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.
SIREN SOUNDS
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.
SHE LAUGHS
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.
SIREN WAILS
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!
THEY LAUGH
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.
THEY LAUGH 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!
THEY LAUGH
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...
HE WINCES 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.
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.