Download Pain in Secure Environments

Pain in Secure
Environments
Addiction to Medicines: Commissioning services after health reforms
Prospero House February 2013
Cathy Stannard: Bristol UK
Pain Management in Secure
Environments
Presentation overview
 Introduction and background to the project
 Process of preparation
 The guidance
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Context
Clinical Issues
Diagnosis and prescribing
Non-pharmacological management
 Pathways
Pain in Secure Environments
Introduction and background
www.britishpainsociety.org
Pain in Secure Environments
Process of preparation
Pain in Secure Environments: cast list
Chairs of project and co-editors
 Dr Linda Harris
Medical Director RCGP Substance Misuse and Associated Health
 Dr Cathy Stannard
Consultant in Pain Medicine British Pain Society, Faculty of Pain Medicine Royal College of Anaesthetists
Members of Consensus Group
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Danny Alba
Prof Mike Bennett
Dr Iain Brew
Dr Michelle Briggs
group)
Ms Helen Carter
Dr Beverly Collett
Mrs Cathy Cooke
Dr Annette Dale-Perera
Mr Kieran Lynch
Mr David Marteau
Ms Jan Palmer
Dr Mary Piper
Dr James Robinson
NHS Wakefield District
University of Leeds, Faculty of Pain Medicine Royal College of Anaesthetists
GP at HMP Leeds and RCGP Secure Environments Group Member
Senior Research Fellow, University of Leeds (on behalf of the Pain in Prisons NIHR programme development
Healthcare Inspector, Her Majesty's Inspectorate of Prisons
Consultant in Pain medicine: Chronic Pain Policy Coalition, Faculty of Pain Medicine Royal College of Anaesthetists
Chair: Secure Environment Pharmacists Group
Central and North West London NHS Foundation Trust
National Treatment Agency
Department of Health
Department of Health
Department of Health
Clinical Lead HMP Styal: RCGP Secure Environments Group
 Mr Mark Warren
 Dr Amanda Williams
Avon and Wilts Mental Health Partnership
Reader in Clinical health Psychology University College London; University College London Hospitals
 Policy Observers
 Mr Mark Edginton
 Dr Mark Prunty
Department of Health
Senior medical officer for substance misuse policy: Department of Health
Pain in Secure Environments
The guidance
 It is the right of every person in custody to have access to
evidence based pain management
 It is the right of every person in custody to have access to
evidence based pain management that can be safely
delivered to them
 It is the right of every person in custody to have access to
evidence based pain management that can be safely
delivered to them
 Medications are properly a cause for concern
 Medications play a partial role only in pain management
 Document aims to empower clinicians working in secure
environments
Pain Management in the Secure
Environment: context
 Size of the problem
 Trends in prescribing
 Additional challenges in specific settings
 Female prison estate
 Male high security prisons
Key points: context
 The prevalence of long term pain in the secure environment
population is unknown
 A number of risk factors for chronic pain exist in this population
including mental health and substance misuse disorders,
physical and emotional trauma
 There may be difficulty in distinguishing patients needing
medication for pain and those requesting drugs to continue
substance misuse or as a commodity for trade
 The secure environment offers an opportunity for regular
assessment of the effect of analgesic medications on pain and
function
 Professional isolation and fear of criticism and complaints erode
confidence in prescribing decisions
Pain Management in the Secure
Environment: clinical issues
 Diagnosis and prescribing
 Diagnosis of persistent pain
 Diagnosis of neuropathic pain
 Diagnosis of visceral pain and poorly defined disorders
Key points: diagnosis of pain
 Pain is a subjective experience and the diagnosis can only be made
by interpretation of the patients’ report
 Good communication with the patients’ community healthcare
providers helps identify pre-existing painful conditions
 Onset of pain can usually be related to an obvious inciting event
including trauma or other tissue damage
 Pain is usually associated with an observable (but variable)
decrement in physical functioning
 Diagnosis of neuropathic pain can be supported by the history
(nerve injury or damage) and by abnormal findings on sensory
examination
 Understanding the complexity of origin of visceral pain and of poorly
defined disorders can help in planning realistic interventions.
Pain Management in the Secure
Environment: clinical issues
 Diagnosis and prescribing
 Role of opioids in persistent pain
 Pharmacological management of neuropathic pain
 Pharmacological management of visceral pain and poorly defined
disorders
 Non-pharmacological management of pain
 Psychological interventions
 Physical rehabilitation
Why are opioids prescribed?
Why are opioids prescribed?
Because…
 they are strong analgesics
 persistent pain is hard to treat so something strong is a tempting idea
 pain sufferers exhibit distress
 distress makes clinicians want to do something
 we know there are risks but think we can handle them
WHO 1986
Why are opioids prescribed?
Because…
 they are strong analgesics
 persistent pain is hard to treat so something strong is a tempting idea
 pain sufferers exhibit distress
 distress makes clinicians want to do something
 we know there are risks but think we can handle them
Population 56.1 million
Figure 4: trends in the prescribing of opiates analgesics in
general practice in England (Source: NHS National
Treatment Agency May 2011).
Figure 5: variation between Strategic Health
Authorities in prescribing of
opioid analgesics (Quarter to March 2010) NHS
prescribing services.
50
Prescriptions- noncancer
45
Prescriptions- cancer
5
40
Patients- noncancer
Patients- cancer
4
35
30
3
25
20
2
15
10
1
5
0
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Total number of prescriptions and
number of patients stratified by
non-cancer and cancer CPRD
2000-2010
Number of prescriptions ( 104)
Number of patients (104)
6
Defined daily doses per 1000 patients per day
CPRD 2000-2010
DDD/1000 patients/day
25
Buprenorphine
Fentanyl
Morphine
Oxycodone
20
15
10
5
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Non-cancer pain
DDD/1000 patients/day
3.0
Buprenorphine
Fentanyl
Morphine
Oxycodone
2.5
2.0
1.5
1.0
0.5
0.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Cancer pain
Opioid use associated with:
 Report of moderate/severe pain
 Poor self-related health
 Unemployment
 Increased use of healthcare system
 Negative influence on QOL
Opioid adverse effects
 No pain relief
 Worsening of pain
 Cognitive impairment/somnolence precluding effective
engagement with pain management strategies
 Endocrine and immune effects
 Addiction
www.britishpainsociety.org
Key points: opioids for persistent
pain
 The WHO analgesic ladder has poor applicability in the treatment of persistent pain
 Evidence for effectiveness of opioids in management of long term pain is lacking,
particularly in relation to important functional outcomes
 Opioid therapy should be used to support other strategies for pain management e.g.
physiotherapy
 If useful relief of symptoms is not achieved at doses of 120mg morphine equivalent/day,
the drugs should be tapered and stopped
 Both strong and weak opioids should be prescribed with caution
 There is no evidence that any opioid produces superior pain relief to morphine
 Symptoms should usually be treated with sustained release opioid preparations
 Fast acting preparations should not be used for the treatment of persistent pain
 Methadone has an established role in the treatment of long-term pain: patients with a
diagnosis of pain receiving methadone opioid substitution therapy can be managed by
maintaining an effective daily dose of methadone given in two divided increments
 Conversion ratios between opioids vary substantially especially when converting to or
from methadone. Cautious conversion ratios should be used and the effect reviewed
regularly
Key points: pharmacotherapy for
neuropathic pain
 Medications are the best way to treat neuropathic pain but
fewer than a third of patients will respond to a given drug
 Pain relief from neuropathic pain medications is modest
 Tricyclic antidepressants are the most effective treatment of
neuropathic pain
 Carbamazepine may be effective in the management of
neuropathic pain
 Gabapentin and pregabalin are unsuitable as first-line drugs
for use in secure environments
Suggested dosing for commonly used drugs in the treatment of
neuropathic pain
(All drugs should be started at a low dose with at least one week
between dose increments: the figures below represent the starting
dose and a suggested upper dose limit)
Amitriptyline
10-75mg once daily
Nortriptyline
10-75mg once daily
Duloxetine
60-120mg once daily
Carbamazepine
200-1200mg daily in two divided
doses
900-2700mg daily in three divided
doses
150-600mg daily in two divided doses
Gabapentin
Pregabalin
Key points: visceral pain and
poorly defined disorders
 Psychological interventions are the mainstay of management
of visceral pain and poorly defined disorders
 Tricyclic antidepressant drugs may play a role in the
management of pain associated with irritable bowel
syndrome
Key points: non-pharmacological
management of pain
 It is important to address fears and mistaken beliefs about the
causes and consequences of pain
 Co-morbid depression and other psychological disorders should
be treated as part of pain management
 There is good evidence for active physical techniques in the
management of pain
 Physical rehabilitation is best combined with cognitive and
behavioural interventions
 Interventions such as TENS and acupuncture are poorly
supported by evidence for benefit but may support selfmanagement of pain
Patient presents with pain
Assess pain including
• History of onset/inciting events
• Current symptom description
• Exacerbating and relieving influences
• Effect of pain on function including sleep
• Previous treatments for pain
• Current medication (confirm from previous HCP)
• Medical/surgical history
• Mental health history including substance misuse
• Social history
• Patient’s understanding of symptoms
Previous
healthcare
provider
confirms preexisting
persistent pain
condition
History suggests
• obvious precipitating event (trauma/tissue damage)
• evidence of functional impairment
History and examination
confirm diagnosis of
neuropathic pain
No
Initiate paracetamol +/NSAIDs
Yes
Initiate amitriptyline 10mg
nocte increasing every few
days as tolerated to 75mg
nocte. If sedation a problem
change to equivalent dose of
nortriptyline
Consider active physiotherapeutic
strategies (paced increase in
exercise) supported by education
about meaning and consequences
of pain
If no response to tricyclic
antidepressants use anti-epileptic
drugs starting with carbamazepine.
For refractory cases of neuropathic
pain of confirmed origin consider
opioid therapy
Consider night-time
amitriptyline if sleep
disturbed by pain
For refractory cases of well-defined
pain consider opioid therapy
Manage depression and other psychological disorder in accordance with
local guidance
Opioid Prescribing Pathway
FOR ALL PATIENTS
Manage depression and other psychological disorder in
accordance with local guidance
Consider active physiotherapeutic strategies (paced increase in
exercise) supported by education about meaning and consequences
of pain
Consider opioid treatment for
• Severe osteoarthritis
• Pain following multiple spinal surgery
• Neuropathic pain unresponsive to tricyclic
antidepressants/antiepileptic drugs
Discuss harms of long term opioids including limited
efficacy, endocrine and immune effects and
hyperalgesia
Initiate time constrained trial of opioid therapy.
• Define goals of therapy
• If symptoms not relieved and functional goals not
met after three upwards dose adjustments, taper
and stop opioids
Start once daily morphine 20mg and review
regularly for upwards dose titration
If no substantial pain relief or functional
improvement at 120mg morphine
equivalent/24 hours taper drug and stop
Patients on methadone
Patient established on methadone
complains of pain on dose
reduction
Previous healthcare
provider confirms preexisting persistent pain
condition
Yes
History suggests
obvious precipitating event
(trauma/tissue damage)
evidence of functional impairment
No
Reassess pain as above
with history and
examination
Suspend methadone
taper and give daily
dose of methadone in
2 x 12 hourly
increments
Convert to once daily morphine
starting with conservative
conversion (Methadone 1mg =
morphine 2mg) and review
regularly for upwards dose
titration
If dose of morphine
exceeds 120mg/24
hours, consider gradual
taper once conversion
complete