Transcript IPA Draft - Irish Pain Society

Non-malignant pain & its treatment in
older people: difficulties & dilemmas
Assoc Prof Martin C Henman
School of Pharmacy & Pharmaceutical Sciences
Trinity College Dublin
Irish Pain Association, Dublin, 2015
Analgesics
• Pain & discomfort are the most common & frequently reported symptoms
• Analgesics the most widely available & frequently purchased non-prescription medicines
• Ireland one of small group of countries with codeine-containing non-prescription products
• Wide range of adjuvants (e.g. caffeine) & other drugs used in combination products
• Among the most extensively prescribed drugs
• In 2011 almost 66% of medical card holders received a prescription
•
•
•
•
•
7% increase in prevalence of analgesic prescribing between 2003-2011
Analgesic users - 60% women, 40% men
Greater life expectancy – more elderly exposed to analgesics for longer
Most widely promoted drug class – best known brands
Everyone knows which drug is prescribed for severe pain & that it is potentially
dangerous
• Many countries are experiencing substantial increases in use of opioids & some leakage
of prescribed opioids into drug abusing population
Lecture Outline
Chronic (≥3 months), non-malignant pain in older people
• Analgesics
• TILDA
• PCRS
• Guidelines & utility
• Prescriber’s views
• Patient’s views
Analgesics
• Non-opioids
• Paracetamol
• Nefopam
• NSAIDs
• Systemic (oral) or Topical
• Selective – Coxcibs & Nimesulide
• Non-selective – Ibuprofen, Diclofenac,
Mefenamic acid
• Weak opioids
• Low dose codeine ≤15mg per unit
• Combined with paracetamol or ibuprofen
• Moderate opioids
• Codeine ≥30mg per unit
• Dihydrocodeine
• Combined with paracetamol
• Tramadol
• Combined with paracetamol
• Tapentadol
• Strong Opioids
•
•
•
•
•
Systemic or Transdermal
Morphine
Buprenorphine
Fentanyl
Oxycodone
• Adjuvants
•
•
•
•
Amitriptyline
Pregabalin
Gabapentin
Duloxetine
The Irish Longitudinal Study of Ageing: TILDA
• National randomised sample of 50y+ , living in community
• “Are you often troubled with pain?”
• Participants classified the severity of pain as mild, moderate or severe &
indicated the location of the pain
• Self-rated physical health categories were collapsed into Excellent/Very Good,
Good/Fair and Poor
• Interviewers asked participants, “to record all medications that you take on a
regular basis, like every day or every week. This will include prescription and
non-prescription medications, over-the-counter medicines, vitamins and
herbal and alternative medicines.”
• Medications were recorded using the WHO Anatomical Group Code (ATC), the
international non-proprietary name (INN), brand name and drug code.
• ATC code for all paracetamol/codeine formulations is same regardless of the
quantity of codeine
• To differentiate the higher strength paracetamol/codeine formulations from
the non-prescription low dose formulations medications were by brand name
& assigned to weak or moderate opioid groups
TILDA results
• 36% of TILDA participants reported NM pain, approximately 40% of women and
31% of men (p<0.001).
• Of those reporting NM pain, 58% were women and 42% were men.
• 38.3% (36.3-40.3%) of those with NM pain reported at least three chronic
conditions, compared to 17.2% (16.1-18.3%)
• Similar proportion to PRIME
• Poor health 10.5% (9.3-11.8%) of NM pain participants vs 2.0% (1.6-2.5%) of the
no NM pain population
• Higher prevalence of clinical depression (≥CESD-16) detected in the NM pain
sample 17.2% (15.7-18.8%) in comparison to 5.8% (5.1-6.6%) of the no NM pain
population.
• A slightly higher proportion of those with NM pain were widowed, 17.9% (16.319.6%) compared to 14.5% (13.4-15.7%) of those with no NM pain
• 36.2% (34.1-38.3%) of NM pain participants indicated they were currently
unemployed/ sick or disabled/ looking after a family member.
Presence and Severity of NM Pain according to agegroup (N=2,692) & by location of pain
• Highest prevalence
•
•
≥75 years 19.1% (17.3-21.1%)
50-54 year olds, 19.0% (17.4-20.7).
• Pain severity constant across all age-groups mean age of those reporting
•
•
•
mild NM pain 63.3(±9.7)
moderate NM pain 63.9(±9.8)
severe NM pain 64.7(±10.0).
Women were more likely to report back pain (56.3%
(53.4-59.2), joint pain (61.9% (57.9-65.7%), all over
pain (65.8% (58.3-72.6%), and other pain (54.9%
(51.4-58.3%), than men (Chi-squared, p<0.01).
TILDA results 2
• Depression was identified using The Centre for Epidemiological Studies Depression (CES-D)
which requires individuals to rate how often they have experienced symptoms of
depression in a week.
• A score of 16 or greater identifies this with clinical depression with good sensitivity and
internal consistency
• In the NM pain sample 17.2% (15.7-18.8%) were depressed according to this method vs
5.8% (5.1-6.6%) of the no NM pain population.
• Higher prevalence of polypharmacy (≥5 medications), amongst those with NM pain 31.7%
(29.9-33.6%) vs 14.4% (13.4-15.5%).
• 54.7% (52.6-56.8%) reporting NM pain attended a GP on 4 or more occasions in the
previous 12 months in comparison to 33.1% (31.6-34.5%) of participants reporting no NM
pain.
• 28% participants reporting pain reported analgesic use
• 5% participants who did not report pain reported analgesic use
• 652 reported severe pain but only 36 of those reported a Strong Opioid
Prevalence of analgesics reported by class by male and female participants
reporting NM pain
Proportion of analgesic taking NM pain population by age-group reporting
use of a specific analgesic medication
TILDA: Analgesics used in pain states & by age
group
•
•
•
•
Mild pain
Non-Opioid
Adjuvant
Selective NSAID
Weak Opioid
•
•
•
•
Moderate pain
Non-selective NSAID
Weak Opioid
Non-Opioid
Moderate Opioid
Severe pain
• Strong Opioid
• Selective NSAID
• Moderate Opioid
• Adjuvant
Concurrent use of analgesics
• NSAIDs are used
mostly with NonOpioids & Moderate
Opioids
• Opioids are not
often used together
• Adjuvants are
mainly used with
Moderate Opioids,
Strong Opioids &
Non-selective
NSAIDs
Sedative & Laxative co-prescribing
Concurrent sedating agent use amongst those
reporting opioids (by class) according to agegroup for participants with NM pain (N=60)
• 65-74y strong opioid group receive most
• Reduced treatment in 75y+
Concurrent laxative use amongst those
reporting opioids (by class) according to agegroup for participants with NM pain (N=11)
• 65-74y strong opioid group receive most
• Reduced treatment in 75y+
Adaptation of the WHO Analgesic Ladder developed for the purposes of
the multinomial regression models 1 & 2
Step 4
Step 3
Strong Opioid
Step 2
Step 1
No Analgesic
Weak Opioid
NonOpioid/NSAID/
Adjuvant
Strong Opioid
Regression Model 1:
Reference group
Moderate
Opioid
Weak Opioid
No Analgesic
Moderate
Opioid
NonOpioid/NSAID/
Adjuvant
Regression Model 2:
Reference group
• For both models, weak,
moderate and strong
opioids were separated so
as to represent distinct
stages of an analgesic
management strategy
• Univariate analysis
determine association
between covariates.
• Those covariates significant
at the p≤0.05 level were
included in the multinomial
model.
• Results reported as relative
risk ratios (RRRs)
Multinomial regression model 1
Step 4
Step 3
Strong Opioid
Step 2
Regression Model 1:
Reference group
No Analgesic
Step 1
Moderate
Opioid
Weak Opioid
NonOpioid/NSAID/
Adjuvant
• The first model evaluates the factors associated with use of an analgesic medication, comparing group
(reference) is the population of NM participants reporting no analgesic usage with users
Significant factors
• Polypharmacy across all 4 steps
• Pain restricted daily activity @ steps 1, 3 & 4
• Severe pain @ steps 1-3
• Current smoker @ 2 & 3
Multinomial regression model 2
Strong Opioid
Regression Model 2:
Reference group
Moderate
Opioid
Weak Opioid
No Analgesic
NonOpioid/NSAID/
Adjuvant
• The second model compares opioid use by NM participants according to the WHO Analgesic Ladder
classification and compares them with non-opioid/NSAID/adjunct users (reference).
Significant factors
• Polypharmacy @ steps 3 & 4
• Current smoker @ 3 & 4; past smoker @ 4
• No relationship between QoL & any analgesic group
CASP-19 QoL
• Measures of Control, Autonomy, Self-Realisation and Pleasure the
extent of satisfaction of each of these domains via Likert Scales
• Total possible score = 57
• TILDA participants mean CASP-19 score was 42.7
• Multinomial regression was used to identify the factors contributing
to the CASP-19
Quality of Life – Factors affecting CASP-19 score
Better
Worse
Primary Care Reimbursement System (PCRS)
• Prescription items dispensed – drawn from pharmacy claims
• Medications coded using WHO ATC code & a 5-Digit Drug Code,
• prescriber information, defined daily dose, strength, quantity, method of administration, net
ingredients and pharmacy dispensing fee per item are also recorded. Gender and age-group
• Patients were categorised by gender and age group, 55-64, 65-69, 70-74 and ≥75
years
• ≥1 dispensing indicates that the individual received at least one analgesic (or
specific class of analgesic e.g. nonopioids) in that year
• Number of people per 1000 in receipt of >3 dispensings of an analgesic or adjunct
medications was also calculated as a method of indicating recurrent use
• Concurrent dispensings of laxatives and sedating agents with weak, moderate
and strong opioids were also extracted. number of adults aged ≥55 years
receiving at least one analgesic medication per 1000 GMS population
PCRS
• In 2011 from 30 to 40% over 55y received
3 or more analgesic prescriptions
• 75y+ were highest users 427.2/1000 vs
327.5/1000 for 55-64y
• Non-opioids = paracetamol (99.9%)
• NSAIDs shift from Selective to Nonselective; also increase in topical
especially in 75y+
• Increase in Moderate & Strong Opioids
particularly after dextropropoxyphene
removed
• In 2011 Pregabalin, Amitriptyline &
duloxetine most frequently used
adjuvants
Opioids according to strength
• The prevalence rate per 1000
population increasing with the
older female population
• And decreasing in the older male
population.
• More repeat use - number
receiving >3 dispensings of a
moderate opioid has increased
from 2009-2011.
300.0
Prevalence Rate per 1000 Population
• Moderate opioid dispensing for
men & women trend in opposite
directions across age-groups
250.0
232
232
217
231
215
209
215
200.0
205
199
197
200
204
150.0
100.0
50.0
79
87
78
34.8
75
40.0
83
77
69.4
38.2
34.7
91
88
80
40.7
88
95
87
79.3
72.9
38.8
37.3
42.3
40.6
0.0
55-64
65-69
70-74
≥75
55-64
2009
65-69
≥75
70-74
2010
Moderate
65-69
70-74
2011
Year & Age-Group
Weak
55-64
Strong
≥75
Number of months dispensed a weak, moderate or strong
opioid analgesic dispensed (per 1000 population receiving that
class of opioid)
Weak Opioid
Moderate Opioid
Strong Opioid
1-7 Months
(95% CI)
8-12 Months
(95% CI)
1-7 Months
(95% CI)
8-12 Months
(95% CI)
1-7 Months
(95% CI)
8-12 Months
(95% CI)
2004
842.8
(838.1-847.5)
157.2
(152.5-161.9)
825.6
(823.5-827.8)
174.4
(172.2-176.5)
846.5
(840.5-852.4)
153.5
(147.6-159.5)
2009
807.7
(804.4-811.3)
192.3
(188.7-196.0)
817.9
(815.7-820.1)
182.1
(179.9-184.3)
754.6
(749.9-759.6)
245.4
(240.3-250.4)
2010
815.8
(812.4-819.3)
184.2
(180.1-187.6)
814.1
(812.0-816.3)
185.9
(183.7-188.0)
735.9
(730.9-740.9)
264.1
(259.1-269.1)
2011
812.5
(809.2-818.8)
187.5
(184.2-190.8)
807.5
(805.3-809.7)
192.5
(190.3-194.7)
732.6
(727.8-737.4)
267.4
(262.6-272.2)
Year
• Growth in Opioid use is in long term use – 8+ months/year
PCRS - transdermal patches
50.0
45.0
Prevalence Rtate Per 1000 Population
• Prevalence of strong opioid
patches increases across both
age-groups each year
• Prevalence of dispensings
considerably higher in the oldest
age group
• And amongst women
43
38
40.0
35
35.0
30.0
25.0
20.0
10.0
15
13
15.0
6
13
13
10
10
9
8
7
17
16
16
16
15
8
6
9
7
7
8
5.0
0.0
55-64 65-69 70-74
2009
≥75
55-64 65-69 70-74
≥75
2010
2011
Year & Age-Group
Female
55-64 65-69 70-74
Male
≥75
Prevalence Rate of Seadting Agents Per 1000
taking a Strong Opioid
• Sedatives were concurrent in 20% of opioid
prescriptions
• Women in the 55-64 year age-group
consistently have the highest rate of
prevalence of concurrent dispensing
• Usage declines with age group in both sexes
• Laxatives were concurrent in around 5% of
prescriptions
• Those aged ≥75 years consistently received
the highest rate of concurrent dispensings of
strong opioids and laxatives.
• However ~85% of those receiving >3
concurrent dispensings of a strong opioid did
not receive a concurrent laxative
• Men also consistently had a higher rate of
concurrent prescribing in comparison to their
female counterparts across all age-groups and
years
900.0
800.0
700.0
600.0
500.0
573
585
494
481
584 563
573 582 556
557
549
524
516
508
508
483
478
477
474
461 461
438
424
421
400.0
300.0
200.0
100.0
0.0
55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥75
2009
2010
Year & Age-Group
Women
Prevalence Rate of Laxatives Per 1000 taking
a Strong Opioid
Sedatives & Laxatives
1000.0
2011
Male
1000.0
900.0
800.0
700.0
600.0
500.0
400.0
300.0
375
307
247 264
471
469
435 445 419
423 443 416
392
377
374
365 345
347
344
316 328
305 327
274
200.0
100.0
0.0
55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥75
2009
2010
2011
Year & Age-Group
Women
Male
Clinical Guidelines & Opioids in CNMP
Clinical Guideline Quality
Clinical Guideline Content
Pain Assessment in Clinical Guidelines
Medicines Information
http://olh.ie/our-services/palliativecare/palliative-meds-info/pain-management/
Qualitative studies
GPs
• GPs were recruited using a snowball
sampling approach.
• Interviews were audio-recorded using
the Audacity® software and a portable
recording device
• GPs were supplied with a copy of the
interview transcript and invited to
edit the document.
• Following application of these
revisions, an electronic copy of the
transcript was transferred to NVivo®
Version 10.
• Twelve GPs were interviewed
Patients
• Members of Chronic Pain Ireland (CPI),
aged 50 years and older were eligible
• Individuals could not take part in the
study if they were not a current
member of CPI, were unwilling
participate in an audio-recorded
telephone interview, had a terminal
illness, or had been diagnosed with
dementia or any other memory
impairment.
• Twenty-eight interviews were
conducted with members of CPI
• Ethics Committee approval was
obtained for both studies
Prescribers’ views: assessment
• I don’t use standardised scales for pain, it is often volunteered by the
patient who comes and says they are in pain and then over time it gets to
where a pattern is established where certain medication is being prescribed
regularly. (GP9)
• No, I don’t use a scale, I probably should, but I don’t. Generally, it’s based
on patients symptomatology and how they can function… what they can’t
do anymore I guess; in terms of their day to day living. (GP12)
• Of course, the other point about pain is this, pain is not just pain, but it’s
also pain plus the anxiety and the whole preconception and all the social
stuff, mood; a whole load of other things feed into pain. (GP10)
• I would use the WHO pain ladder so starting off with a simple analgesic
then moving up to NSAIDs. (GP6)
Prescribers’ views: treatment
• Patients usually don’t like paracetamol regularly they don’t have any faith in it because you can buy it over
the counter so you always have this conversation where they say that is no use and then you explain you
have to try to take it regularly...it is interesting… definitely… in my experience patients perceptions of
paracetamol… they do not equate it with good pain relief. (GP4)
• Usually I would start with an NSAID if it’s OA [osteoarthritis] type pain or I usually do try to get people onto
regular paracetamol 1gr tds ongoing but I find that people don’t have much faith in it … and they have
usually tried it and even if it’s in conjunction with something else, they will usually be not keen on starting it
[pause] but ideally I would start them on paracetamol and move up to an NSAID and then onto something
like tramadol (GP2)
• If I am needing to use something in the longer term then I would try to use a combination low dose, a
paracetamol with a codeine. So I would probably step up to something like Solpadeine® [Paracetamol
500mg/Codeine 8mg/Caffeine 30mg] to see if that would help and try to get them to come back and review
in two weeks to see where they are at. (GP4)
• ... and low and behold when you go to their house you find that they have got those little red boxes that you
buy as well as those that you prescribe so they do buy them and they can get them… (GP5)
• It’s a very fine balancing act, I mean you have to take into consideration that there are serious side effects,
but on the other hand sometimes if their pain isn’t well controlled then you have no choice but … to step up
the ladder and put them on stronger painkillers. (GP12)
Prescribers’ views: Opioids
• I would be quite cautious about starting patients on those, particularly for what appears to be a
[pause] what is likely to be a chronic problem. I do prescribe them but with a lot of reservations
particularly Solpadol® [Paracetamol 500mg/Codeine 30mg] and Ixprim® [Tramadol
37.5mg/Paracetamol 325mg] things like that. Solpadeine® [Paracetamol 500mg/Codeine
8mg/Caffeine 30mg], I would prescribe a bit more easily. (GP6)
• I tend to be careful with codeine based medicines really. I don’t tend to use codeine a lot
particularly in the elderly because it is nauseating and constipating and sedating and a lot of other
things. (GP7)
• I did find the arrival of the opiate patches a huge relief to my stress over managing people who
were going to have ongoing, continuous pain and we really have to put something significant in
place on an ongoing basis (GP11)
• I’m certainly not a fan of using opiate patches… I know they are very commonly used, …certainly in
people I have used them in…it would be for an agreed period of time …and with a view to getting
them on to the lowest dose that you possibly can I am always trying to get them to wean down to
the step below, I certainly try not to leave people on patches long term. (GP5)
• Battling to try and keep people on the lower end of the scale so you know encourage them to stay
with regular paracetamol qds, or moving to Solpadeine® [Paracetamol 500mg/Codeine
8mg/Caffeine 30mg], so I would rarely move to something higher than that until you get into I
guess what you are talking about, chronic pain patients. (GP9)
Prescribers' views: Opioids & adjuvants
• I’m certainly not a fan of using opiate patches… I know they are very commonly used, I
am not a fan of them…certainly in people I have used them in…it would be for an agreed
period of time with a view to reviewing them and with a view to getting them on to the
lowest dose that you possibly can I am always trying to get them to wean down to the
step below, I certainly try not to leave people on patches long term. (GP5)
• Yes for non-malignant chronic pain I would move up to tramadol and then I would add in
probably at that point then Amitriptyline or Pregabalin...I generally….I wouldn’t go much
beyond...in terms of me initiating the treatment I wouldn’t go much beyond
tramadol...(GP6)
• I have reservations about pregabalin and Lyrica® because it seems in a way… it is just
being pushed by pharmaceutical companies as super effective whereas, in reality, it isn’t
any more effective (GP9)
• I identify with Amitriptyline being a potentially inappropriate drug in an older population.
Amitriptyline would be bad, so yeah, probably go with for neuropathic pain pregabalin or
gabapentin. (GP9)
Prescribers' views: Opioids & laxatives
• Depending on a few factors I try to avoid NSAIDs in the elderly except
for very short periods of time obviously because of the risk of renal
impairment and GI stuff but I will use them for short periods of time in
people who don’t have contraindications. (GP4)
• I would think I have been uniformly conservative about non-steroidal
in any age group really. For most of my career, I don’t know, I just
always was. (GP11)
• I tend to be careful with codeine based medicines really. I don’t tend
to use codeine a lot particularly in the elderly because it is nauseating
and constipating and sedating and a lot of other things. (GP7)
Prescribers' views: the system
• It’s kind of silo medicine, but that’s an awful lot of Irish medicine is silo medicine,
and I think a lot of the primary care teams are only teams in name. (GP10)
• We don’t have Primary Care teams on the ground that are supposed to be there
so, you know, it is very much you having to refer to different… I wish there was a
team we could refer them to that would look after them, but there isn’t. You can
do a Physio referral or you can get the PHN [public health nurse] to call, it’s very
disjointed. (GP12)
• I don’t think you are supported at all except by the drug companies who are mad
keen to support you (GP8)
• [Access is] very bad unless you have a thing called money...and you could easily
be waiting a long, long time if you have a medical card to see a pain specialist, it
is a very under-staffed under resourced... unless you have money in which case
you can head to the _________next week... a very bad system and a very unfair
system unless you can afford it...(GP5)
Prescribers’ views: Clinics & collaboration
• What happens is the people who staff those pain clinics have no real connection
to that person, they don’t really care about them, they have standardised scales
for pains, they have a clinic waiting list they have to get though and they will see
them again in six months’ time and they also have a book of medications that
they use and they just throw them at them. (GP9)
• Things fall apart quite often with those patients and then they get into crisis and
then you have to increase their painkillers and then....and there is a lack of
structure in terms of how we deal with them and what they expect as well. That
is where the pain clinics are very useful that they give a structure and they get a
plan…(GP6)
• Recently I had a lady discharged from hospital and she was sent out on Lyrica®
and Palexia® and Solpadeine® after one visit...it’s hard to figure out the rationale
sometimes and then you think she is on that medication now for months because
she could...and yet she has not got any nociceptive pain that I can figure. (GP5)
Patients’ views: Pain
• The pain was inhibiting me from doing other things. I do as much as I
can while I am fit. That is the other thing, my stamina isn’t nearly
what it was. I could do a full day’s work and do three meetings back
to back whereas if I can do one expedition out of the house now in
one day it is about as much as I can manage. (P28)
• Getting dressed in the morning is okay, and I sort of manage a way
around doing things, but I would say now, in the evening now, at this
time it would be, like if I was to go out say, to do something I just
couldn’t go out, I wouldn't be able to sit, I wouldn’t be able to manage
even if I go to a play or something like that, it would just be, the pain
would be too intolerable. (P19)
Patients’s views: Medicines
• My perception of it is that it’s essential for the maintenance of my health
and wellbeing. It also assists in maintaining my relationship with my wife,
my children and my grandchildren. (P13)
• If I happen to forget taking them or maybe went off by mistake, and I
wouldn’t have taken them, I’d know that evening that it would be much,
much more painful anyway. (P8)
• And you know it is a terrible vicious circle that you get into, you are taking
the medication, you know it is not going to cure it and at the same time
you keep taking it in the hope of just bringing it down a few levels and that
is [pause] I think if I was dealing with somebody else, I would be telling
them for God’s sake [sic] come off that medication, and here I am. I am
caught up in it. (P18)
Patients’ views: Family concerns
• Probably my family would be different because they’ve actually seen
me and seen me in pain and they would be very much inclined to say
look you know you’re going to end up taking it, why don’t you just
take it now instead of in 4 hours time when you’re much worse. They
would try to encourage me to take it much more. (P7)
• My husband is the worst…He doesn’t understand like, why I don’t take
them all the time, you know…he wants me to be better…And he wants
me to do things, you know, as a couple, as a family. (P4)
Patients’ views: Adverse effects
• I have osteoarthritis, a pain in my back, then eventually I got a stomach ulcer
from taking Difene® [diclofenac] They say that it may have been stress but it may
have been Difene® [diclofenac]. (P27)
Opioid side effects
• That would have been the main reason I would have taken a break from them. I
found that I was too sedated [pause] not so much sedated more that I felt maybe
a detached, like feeling like the world was going on around me. Even the children
were saying that my favourite hobby was sleeping! (P26)
• I tried this other one that came out a few years ago, in 2010, Palexia®
[Tapentadol], and I was very excited about it, but I couldn’t take it at all, I actually
fainted after taking it, within an hour of taking one [pause] I was sick with them,
and weak … well I was taking them for the two weeks and that’s it, it was only for
two weeks, it sort of helped with the pain but I couldn’t [pause] you see I am
trying to balance. (P11)
Patients’ views: Long term effects
• Addiction would be of a concern for me and with the family here and
you’re concerned about things like this. And they are very much aware
of what they do. And they’re concerned that I might be dependent too
much on them. (P16)
• In my opinion, and in my experience people with chronic pain people
don’t become addicted to opiates because it is just not something
they would want to do. (P11)
• I was speaking to a colleague at work about the very same thing, we
were sitting on night duty talking about it and she said, now you
might die younger, but at least you won’t be in as much pain.
[Laughter] (P 21)
Patients’ views: GPs, & the system
• The GPs there is a real need for more training and up-skilling in the area with me they
just don’t know what to do anymore and they haven’t known what to do for a good while
really. (P12)
• My doctor, I would give her, you know, top marks. She is excellent you know, and she kept
going until she got a diagnosis, and she is proactive in looking up new medication and
trying to get it right you know get it sorted, and as I said I always get her to check what
the hospital say. (P2)
• I know there were doctors who were writing out things but no one was paying any
attention to what the other fella was doing. (P23)
• It is so frightening and then you go from doctor to doctor, and surgeons to consultants,
and all the different specialities and all trying to look at you from this angle and that
angle. (P11)
• The way I have sort of gone because paying, not that I can afford it, but paying you will
get in somewhere much quicker anyway and you sort of have to weigh up things. (P1)
Qualitative interpretation - GPs
• Assessment
• Pragmatic approach taken, but neither holistic nor systematic
• WHO ladder useful at outset in Assessment but some GPs concerned to
slow/prevent progression/intensification of treatment
• Clinical Guidelines, except perhaps Palliative guidelines not routinely
useful
• Drug information – industry is main provider
• Silos, lack of access for referral - Collaborative care
• Primary Care Centres?
• Community Pharmacists?
Qualitative Interpretation - Patients
• Barriers to establishing relationships & working together at every level
• Influence care pathway that patient pursues
• Hard to understand difficulty in Assessment & Treatment selection
• Increases perception of need for ‘specialist’
• Practical modification & utilisation of treatments/adjuvants
• Family’s needs influence behaviour
• Patient’s role as manager of their condition & in deciding about use of
treatment/adjuvants is usually unrecognised
Unexplored
• Stigma & analgesics
• Vulnerable patients
• Cognitively impaired
• People with Intellectual Disability
Acknowledgements
• Anna Dahlgren
• Maire O’Dwyer
• Mary-Claire Kennedy
• Eimear O’Dwyer
Thank you - Go Raibh Maith Agaibh
Martin Henman