Five minutes with… Dr Harbinder Sandhu

Chief Investigator on the I-WOTCH trial (Improving the Wellbeing of People with Opioid Treated Chronic Pain) funded by the National Institute of Health Research, Dr Harbinder Sandhu spoke to our journalist Ella Rhodes about the issues that people who use opioids face and the randomised control trial that is set to start early in the new year.

Could you tell me about the state of opioid prescription for chronic pain in the UK and some of the difficulties patients experience?
There are eight to ten million people live in the UK with moderate to severe pain, and the number of people using strong opioids for pain has increased nearly fivefold between 2000 and 2010. This is a huge increase to NHS costs for a treatment that is largely ineffective with high incidences of serious side-effects including sedation, decreased concentration and memory, drowsiness, changes in mood, constipation, hormonal changes with consequences like sexual dysfunction, and opioid hyperalgesia where the more opioids are taken the more sensitive people become to pain.

In 2014 there were around 23 million opioid prescriptions costing £322 million. The trend is showing that we are still increasingly prescribing more; the USA is experiencing a national epidemic, and there's debate over whether we're heading that way. However Public Health England has commissioned a review of the extent of the problem we have with prescription drugs, including painkillers, and the impact of long-term use… so we'll have some data on that soon.

I've worked clinically with patients experiencing chronic pain, and since we launched the trial we've had media coverage and people have contacted us to tell us their stories. A common term I hear is being 'zombified'… that's how people feel on high doses of strong opiates for a very long period of time. They tell me they feel like they're living in a fog and that every day is a struggle. It affects their memory, it affects relationships within the family, they become quite isolated and don't always actually put it down to the opiates. It's a medication that's been prescribed, and quite often that link isn't made between the quality of life and what they're taking.

What will the study involve?
Our research team includes clinicians, methodologists, statisticians and health economists, because we're also doing a cost-effectiveness analysis. We've just about finished recruiting our sample of 468 participants, and as it's a randomised control trial there's a 50-50 chance participants will have the intervention or best usual care. Our usual care arm looked at what's available now for people to come off opiates, and in fact there's very little. Rather than give participants nothing we've got a self-help booklet called My Opioid Manager developed by one of our collaborators in Canada, which gives some education on opiates and how to withdraw safely and information on the self-management of pain, and these participants will also get a relaxation CD.

The intervention itself is partly based on a previous interdisciplinary intervention for pain management called COPERS. Our intervention has more of a focus on opiates and involves three days of group session. The sessions are delivered by a trained I-WOTCH nurse and layperson who has tapered off opiates themselves. The topics covered include, managing stress, mood, goal setting, communication, managing flare-ups, movement, mindfulness, relaxation and education about what opiates are and why they're taking them. Between the second and third sessions participants receive a one-on-one appointment with a nurse, and that's where the tapering is agreed and a plan put into place. After the last group session participants have three more points of contact with a nurse for ongoing support.

We're collecting data at baseline, after four, eight, and 12 months. Our main primary outcome measure is pain interference and how much it interferes with daily activities, and we also have secondary outcomes, including opiate use to see if it has reduced or not. We have an embedded process evaluation in this trial too, it will tell us which components of the programme are important in terms of behaviour change, motivating people and supporting them to come off their opioids whilst providing them with skills to manage their pain using non-pharmacological strategies

How has this project been for you personally?
It's been a real whirlwind of a year. It's such an important health issue and I feel very privileged to work with a massive team bringing together expertise from all over. I really hope we're able to get some good results and really make a difference and have this available for people who need it.

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