Transcript presentation

Pain & Dependency Better Together
Dr Rebecca Lawrence
Consultant Psychiatrist in
Addictions
NHS Lothian
November 2014
Acknowledgements
Thank you to my colleagues,
Dr Lesley Colvin & Dr Colin
Baird, for shared expertise /
input to slides
Declaration of Interests /
Funding
 Edinburgh & Lothians Health Foundation
Alcohol Problems Endowment Fund –
contribution to MSc in Pain Management
 Astellas Pharma Ltd – funding to attend
BPS annual scientific meeting (2014)
 Reckitt Benckiser – funding to attend
Opioid Painkiller Dependence Education
Nexus (September 2014)
Overview
 Background / brief epidemiology
 Lothian Pain & Dependency Clinic
• History
• Criteria for referral
• Patients seen
 Other possible models
of service delivery
in the future
center-for-addiction-recovery.com
Chronic Pain and Dependency
the emerging co-morbidity?
 Chronic pain of moderate to severe intensity occurs
in 19% of adult Europeans, seriously affecting the
quality of their social and working lives (Breivik, H., et
al, 2006. Eur J Pain) (BPS figure - one in seven of
UK population)
 Estimated prevalence of problem drug use (opiates
and/or benzodiazepines) Scotland 2012-13 of 1.68%
population aged 15-64 (Scottish Government)
 Up to 50% men and 30% women across Scotland
exceeding weekly recommended guidelines
(Changing Scotland’s Relationship with Alcohol: A
Framework for Action, 2009)
Access to pain relief – an essential
human right
IASP, the WHO and EFIC
 The UN Universal Declaration of Human Rights
conceptualises human rights as based on inherent
human dignity
 Perception and expression of pain is individual:
 It is essential to listen to and believe the patient –
only they know what the pain feels like
(A report for World Hospice and Palliative Care Day 2007 Published by
Help the Hospices for the Worldwide Palliative Care Alliance )
Substance misuse patients
 Increased prevalence of pain
 Poorer treatment outcomes. Yet treating
pain improves outcomes
 More likely to use illicit opioids / more
drug-seeking
Chronic Pain Patients
• Increased prevalence of alcohol & drug
misuse
• Hoffman et al (1995) – 23.4% of 414
hospitalized chronic pain patients in
Sweden met criteria for active diagnosis of
alcohol, analgesic or sedative misuse or
dependence
• No demographic / clinical factors that
consistently differentiate CNCP (chronic noncancer pain) patients with comorbid SUD
(substance use disorder) from patients
without SUD, though may be at greater risk
for aberrant medication-related behaviors.
Morasco, B.J., Gritzner, S., Lewis, L., Oldham, R., Turk, D.C., Dobscha,
S.K., 2011. Systematic review of prevalence, correlates, and treatment
outcomes for chronic non-cancer pain in patients with comorbid
substance use disorder. PAIN 152, 488–497.
doi:10.1016/j.pain.2010.10.009
Per-capita consumption in UK =
US 10 years ago
US: 5% of world’s population,
consume 80% of world’s opioids
Opioid prescriptions are
increasing
Painkiller Addict – From
Wreckage To Redemption
Cathryn Kemp
Has increased opioid use improved
patient outcomes?
A number of comprehensive reviews
have failed to show compelling
evidence for opioids in chronic noncancer pain.
Manchikanti L, Vallejo R, Manchikanti KN, Benyamin RM, Datta S, Christo PJ.
(2011). Effectiveness of long-term opioid therapy for chronic non-cancer pain.
Pain Physician; 14: E133–56.
Chaparro LE1, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC.
(2014). Opioids compared with placebo or other treatments for chronic low back
pain: an update of the Cochrane review.
McNicol ED1, Midbari A, Eisenberg E. (2013). Opioids
for neuropathic pain.
Cochrane Database Syst Rev. 29;8:CD006146. doi:
10.1002/14651858.CD006146.pub2.
Pain & Opioid Dependency
 Physical Dependence
 Tolerance (side effects/
analgesia)
 Aberrant drug-related behaviour (“Red flags”)
 Abuse (DSM IV: Psychoactive Substance Abuse: A
maladaptive pattern of drug use that results in harm or
places the individual at risk)
Pseudoaddiction: Aberrant drug-related behaviour in
patients reacting to under treatment of pain
It’s not just opioids...
Substance misuse clinic
 79% (102/129) prescribed methadone for opiate
dependency
 19% of these (19/102) using additional nonprescribed methadone
 7% of these (7/102) continuing to use heroin
Prescribed
Non-prescribed
Gabapentin
7% (9/129)
19% (25/129)
Pregabalin
1.5% (2/129)
3% (4/129)
Baird CR, et al. (3013). Gabapentinoid Abuse in Order to Potentiate the Effect of Methadone: A
Survey among Substance Misusers. European Addiction Research 20(3):115-118
Pain, Mental Health & Alcohol
• Strong association between pain &
psychopathology, particularly depressive
disorders, anxiety disorders, somatoform
disorders, substance use disorders &
personality disorders
Dersh J, Polatin GB & Gatchel RJ (2002). Chronic pain
and psychopathology: research findings and theoretical
considerations. Psychosom Med 64(5):773-86.
Licensed Treatments
 Amitriptyline – depression & neuropathic
pain
 Duloxetine – depression, generalized
anxiety & diabetic neuropathy
 Pregabalin – peripheral / central
neuropathic pain & generalized anxiety
 Carbamazepine – trigeminal neuralgia,
prophylaxis of bipolar disorder
 PSYCHOLOGICAL INTERVENTIONS
Other treatments for pain, mental
disorders & substance misuse
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Valproate
 Ketamine infusion
Gabapentin
 Deep brain
stimulation
Topiramate
Lamotrigine
Other antidepressants
Baclofen
Opiates
Benzodiazepines
Pain & Dependency (PAD)–
the Edinburgh experience:
 Development of combined Pain & Dependency
(PAD) Clinic – 2003 (by Dr Lesley Colvin & Dr
Michael Orgel)
 Patients with drug dependence should not be
denied adequate pain relief
 Access to specialised services with experience in
managing this patient group is essential
Scimeca, MC (2000)
What is the PAD Clinic?
 Multidisciplinary
– Pain Specialist
– Addiction Psychiatrist
– Specialist Nurse
– Clinical Psychologist
Location & Referrals
 PAD clinic is located in, & funded by, the
Chronic Pain Service
 Majority of referrals from GPs, also from
Substance Misuse Service, and some
diverted from Pain Service
Triage to PAD
 Current input from SMD (Substance Misuse Directorate)
 Current misuse of / dependence on illicit drugs (includes
legal highs - increasing problem)
 Current misuse of / dependence on alcohol
 Any history of drug / alcohol misuse with associated ongoing
mental health problems
 Not stable on prescribed methadone
 Prescribed > 150mg methadone (guide)
 Iatrogenic opioid misuse / dependence
 Misuse of over the counter or other prescribed medication
 Concern regarding gabapentin or pregabalin use (prescribed
or unprescribed)
PAD Clinic
 Assessment of pain, mental health and
substance misuse / addiction
• Does not matter which “came first”
• Verify past assessment
• Initiate further assessment/ investigations
 Does not provide key work or prescribing
• Liaison with appropriate services
 Mental health assessment (not ongoing
monitoring and treatment)
• Liaison with appropriate services
History:
Pain and Substance Misuse
 Pain
• Diagram, BPI & associated symptoms
• Past treatment & investigations
 Substance misuse history
• Stable/ chaotic – prescription? Support?
• IVDA – Hep C/ HIV (BBV) status and Rx
• Alcohol; stimulants & / or benzos; cannabis;
NPS; gabapentin…
 Mental Health
 Social history
 Child protection issues
Examination:
Pain and Substance Misuse
 Pain:
• Sensory changes/ ? neuropathic
• motor impairment/ impact on function
• Sympathetic involvement
 Substance misuse:
• Toxicology – urine / oral swab
• Breathalyse
• Signs of chronic drug / alcohol use
• Track marks
• Intoxication
Patients
 “Established” drug users with pain (often
on substitute prescriptions). Pain often a
result of chaotic lifestyle
 Pain resulting from alcohol dependence
 Concerning use of over the counter or
prescribed medication (usually opioids, but
may be other drugs, eg gabapentin)
 Past history of drug or alcohol use
Review of last 36 new patients
seen in PAD
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25 male, 11 female
Average age 41(26-59)
None in employment
Addiction first – 18
Pain first – 7
Unstable use of opioids – 19
Mental health problem - 26
Review of last 36 new patients
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On methadone – 15
On dihydrocodeine – 4
On buprenorphine – 0
On gabapentin or pregabalin – 14
Use of NPS – 2
Problem alcohol use – 13
Cannabis use - 15
Comments - last 36 new patients
 Previously on gabapentin, stopped as
possible misuse
 On methadone, MST & sevredol; also
diazepam 95mg daily
 Prescribed oxycodone, difficulty reducing
 High dose prescribed MST, oramorph,
pregabalin & baclofen
Comments - last 36 new patients
 Clonazepam dependence, converted to
diazepam
 Prescribed both diazepam and nitrazepam
 Possible iatrogenic benzodiazepine
misuse
 Unexplained +ve benzodiazepine
 Prescribed nitrazepam, diazepam &
baclofen
 Previous NPS induced psychosis
Management
 Assessment & Explanation
 Non-pharmacological – eg TENS (also
acupuncture, craniosacral therapy,
massage - availability)
 Pain Management Programme
 Individual psychological work
 Nerve blocks if appropriate
 Community support – substance misuse
services
Management
 Antidepressants - ? amitriptyline
 ?Gabapentin / Pregabalin
 Non-opioids – NSAIDs
 Optimise current opioid prescribing
 Strong opioids if needed – monitor
 Strong opioids – which?
 Topical treatments
 In patient assessment & treatment
Other Models??
• Managing pain within substance misuse
services
• Outreach to community services, including
primary care
• Liaison services in general hospitals
• Consultation by video link
The Future?
 Wider access to specialist care – where best
to deliver this?
 The changing patterns of drug misuse and
management of pain – abuse of prescribed
drugs other than opioids, alcohol misuse and
the spread of novel psychoactive substances
 Long term side effects of opioids and
implications for practice
 Better liaison with acute hospitals & primary
care