Nine million people live with chronic pain in Spain. 62% of them, five and a half million, have never been referred to the specific services that exist in public hospitals, according to the Study on Pain Units in Spain: updating their resources and activities, published in 2019. There are 183 pain units distributed throughout the territory, but only one in three has a psychologist on the team. This explains in an important part, according to the experts consulted, why the abuse of opiate analgesics to relieve pain is becoming a problem in Spain. The number of doses consumed per 1,000 inhabitants per day (DHD) has grown by 53% between 2013 and 2020, going from 3.57 to 5.48. This growing trend in consumption has pushed the Ministry of Health to take action. It has just approved, together with the autonomous communities, a plan to “optimize” the use of these drugs due to their addictive risks.
“We are 10 million patients in pain. Let us make cannabis an option”
“The pain units are totally overcrowded. There are not enough personnel, nor resources; horrible waiting lists. If they refer you in five years, what do you do in the meantime?” Asks Ana Isabel Henche, coordinator of the Addictions Unit of the Toledo Hospital and part of the team that has developed the national plan. Patients with strong physical dependence on opioid analgesics (fentanyl, tramadol …) come to his office; in the worst cases, addiction, although “it is not always easy to differentiate one stage from the other”, explains the expert.
Henche remembers his first patient in great detail. It was October 2013. “She took a fentanyl tablet every hour. Once we managed to detoxify her, she confessed to me that she asked that it hurt to consume it.” Behind the physical pain, there was a “major emotional lash.” Is that the stepping stone that separates dependence from addiction? “Dependence is expected and accepted. Although there is no addiction, there may be withdrawal syndrome. What is not expected is that control over its use is lost,” he clarifies.
Opioids are effective drugs for the treatment of pain. There is medical consensus on its use for cancer patients, but its prescription raises more debate in the case of people with chronic pain and long life expectancy. Some are ultra-fast, such as a type of fentanyl that takes effect in just a few minutes and whose use should be limited to “breakthrough” pain.
Fentanyl is the compound that generates the most controversy, since it accounts for 50% of consumption. Tramadol is also widely used, and tapentadol, a next-generation morphine-like molecule, has burst onto the market in high demand.
Alicia Alonso Cardoña, anesthesiologist at the University Hospital of León, defends that, “used well”, opiates are “beneficial and useful”. “I do not think there is abuse. Chronic pain is diagnosed more, more medications are prescribed, but we have more knowledge about the effects that they can produce in the long term and we control those treatments better,” says this doctor in conversation with elDiario.es. She has been working in the pain unit of the Leon center for 15 years.
What then is meant by misuse? “Consumption for longer than desired or in higher doses. Also, that it is not used for the prescribed purposes, such as relieving anxiety. Symptoms can be confused because chronic pain causes frustration and you have to do psychological work,” he says. Alonso. The problem with this type of drug, the two doctors agree, is that the body becomes tolerant to the doses and each time higher amounts are needed for the effect to be maintained. The prescription has no ceiling.
Time and psychological support, the keys
Both also insist on the importance of psychological support and of spending time with the patient. “In the unit we explain to the patient that the treatment is for a time, we explain the risks and thus it is easier for them to be able to reduce the intake supervised by us. We also have a psychiatrist who helps us. The cases have not been been many “, describes the anesthesiologist.
“I am giving a course to Primary Care doctors. They tell us that patients arrive who tell them: it hurts more every day, but they don’t have time if they have an agenda of 60 people every day to explain what the drug is, what problems it has, why can’t the dose be increased, “Henche points out.
The Health plan has been well received by medical societies and professionals, who have been warning since at least 2017 that a framework of action was necessary to control consumption. “I have been giving the warning sign since the first patient came to me in 2013. It is never too late if we can prevent patients from escaping these situations,” Henche values.
The two doctors with whom this media has contacted regret, however, that the document does not offer “alternatives” to the use of opiates. “Administrations must make an effort to promote alternative treatments: rehabilitation, physical therapy, occupational and behavioral therapy, interventionist techniques (infiltrations, blockages) … It is missed that the plan defines them. The patient suffers a lot and must be cared for” , Alonso sentence, also coordinator of the opioid working group of the Spanish Pain Society.
There is another alternative without, for the moment, regulation, and therefore not prescribed by doctors, but that is on the way: cannabis for medicinal purposes. Congress approved in June the creation of an ad hoc subcommittee to “analyze experiences of regulation of cannabis for medicinal use” with the ultimate intention of preparing a report “on the existing scientific evidence” on the matter.
The document will be sent to the Government “to be used in the regulation of cannabis as medical use in the State (…), thus endowing patients with the same rights and guarantees that thousands of patients from other countries already enjoy. of the surroundings “, according to the proposal of the PNV from which subcommission was created. As is the relationship of forces in Congress, the willingness of the PSOE to study the problem after years of refusal, places partial legalization closer than ever.
In any case, both the Health Plan and the experts affirm that the Spanish approach “is preventive.” There is no regret, they say, a crisis like the one that has been experienced in the United States with a large increase in addicts and deaths from the abuse of these drugs. “There is no such risk because our health system is completely different. Here there is much more control with prescriptions. There are clients, if a doctor does not prescribe them, you go to another”, concludes Ana Isabel Henche.