Killing painkillers

We have a complex relationship with painkillers. The opioid crisis in the West — and our response to it — is changing that

Withdrawal felt like hell for Ivy Li. There was a great sense of fear, anxiety and loneliness.

Something in Li’s head told her that nobody loved her anymore; that she’d be condemned forever.

“It feels like you’re going to hell,” she says. “It was as if the whole world was crumbling around me.”

While being warded for her lower back pain in 2014, Li had been prescribed Oxycontin, an extended-release opioid.

The 30-year-old freelance makeup artist never got high — it just felt normal to her, “just taking a pill to suppress the pain”. Without it, she would have intense, bad pain that went from her back down to her legs.

She was also given some morphine, which hospital staff said wouldn’t cause any withdrawal after she was discharged.

But she just felt something was wrong. “I didn’t realise what was causing it,” Li says. “How come I suddenly had this intense feeling of desperation? I can’t breathe, I can’t do anything and I’m going to die.”

She took a “slightly warm shower”. “I felt like my skin was boiling, like I’m on fire,” she says.

“And to combat that, I took a cooler shower, and it felt that I was in Antarctica or something.”

Eventually, though, the feeling went away.

Li was aware that the drug — along with others like it — is the main cause of an addiction crisis in the U.S.

The distant crisis far from our shores has made people worry about addiction from painkillers — despite it being virtually non-existent here; there are fewer than 30 opiate abusers per 100,000 people here, compared with 600 per 100,000 in the United States, according to the Ministry of Home Affairs.

Some have been wary about taking opioids because they are worried about addiction, says Prof Lee Tat Leang, senior consultant in NUH’s acupuncture service. In the short term, if the patient is given opioids only when they have severe pain, and prescribed other painkillers when their pain becomes less intense, the drugs will not be addictive, he adds.

Lim Hwei Ming, a 38-year-old business development manager, says that she doesn’t want to rely on painkillers, especially tramadol, an opioid she was prescribed for her back pain. “Tramadol is of a higher level than the NSAIDs the doctor will give me,” she says. “I feel if my pain hasn’t peaked to a level too much for me to bear, then I wouldn’t want to try it.”

Lim believes painkillers won’t hinder her life, but she is aware of their potential side effects. “If we heed the doctor’s advice and use painkillers safely, it should be fine,” she says.

Timothy Soh — who self-medicates using a stock of painkillers he was prescribed for his kneecaps, says that he tries not to take them because he’s “kind of used to the pain.”

Soh has never asked for an adjustment for his medication, but he would turn to his GP for painkillers when he needs it, he says.

“I don’t rely much on painkillers because they interfere with my mental faculties — when I do get stronger painkillers it leaves me with gastric pains and a lousy mood.”

He sees a physiotherapist once a month, and does static exercises as part of his conditioning at home, he adds. The conditioning helps strengthen his muscles so he can move without causing any pain. “But it’s extremely challenging for lazy me to keep that up.”

Patient guidelines

Doctors are also wary of prescribing medication to people who may abuse it. “The government’s policy on opioids is strict — you read the newspaper and you hear of all the GPs giving cough syrup and addictive drugs and getting punished,” says NUH’s Dr James Tan.

“A lot of doctors are actually quite scared,” he adds.

There is a small group of patients who are drug-seeking — especially for opioids, says Dr Ho Kok Yuen of Raffles Hospital. “Those patients will try all means to doctor-hop, to try to get what they want, and they’re not really looking for pain relief — they consume these medications for the euphoric effect,” he adds.

Both Dr Ho and Dr Tan are authors of a guideline outlining the prescription of opioids for chronic non-cancer pain, published by the Pain Association of Singapore in 2013.

The guidelines outline a process for doctors to discover whether opioids are suitable for patients in individual pain conditions, how opioids will be administered and monitored, and how to wean patients off opioids if they have a problem with them, Dr Tan says.

“There is an essentially broad agreement throughout the world about how we should use opioids, and it should be basically that we use it in a very carefully selected group of patients who have severe pain that is known to have a clear reason,” he adds.

Important to dispel narratives

The people who need painkillers are in the shadow of a narrative that opioids are bad, says NTU’s Prof Andy Ho, a community health psychologist. “They, too, believe that opioids could be bad.”

Believing that medication will get people addicted is very disempowering, Prof Ho adds.

“We need to really put the science into pain control and allow people to understand that adequate treatment through medication is a useful way to help people get back to normal or near-normal,” he says. “It’s important to educate the public about the effect of opioids, what it’s used for, and how it can be effective.”

Sharon Mak, Southeast Asian director of communications for GSK Consumer Healthcare, says that the pharmaceutical giant — which manufactures Panadol — has taken steps to making sure people read labels so they take the right dose.

Most Singaporeans self-diagnose their pain, according to a 2017 global GSK study. “A lot of people have gone on the internet to get information, different resources, and they have also indicated they’re not so sure what would be the legitimate resource,” Mak adds.

“With more knowledge, some people just go to the pharmacist to get their medicine,” Mak says. “What we want to do is to make sure they read the labels.”

A deluge of information on the internet has made it more confusing, and more people now seek advice from other healthcare professionals, including their pharmacist, Mak says.

“It’s a continuous cycle of educating people, which we do through various channels,” Mak says.

Li’s relationship with pregabalin, which she now takes for her lower back pain thrice a day, has been tenuous. A major side effect from the drug has been weight gain, which has changed the way she looked at herself. “I don’t actually look at myself in the mirror,” she says.

The pills are expensive, too — in order to get pregabalin, she has to go to her local emergency ward, which will cost her around $120. She also stocks up on the painkiller at the Institute of Mental Health, where it’s used to treat general anxiety.

“If I can, I wouldn’t want to take anything.”

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