yeah, now it's so much better.
I'm so glad that she's not
on 'em no more.
With help from her family,
Karen has managed to come off
the opioids completely,
using a surprisingly low-tech
intervention...
...group therapy sessions.
Joining different groups
that have different ideas
on how to live with pain
can make a huge difference to where
you go with your pain medication.
I think we've got one more to come,
probably.
The group is run by addiction worker
Rob Ralph to provide pain sufferers
with an alternative to opioids.
This is Michael, everybody.
Hello! Hi, there.
You've managed a massive dose
reduction
from a really dangerous dose of
opiates down to a much safer dose.
I'd rather not take them.
But because we had such a laugh...
Karen has now been off the opioids
for a year,
but she still attends the weekly
group.
And after being recruited by Rob,
Malcolm is also finding
solace at the meetings. I know.
So I'm looking for answers.
I'm looking for anything
that will help me.
I'm going to see you,
going to see the doctors.
They're all things that
could possibly help me.
I go through phases of pain
I can't bear.
And to be in pain like you are,
I know,
cos I've seen it in your face,
I've got to say,
that's a tough one.
I've got a good group of people
that I go to the pain group with.
We share our stories
and comfort each other, really.
And that helps a whole lot.
It's the one thing I do
every week.
I end up being knocked out for five
hours when I come home,
but it's worth doing, you know?
I don't think you ever missed
an appointment with me
or a group at the surgery.
You've never missed a group here.
No, I was late for one.
Well, we'll let you off that.
Rob's programme has been
a great success.
Half the 235 people he's worked
with
have either stopped or significantly
reduced their opioid use.
Imagine if more schemes like this
were rolled out nationwide.
But the sad truth is,
running successful courses like
Rob's
is harder and more expensive
than prescribing opioids
to people like Malcolm.
On this journey,
I've come to realise the true nature
of our opioid crisis,
that too many have been prescribed
opioids
that are too strong for too long,
even though they rarely work
for chronic pain.
I have been shocked
by just how easy it is
to get
opioids over the counter or online.
I do think we need to do
more to tackle the link
between deprivation, mental illness
and opioid prescribing,
and we do desperately need
alternatives to opioids
when it comes
to treating chronic pain.
I think we owe it to the millions
of people
who have got hooked on opioids
through no fault of their own
and who are now
desperately trying to come off.