Transcript Prescribing opioids for chronic non-malignant pain

Schedule 8 medicines:
Prescribing opioids for chronic
non-malignant pain
Pharmaceutical Services Branch
January 2014
Version: C20140101AG1
Aims of presentation
This presentation will focus on the prescribing of
opioid Schedule 8 (S8) medications for chronic
non-malignant pain (CNMP) and includes:
 patient management options
 pharmacological or non-pharmacological
treatment
 difficult patients
 documentation
 practice monitoring.
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Initiation of opioid therapy for CNMP
 Before a short term therapeutic trial (< 60 days):
 establish a definite pain diagnosis
 do not use opioids to treat headaches
(including migraine) and poorly or undefined
general pain states such as fibromyalgia,
chronic visceral pain or non-specific lower
back pain
 confirm that trials of non-opioid or non-drug
treatment have failed.
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Initiation of opioid therapy for CNMP
 Evaluate mental health issues and
current/previous substance misuse (including
alcohol and benzodiazepines).
 Consider referral to a clinical psychologist or
other allied health professional (physiotherapist,
occupational therapist).
 Ensure patient is not a registered drug addict (if
a notified addict, consultant support is required
prior to prescribing).
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Initiation of opioid therapy for CNMP
 Have an exit strategy for each opioid trial.
 Agree on this exit strategy with the patient and
document this in the notes.
 Introduce an opioid contract before you initiate a
trial.
 A valid outcome of an opioid trial maybe the
decision not to proceed with opioids.
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An opioid contract:
 represents the gold standard
 is recommended for all patients as a form of informed
consent prior to initiating treatment
 clearly outlines both the patient’s and the prescriber’s
responsibilities
 describes the rules of prescribing
 states the need for adherence to the authorised dose
 specifies the need for GP to discuss adverse effects
 may contain additional conditions e.g. daily medication
pick ups
 is routinely used in specialist pain clinics
 may be issued as a condition of authorisation
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Initiation of opioid therapy for CNMP
 Start cautiously with low doses of an appropriate
long-acting or slow release opioid.
 Be careful in particular with:
 opioid naïve
 frail elderly
 significant co-morbidities.
 Individualise dose during trial with incremental
dose escalations.
 Avoid use of immediate release or short-acting
opioids in chronic pain states.
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Initiation of opioid therapy for CNMP
 Consider opioids only as one component of a
multimodal treatment plan:
 Opioids should facilitate mobilisation, participation in
physiotherapy or other activation.
 Consider early referral for specialist pain
advice/management.
 Opioids commenced as an inpatient: The pain
team should consider:
 changing to Schedule 4 opioids before discharge
 the need to advise if S8s are to be continued on discharge (prior
to discharge)
 communication of plan back to the patient’s GP.
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Prior to proceeding to long-term prescribing
consider:
 progress toward meeting therapeutic goals
including pain relief, but in particular improved
level of function
 presence of adverse affects
 changes in psychiatric or underlying medical comorbidities
 evidence of aberrant drug-related behaviours
e.g. doctor shopping and escalating S8 dose
 evidence of diversion.
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Monitoring
 regular monitoring required:
 Is the treatment plan working?
 Is there functional improvement?
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need for additional non-opioid therapies
benefit outweighed by harm
is referral (specialist, allied health, other) required?
increasing the opioid dose is not always the
correct response to missed goals of treatment
 do not exceed recommended dose limits.
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Monitoring
 Regularly review the pain diagnosis
and co-morbid conditions using the 4As
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Analgesia
Activity
Adverse effects
Aberrant behaviour
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Monitoring
 Documentation of:
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pain severity
functional ability
progress towards achieving therapeutic goals
adverse effects
signs for presence of
 aberrant drug related behaviours
 substance abuse
 psychological issues.
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Monitoring – patients at high risk of
substance misuse
 Minimise risk via
 intense and frequent monitoring
 limiting prescription quantities and dispensing
intervals as a condition
 consultation / co-management with persons who
have expertise in mental health or addiction
medicine
 low threshold for referral to Next Step or other
addiction service.
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Pharmacological treatments for pain
 Nociceptive pain
 paracetamol
 NSAIDs
 Neuropathic pain
 tricyclic antidepressants (e.g. amitriptyline)
 serotonin-noradrenergic reuptake inhibitors (e.g.
venlafaxine, duloxetine)
 anticonvulsants (e.g. gabapentin, pregabalin)
 Nociceptive and/or neuropathic pain
 tramadol
 opioids
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Non-pharmacological pain management
 Physiotherapy
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paced exercise programs
hydrotherapy
aquarobics (in public pools)
any physical training e.g. gym membership
 TENS treatment
 Psychological options
 CBT: focuses on patients developing coping
strategies for their CNMP to improve function. Has
shown consistently to be effective in the management
of CNMP
 mindfulness training
 relaxation techniques
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Non-pharmacological pain management
 patient support groups
 complementary therapies
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massage
reflexology
aromatherapy
acupuncture
nutrition
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Interventional therapies for pain
 Nerve blocks/steroid injections
 joint injections (including facet joints)
 epidural steroid injections
 Destructive procedures
 facet joint denervation (rhizotomy)
 Implanted devices
 intrathecal drug therapies
 dorsal Column Stimulators
 Surgical options e.g. joint replacements
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Summary of opioid management for CNMP
 Evaluation of the patient
 standard work up
 pain diagnosis appropriate for treatment?
 assess risk of misuse
 Informed consent & contract
 inform of side effects/risks/potential of ineffectiveness
 outline expectations between provider and patient
 Opioid trial
 including exit strategy
 Periodic review of long-term treatment
 The 4 As: Analgesia, Activity, Adverse effects, Aberrant behaviour
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Summary of opioid management for CNMP
 Specialist consultation referral
 registered drug addict (mandatory prior to prescribing)
 if patient is not responding or diagnosis is unclear
 high risk (e.g. dose refer to Schedule 8 Medicines
Prescribing Code).
 Review the four As (useful follow-up questions)
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Analgesia
Activities of Daily Living (ADLs)
Adverse events
Aberrant behaviours
 Compliance with WA state legislation
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Resources
 Pharmaceutical Services Branch:
www.health.wa.gov.au/S8
 Royal Australasian College of Physicians:
www.racp.edu.au/page/policy-and-advocacy/publichealth-and-social-policy
 Drug and Alcohol Office:
www.dao.health.wa.gov.au/Informationandresources/pub
licationsandresources/healthprofessionals.aspx
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Pharmaceutical Services Branch contacts
 Telephone: (08) 9222 4424
 Fax: (08) 9222 2463
 Email: [email protected]
 Post:
The Pharmaceutical Services Branch
PO Box 8172
Perth Business Centre
WA 6849
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Other contacts
 Medicare Australia Medicines Information Line
 1800 631 181
 Next Step Specialist Drug and Alcohol Services
 (08) 9219 1919
 Alcohol and Drug Information services (ADIS)
 (08) 9442 5000 or 1800 198 024
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