Transcript Rebecca Lawrence and Colin Baird

Pain and Dependency / Pain Management in
the Prison Population
Dr Rebecca Lawrence
Consultant in Addictions Psychiatry
Ritson Unit
Royal Edinburgh Hospital
Dr Lesley Colvin
Consultant / Honorary Reader in Anaesthesia
and Pain Medicine
University of Edinburgh
Dr Colin Baird
Consultant in Anaesthesia & Pain Medicine
Western General Hospital
Leith Community Treatment Centre
Summary
Pain and Dependency – an overview
•Dr Rebecca Lawrence
Management of Neuropathic Pain and how
SIGN 136 can be implemented in the PAD
clinic
•Dr Colin Baird
Opioids for chronic pain in the prison
population – good or bad?
•Dr Lesley Colvin
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 model
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
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
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 36 new patients seen in
PAD in 2014
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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 36 new patients (2)
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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
Benzodiazepines frequently used /
prescribed
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
The Future?
 Wider access to specialist care – where and
how 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
Management of Neuropathic Pain
and how SIGN 136 can be
implemented in the PAD clinic
Dr Colin Baird
Summary
Neuropathic pain – the problem
Management of neuropathic pain
SIGN 136
How can this be applied to the prison /
PAD clinic population?
Gabapentin and pregabalin…!
Pain: ‘An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms thereof’
Neuropathic pain: ‘Pain arising as a direct consequence
of a lesion or disease affecting the somatosensory
system’
Neuropathic pain – the problem
Between 8 and 18% of adults in the UK,
USA and Europe will suffer from
neuropathic pain
It has a negative impact on mood, ability
to function and general wellbeing
16% of sufferers rate it as ‘worse than
death’ on the EQ5D
Current treatment is limited by side effects, lack of
efficacy and variable individual response
Doth et al. Pain (2010); Torrance et al. J Pain (2006); Toth C et al. Pain Medicine
(2009); B Smith
What causes neuropathic pain to develop?
Damage to the somatosensory nervous system
Surgery / Trauma
Disease – diabetes, HIV
Infection (PHN)
Drugs – chemotherapy, alcohol
Features of neuropathic pain
Spontaneous
Hyperalgesia
Evoked
Allodynia
Impaired ability to function
Negative impact on mood
SIGN 136 – now available!
http://www.sign.ac.uk/guidelines/fulltext/136/index.html)
Key recommendations:
Assessment and planning of care
Supported self-management
Pharmacological management
Psychologically based interventions
Physical therapies
Three consensus pathways:
Assessment, early management and care planning
Neuropathic pain
Use of strong opioids
Complementary to the British Pain Society Map of Medicine Pathways
(http://bps.mapofmedicine.com/evidence/bps/index.html)
LANSS DN4
NPQ
Pain
DETECT
Id-Pain
Country
UK
France USA
Germany
USA
Validated
100
160
382
392
308
Sensitivity 82 - 91
83
66
85
NA
Specificity 80 - 94
90
74
80
NA
Common
symptoms
Pricking, tingling,pins and needles; Electric
shocks/ shooting; hot/ burning
Common
signs
Brush
allodynia;
raised pin prick
Case history - NF
45 year old male – stab wound to the
chest 10 years ago
Pain since incident. Had been managed with
gabapentin but this was stopped due to
suspicion of drug diversion
On amitriptyline 50mg at night
Referred to the PAD clinic
Symptoms: Burning, shooting pain ‘like toothache
doctor!’
Signs: Hyperalgesia and allodynia around
the affected area.
Pharmacological options – 1st line therapy
Amitriptyline: 25 – 125mg daily. Titrate up by 10mg per
week
Gabapentin: Titrate up by 300mg per week to 1200 –
18—mg daily
Pregabalin: 75mg BD, titrate up by 75mg
per week to 300 – 600mg daily.
Gabapentin
Pregabalin
Gabapentinoids
How should we incorporate these
conclusions into our clinical
practice?
Advice for prescribers on the risk of the misuse of pregabalin and
gabapentin
Ref: PHE publications gateway number: 2014586; NHS England publications
gateway number 02387 PDF, 157KB, 9 pages
Which if any, are options for NF?
Gabapentin
Pregabalin
Amitriptyline
Pharmocological options – 2nd line therapy
Alternative TCA: Nortriptyline, Imipramine – same dosing regime as
amitriptyline but may have more favourable side-effect profile
SNRI: Duloxetine, 30-60mg daily, can increase to 120mg
daily. Nausea is main side-effect
Carbamazepine: In trigeminal neuralgia
Could try alternative TCA?
Duloxetine?
Topical agents for neuropathic pain
Lidocaine patches: Good side-effect profile. Application may
be problematic
8% Capsaicin patch: For PHN, HIV neuropathy, postsurgical scar pain.
TENS machine
8% Capsaicin patch
1 application
Pain scores have fallen from 9 to 4 after 2 weeks
Plan to repeat the application after
12 weeks
Look for improvements in sleep and function
Pharmacological options – Opioids!!