Opiates in Chronic Pain

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Opiates in Chronic Pain

• Dr S Vas, Barnsley VTS October 2014

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Quiz True or False

• 1.Deaths for adults aged 35 54 yrs of age
  exceed road traffic collisions and firearms
  incidents combined in the USA
• 2.55 of patients prescribed opiates will
  experience at least 1 side effect
• 3.Patients taking gt 100mg of morphine/day are
  more than 9 times more likely to accidentally
  over-dose than those taking lt 20mg of
  morphine/day
• 4.There is no evidence for the short term use of
  opiates in relieving pain
• 5.Medications such as Amitriptyline and
  Gabapentin should always be used before Opiates
  for persistent pain
• 6.Modified Release medications are more likely to
  cause tolerance and problem drug use

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Quiz True or False

• 7.Red flags indicating problem use include
• A.Earlier prescription seeking
• B.Frequent telephone appointments
• C.Claims of lost medication
• D.Presenting with other symptoms
• E.Intoxication
• F.Admissions to AE
• G.Frequent missed appointments
• H.Use of other scheduled drugs

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Intended Learning Outcomes

• Recognise the potential pitfalls of prescribing
  opiates in chronic pain
• Describe how to assess patients who will be
  prescribed opiates for chronic pain
• Understand the barriers to managing patients who
  use opiates for chronic pain

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Why focus on this?
http//www.dailymail.co.uk/health/article-2774300/
GPs-creating-nation-hooked-painkillers-Addictions-
codeine-morphine-drugs-reached-dangerous-levels.ht
ml
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Stats

• Deaths for adults aged between 35 and 54 yrs of
  age exceed road accidents and firearms incidents
  (Opioids for chronic non-cancer pain A position
  paper of the American Academy of Neurology, Sep
  2014)
• Comparable trends in the UK (http//www.hscic.gov.
  uk/searchcatalogue?productid12055returnid1683)
• Opioids are prescribed more often and for longer
  periods than would be predicted by their known
  efficacy in the management of persistent pain.
• Opioids are often prescribed in doses above which
  we know that harms outweigh benefits
  http//www.bmj.com/content/347/bmj.f5108?sso

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Other worrying evidence

• 80 of patients taking opioids will experience at
  least one adverse effect
• Common side effects directly related to opiates
  include
• Constipation, nausea, somnolence, itching,
  dizziness, vomiting
• Serious long term consequences include
• Hypogonadism and infertility, immunosuppression,
  falls and fractures in older adults,
  sleep-disordered breathing, nonfatal overdose
  hospitalizations and death from unintentional
  poisoning.
• There is a 9 fold increase in over-doses over
  100mg/day of Morphine equivalent dose (MED)
  compared to doses below 20 mg/day MED. There is
  3.7 4.6 increase in overdoses for amounts
  between 50 100mg/day.

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Efficacy

• There is evidence for significant short-term pain
  relief (average duration in trials was 5 weeks)
• There is no substantial evidence for maintenance
  of pain relief or improved function over long
  periods of time without incurring serious risk of
  overdose, dependence or addiction.
• One study found that patients with chronic pain
  on opioids reported decreased pain relief,
  functional capacity, and quality of life vs
  persons in chronic pain not on opioids, adjusting
  for severity

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Prescribing

• Drugs with demonstrated efficacy for persistent
  pain syndromes (e.g. tricyclic antidepressants
  and antiepileptic drugs for neuropathic pain)
  should always be prescribed before starting
  opioids.
• Discuss the risks and benefits with the patient
  and consider giving them written information
• Modified release preparations at regular
  intervals should be used
• Immediate release preparations are more
  associated with tolerance and problem drug use
  if they are required for persistent pain then
  consider pain team referral

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Prescribing

• Do NOT use Pethidine lipid soluble with rapid
  onset/offset action means a higher risk of
  problem drug use
• Consider potentially serious drug interaction
  i.e. Tramadol TCAs/SSRIs causing Serotonin
  Syndrome
• Start low and slowly titrate up
• British Pain Society suggest referral if no
  useful relief of pain symptoms at 120mg Morphine
  equivalent/24 hrs (I would suggest lower)

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Trial of Opioid Therapy

• This is recommended before prescribing opioids
  for long term use
• Assess mental health, including
• Current/past history of anxiety or depression
• Current/past history of substance misuse
• Family history of substance misuse
• Review should be at least monthly in the first 6
  months
• Goals of therapy should be agreed before starting
  treatment and reviewed at each assessment
• Consider a formal opioid contract

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Long Term Opioid Prescribing

• Treatment may be continued until
• the underlying painful condition resolves
• the patient receives a definitive pain relieving
  intervention (e.g. joint replacement)
• the patient no longer derives benefit from opioid
  treatment
• the patient develops intolerable side effects
• use of opioids becomes problematic

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Opioids and problem drug use

• May result in problem drug use, this is
  influenced by
• Social, psychological and health related factors
• Consider whether medications are being diverted
  to other people
• Addiction
• Characterised by certain behaviours such as
  impaired control over drug use, compulsive use,
  continued use despite harm and craving
• Dependence
• Specific withdrawal syndrome that can be produced
  by abrupt cessation, rapid dose reduction,
  decreasing blood level of the drug, or
  administration of an antagonist.
• Tolerance
• diminution of one or more of the drugs effects
  over time.

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Problem drug use

• elicit the patients thoughts on how they are
  using opioid analgaesia
• pattern of use is possibly more important than
  quantity especially if being used for improving
  mood
• Other red flags which may indicate problem drug
  use
• earlier prescription seeking
• claims of lost medication
• intoxication
• frequent missed appointments
• use of other scheduled drugs

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Opiates and driving

• Patients taking prescribed opioids may still
  drive
• Patients cannot drive if their use constitutes
  misuse or dependancy
• Patients being treated with opioids should be
  advised to avoid driving when
• the condition for which they are being treated
  has physical consequences that might impair their
  driving ability
• they feel unfit to drive
• they have just started opioid treatment
• their dose of opioids has been recently adjusted
  upwards or downwards (as withdrawal may have an
  impact on capability)
• they have consumed alcohol or other drugs that
  can produce an additive sedative effect.
• Patients should be advised to inform the DVLA
  they are taking opioids

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An example of a consultation

• http//www.opioidprescribing.com/module_5-video_1a
  

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Questions