Transcript Slide 1
Pain management for people on opiate substitute medication Use and abuse of prescribed drugs Over the counter medications of abuse Dr Susanna Lawrence Clinical Executive Director St Martins Healthcare Services May 2013 Is ‘primary problem’ helpful? Patient with substance misuse uses prescribed and OTC medicines to supplement illicit use Patient with substance misuse develops pain Iatrogenic: dependence develops on prescribed medication leading to change in behaviour Patient with chronic pain develops OTC analgesic substance misuse Co-morbidities exacerbate pain and substance misuse Scenario 1 Patient prescribed and stable on methadone, with no illicit drug use, using prescribed fentanyl patches for ‘longstanding’ back pain Scenario 1 Patient prescribed and stable on methadone, with no illicit drug use, using prescribed fentanyl patches for ‘longstanding’ back pain – – Genuine pain? Why short acting analgesic? Assessing pain Mechanical pain usually associated with decreased (though variable) physical functioning – OBSERVE AND EXAMINE! Neuropathic pain – history of nerve damage, abnormal findings on sensory examination Visceral pain – more difficult Identifying possible supplementation/diversion In addition to usual ‘doctor hopping’, patient Is not interested in investigation of pain Is not interested in non-pharmacological interventions Knows exactly what preparation they want Is resistant to discussing alternatives Why do substance misusers get pain? Part of general populaton Hyperalgesia associated with long term opioid use Culture of self-medication Low tolerance of non-pharmacological interventions Frequent episodes of intoxication and withdrawal, increasing intensity of pain experience Sleep disturbance and mood disorder – well established exacerbating factors in chronic pain Increased incidence of injury May use medication as currency What to do? Observe, Examine, Explore beliefs Keep symptom and analgesic use diary 2wks Convert to long acting opioid - morphine No evidence that any opioid produces superior pain relief to morphine Keep OST and analgesic opioids separate Scenario 2 Patient on methadone 4 years, following dihydrocodeine dependence developed post LSCS, now successfully reducing by 5mls/fortnight, from 60mls. Pain free on 30mls, severe pelvic pain develops once methadone reduced to 20mls. Scenario 2 Patient on methadone 4 years, following dihydrocodeine dependence developed post LSCS, now successfully reducing by 5mls/fortnight, from 60mls. Pain free on 30mls, severe pelvic pain develops once methadone reduced to 20mls. – – – Is patient becoming anxious about abstinence? Methadone is an effective analgesic, is this genuine breakthrough pain as opioid reduced? How is the patient taking the methadone? What to do? Establish appropriate need for analgesia Explore non-pharmacological adjunct Split dose of methadone to bd Titrate back to dose of methadone where client is pain free Convert to long acting morphine (conversion rates vary ++, be cautious) Scenario 3 Patient (59y male) just registered with GP, recently discharged from hospital following a fall, requesting pregabalin for ‘sciatica’, says tramadol (prescribed in hospital) not effective, pregabalin only effective medication. Has repeat slip from previous GP citing pregabalin. Scenario 3 Patient (59y male) just registered with GP, recently discharged from hospital following a fall, requesting pregabalin for ‘sciatica’, says tramadol (prescribed in hospital) not effective, pregabalin only effective medication. Has repeat slip from previous GP citing pregabalin. – – Why did he fall? Why not prescribed pregabalin in hospital? GABA-ergics: The Evidence Base 2004 – first reports of abuse Increasing EB What to do Review and/or obtain evidence for neuropathic pain Offer alternatives: – – – Explore possibility of abuse/overuse If established dependence, reduce by max: – – Amitriptyline Duloxetine Carbamazepine 50mg/week pregabalin 300mg/week gabapentin Offer physical therapy Neuropathic pain Medication best treatment but <30% respond NICE supports GABA-ergics – – Anxiety: if SSRIs or SNRIs not tolerated (2011) Neuropathic pain: TCA or PG/GBP (2010) If any concern about/history of substance misuse Tricyclic antidepressants – Carbamazepine – Gabapentin and pregabalin are unsuitable as first-line drugs NOT caused by healed fractures or DVTs. – Suggested starting and maximum doses for neuropathic pain Amitriptyline 10-75mg once daily Nortriptyline 10-75mg once daily Duloxetine 60-120mg once daily Carbamazepine 200-1200mg daily in two divided doses Scenario 4 Patient has been requesting repeat prescriptions for co-codamol 30/500mg more frequently than prescribed, increasing over 6mth period. Scenario 4 Patient has been requesting repeat prescriptions for co-codamol 30/500mg more frequently than prescribed, increasing over 6mth period. – – – Has she been into the surgery to discuss escalating symptoms/need? Is there anyone in the family who might be using? Is she avoiding any particular prescriber? What to do Once overuse/misuse established Prescribe codeine separately from paracetamol (codeine phosphate) Offer managed reduction of codeine, reducing by 10% every 2 weeks Offer alternative pain management, use analgesic ladder etc. Scenario 5 Patient on buprenorphine 16mg daily for opioid dependence presents with acute low back pain. Scenario 5 Patient on buprenorphine 16mg daily for opioid dependence presents with acute low back pain. – – Is it likely to have pain if on such a high dose of opioid? What options are open to me if on buprenorphine? What to do? Treat like anyone else Treat the pain Opioids contraindicated (buprenorphine) Use combination of non-opioid analgesia and benzodiazepine if muscle spasm Acute pain management - patients on current or previous OST Analgesic needs may be higher due to cross tolerance and/or hyperalgesia) Don’t assume methadone/buprenorphine will cover analgesic needs In a former user, treating acute pain unlikely to precipitate relapse – but neglecting to treat pain very likely to. Opioid analgesia can & should be used if simple analgesia ineffective or inappropriate Scenario 6 Patient attends on behalf of elderly mother saying she is ‘always’ coughing and can she have something to help her settle at night. There is no history recorded in her mother’s notes. Scenario 6 Patient attends on behalf of elderly mother saying she is ‘always’ coughing and can she have something to help her settle at night. There is no history recorded in her mothers notes. – – – Genuine request? What is she wanting? Who for? OTC medicines open to abuse Opioids – – – codeine analgesics cough preparations kaolin and morphine Antihistamines Laxatives Caffeine – Red Bull Summary Keep alert for diverters, but treat pain effectively Use long acting opioids for chronic pain to minimise diversion Keep opioid dependence and analgesic prescribing separate Use amitriptyline or duloxetine, not pregabalin Beware buprenorphine – partial agonist CAUTION prescribing addictive analgesics Drug Service role mainly advisory but we can offer practical help including with the management of certain behaviours GP And/Or Neurology Pain Clinic Drug Service Pharmacotherapy for persistent pain Addiction to Medicines Consensus Statement January 2013: Care needed initiating drugs which may lead to dependence Professionals should work towards preventing addiction Non pharmacological options should be explored, including giving of advice on physical rehabilitation and the offering of psychosocial interventions Anxiety and depression need to be addressed Support must be given to those who suffer from addiction irrespective of route into addiction Consensus from: DOH, Royal Colleges, Professional Groups, Specialist Services & Voluntary Organisations. Resources RCGP/Royal Pharmaceutical Society November 2012: Safer Prescribing in Prisons. RCGP/British Pain Society. July 2012: Pain in secure environments – final draft The British Pain Society’s: Opioids for persistent pain – good practice. January 2010. BPS/RCPsych/RCGP April 2007: Pain & substance misuse: improving the patient experience. PHE: Commissioning treatment for dependence on prescribed and OTC Medicines (draft - 2013) Assessment of pain Causation – corroboration of physical factors Aggravating and relieving factors Severity – visual analogue scores Variability – may be pain free intervals Affect on sleep Social situation – beware co-dependancy Affect on function: activities of daily living – consistency? What has been tried? Expectations – are they reasonable? Functional assessment Look for consistency – or inconsistency Chronic disabling limb pain usually associated with objective signs such as muscle wasting/lack of callous Ability to lower and rise from sitting requires good spinal function. Walking can be observed Activities of daily living – are they affected?