Pain and Dependency / Pain Management in the Prison Population Dr Colin Baird Consultant in Anaesthesia & Pain Medicine Western General Hospital Leith.

Pain and Dependency / Pain Management in the Prison Population

Dr Colin BairdDr Colin Baird

Consultant in Anaesthesia & Pain MedicineConsultant in Anaesthesia & Pain Medicine

Western General HospitalWestern General Hospital

Leith Community Treatment CentreLeith Community Treatment Centre

Dr Rebecca LawrenceConsultant in Addictions PsychiatryRitson UnitRoyal Edinburgh Hospital

Dr Lesley ColvinConsultant / Honorary Reader in Anaesthesia and Pain MedicineUniversity of Edinburgh

Summary

Pain and Dependency – an overview•Dr Rebecca Lawrence

Management of Neuropathic Pain and how SIGN 136 can be implemented in the PAD clinic•Dr Colin Baird

Opioids for chronic pain in the prison population – good or bad?•Dr Lesley Colvin

Declaration of Interests / Funding

Edinburgh & Lothians Health Foundation Alcohol Problems Endowment Fund – contribution to MSc in Pain Management

Astellas Pharma Ltd – funding to attend BPS annual scientific meeting (2014)

Reckitt Benckiser – funding to attend Opioid Painkiller Dependence Education Nexus (September 2014)

Overview

Background / brief epidemiology

Lothian Pain & Dependency Clinic model

center-for-addiction-recovery.com

Chronic Pain and Dependencythe emerging co-morbidity?

Chronic pain of moderate to severe intensity occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives (Breivik, H., et al, 2006. Eur J Pain) (BPS figure - one in seven of UK population)

Estimated prevalence of problem drug use (opiates and/or benzodiazepines) Scotland 2012-13 of 1.68% population aged 15-64 (Scottish Government)

Up to 50% men and 30% women across Scotland exceeding weekly recommended guidelines (Changing Scotland’s Relationship with Alcohol: A Framework for Action, 2009)

Access to pain relief – an essential human right IASP, the WHO and EFIC

The UN Universal Declaration of Human Rights conceptualises human rights as based on inherent human dignity

Perception and expression of pain is individual: It is essential to listen to and believe the patient –

only they know what the pain feels like (A report for World Hospice and Palliative Care Day 2007 Published by

Help the Hospices for the Worldwide Palliative Care Alliance )

Substance misuse patients

Increased prevalence of pain

Poorer treatment outcomes. Yet treating pain improves outcomes

More likely to use illicit opioids / more drug-seeking

Chronic Pain Patients

• Increased prevalence of alcohol & drug misuse

• Hoffman et al (1995) – 23.4% of 414 hospitalized chronic pain patients in Sweden met criteria for active diagnosis of alcohol, analgesic or sedative misuse or dependence

• No demographic / clinical factors that consistently differentiate CNCP (chronic non-cancer pain) patients with comorbid SUD (substance use disorder) from patients without SUD, though may be at greater risk for aberrant medication-related behaviors.

Morasco, B.J., Gritzner, S., Lewis, L., Oldham, R., Turk, D.C., Dobscha, S.K., 2011. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. PAIN 152, 488–497. doi:10.1016/j.pain.2010.10.009

Pain & Opioid Dependency

Aberrant drug-related behaviour (Aberrant drug-related behaviour (““Red flagsRed flags””))

AbuseAbuse ( (DSM IV: Psychoactive Substance Abuse: A maladaptive pattern of drug use that results in harm or places the individual at risk)

PseudoaddictionPseudoaddiction: : Aberrant drug-related behaviour in patients reacting to under treatment of pain

Physical DependencePhysical Dependence Tolerance (side effects/ Tolerance (side effects/

analgesia)analgesia)

Pain, Mental Health & Alcohol

• Strong association between pain & psychopathology, particularly depressive disorders, anxiety disorders, somatoform disorders, substance use disorders & personality disorders

Dersh J, Polatin GB & Gatchel RJ (2002). Chronic pain and psychopathology: research findings and theoretical considerations. Psychosom Med 64(5):773-86.

Licensed Treatments Amitriptyline – depression & neuropathic

pain Duloxetine – depression, generalized

anxiety & diabetic neuropathy Pregabalin – peripheral / central

neuropathic pain & generalized anxiety Carbamazepine – trigeminal neuralgia,

prophylaxis of bipolar disorder

PSYCHOLOGICAL INTERVENTIONS

Other treatments for pain, mental disorders & substance misuse

Valproate Gabapentin Topiramate Lamotrigine Other antidepressants Baclofen Opiates Benzodiazepines

Ketamine infusion Deep brain

stimulation

Pain & Dependency (PAD)– the Edinburgh experience:

Development of combined Pain & Dependency (PAD) Clinic – 2003 (by Dr Lesley Colvin & Dr Michael Orgel)

Patients with drug dependence should not be denied adequate pain relief

Access to specialised services with experience in managing this patient group is essential

Scimeca, MC (2000)

Multidisciplinary

– Pain Specialist

– Addiction Psychiatrist

– Specialist Nurse

– Clinical Psychologist

What is the PAD Clinic?

Location & Referrals

PAD clinic is located in, & funded by, the Chronic Pain Service

Majority of referrals from GPs, also from Substance Misuse Service, and some diverted from Pain Service

Triage to PAD Current input from SMD (Substance Misuse Directorate) Current misuse of / dependence on illicit drugs (includes

legal highs - increasing problem) Current misuse of / dependence on alcohol Any history of drug / alcohol misuse with associated ongoing

mental health problems Not stable on prescribed methadone Prescribed > 150mg methadone (guide) Iatrogenic opioid misuse / dependence Misuse of over the counter or other prescribed medication Concern regarding gabapentin or pregabalin use (prescribed

or unprescribed)

PAD Clinic Assessment of pain, mental health and

substance misuse / addiction• Does not matter which “came first”• Verify past assessment• Initiate further assessment/ investigations

Does not provide key work or prescribing• Liaison with appropriate services

Mental health assessment (not ongoing monitoring and treatment)• Liaison with appropriate services

History: Pain and Substance Misuse

Pain• Diagram, BPI & associated symptoms• Past treatment & investigations

Substance misuse history• Stable/ chaotic – prescription? Support?• IVDA – Hep C/ HIV (BBV) status and Rx• Alcohol; stimulants & / or benzos; cannabis;

NPS; gabapentin…

Mental Health Social history Child protection issues

Examination: Pain and Substance Misuse

Pain: • Sensory changes/ ? neuropathic• motor impairment/ impact on function• Sympathetic involvement

Substance misuse: • Toxicology – urine / oral swab• Breathalyse• Signs of chronic drug / alcohol use• Track marks• Intoxication

Patients

“Established” drug users with pain (often on substitute prescriptions). Pain often a result of chaotic lifestyle

Pain resulting from alcohol dependence Concerning use of over the counter or

prescribed medication (usually opioids, but may be other drugs, eg gabapentin)

Past history of drug or alcohol use

Review of 36 new patients seen in PAD in 2014

25 male, 11 female Average age 41(26-59) None in employment Addiction first – 18 Pain first – 7 Unstable use of opioids – 19 Mental health problem - 26

Review of 36 new patients (2)

On methadone – 15 On dihydrocodeine – 4 On buprenorphine – 0 On gabapentin or pregabalin – 14 Use of NPS – 2 Problem alcohol use – 13 Cannabis use – 15 Benzodiazepines frequently used /

prescribed

Management

Assessment & Explanation Non-pharmacological – eg TENS (also

acupuncture, craniosacral therapy, massage - availability)

Pain Management Programme Individual psychological work Nerve blocks if appropriate Community support – substance misuse

services

Management Antidepressants - ? amitriptyline ?Gabapentin / Pregabalin Non-opioids – NSAIDs Optimise current opioid prescribing Strong opioids if needed – monitor Strong opioids – which? Topical treatments In patient assessment & treatment

The Future? Wider access to specialist care – where and

how best to deliver this? The changing patterns of drug misuse and

management of pain – abuse of prescribed drugs other than opioids, alcohol misuse and the spread of novel psychoactive substances

Long term side effects of opioids and implications for practice

Management of Neuropathic Pain and how SIGN 136 can be implemented in the PAD clinic

Dr Colin Baird

Summary

Neuropathic pain – the problem

SIGN 136

Management of neuropathic pain

How can this be applied to the prison / PAD clinic population?

Gabapentin and pregabalin…!

Neuropathic pain: ‘Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system’

Pain: ‘An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms thereof’

Neuropathic pain – the problem

Between 8 and 18% of adults in the UK, USA and Europe will suffer from neuropathic pain

It has a negative impact on mood, ability to function and general wellbeing

16% of sufferers rate it as ‘worse than death’ on the EQ5D

Current treatment is limited by side effects, lack of efficacy and variable individual response

Doth et al. Pain (2010); Torrance et al. J Pain (2006); Toth C et al. Pain Medicine (2009); B Smith

What causes neuropathic pain to develop?

Damage to the somatosensory nervous system

Surgery / Trauma

Infection (PHN)

Drugs – chemotherapy, alcohol

Disease – diabetes, HIV

Features of neuropathic pain

Spontaneous

EvokedHyperalgesia

Allodynia

Impaired ability to function

Negative impact on mood

SIGN 136 – now available!

http://www.sign.ac.uk/guidelines/fulltext/136/index.html)

Key recommendations:

Assessment and planning of care

Supported self-management

Pharmacological management

Psychologically based interventions

Physical therapies

Three consensus pathways:

Assessment, early management and care planning

Neuropathic pain

Use of strong opioids

Complementary to the British Pain Society Map of Medicine PathwaysComplementary to the British Pain Society Map of Medicine Pathways((http://bps.mapofmedicine.com/evidence/bps/index.html) )

LANSS

DN4 NPQ PainDETECT

Id-Pain

Country UK France USA Germany USA

Validated 100 160 382 392 308

Sensitivity

82 - 91 83 66 85 NA

Specificity

80 - 94 90 74 80 NA

Common symptoms

Pricking, tingling,pins and needles; Electric shocks/ shooting; hot/ burning

Common signs

Brush allodynia; raised pin prick threshold

Case history - NF

45 year old male – stab wound to the chest 10 years ago

Pain since incident. Had been managed with gabapentin but this was stopped due to suspicion of drug diversion

Referred to the PAD clinic

On amitriptyline 50mg at night

Symptoms: Burning, shooting pain ‘like toothache doctor!’

Signs: Hyperalgesia and allodynia around the affected area.

Pharmacological options – 1st line therapy

Amitriptyline: 25 – 125mg daily. Titrate up by 10mg per week

Gabapentin: Titrate up by 300mg per week to 1200 – 18—mg daily

Pregabalin: 75mg BD, titrate up by 75mg per week to 300 – 600mg daily.

GabapentinoidsGabapentinoids

GabapentinGabapentin PregabalinPregabalin

How should we incorporate these conclusions into our clinical practice?

Advice for prescribers on the risk of the misuse of pregabalin and gabapentin

Ref: PHE publications gateway number: 2014586; NHS England publications gateway number 02387 PDF, 157KB, 9 pages

Which if any, are options for NF?

GabapentinPregabalin

Amitriptyline

Pharmocological options – 2nd line therapy

Alternative TCA: Nortriptyline, Imipramine – same dosing regime as amitriptyline but may have more favourable side-effect profile

SNRI: Duloxetine, 30-60mg daily, can increase to 120mg daily. Nausea is main side-effect

Carbamazepine: In trigeminal neuralgia

Could try alternative TCA?

Duloxetine?

Topical agents for neuropathic pain

Lidocaine patches: Good side-effect profile. Application may be problematic

8% Capsaicin patch: For PHN, HIV neuropathy, post-surgical scar pain.

TENS machine

8% Capsaicin patch

1 application

Pain scores have fallen from 9 to 4 after 2 weeks

Look for improvements in sleep and function

Plan to repeat the application after 12 weeks

Pharmacological options – Opioids!!