Pain in Secure Environments Addiction to Medicines: Commissioning services after health reforms Prospero House February 2013 Cathy Stannard: Bristol UK
Mar 28, 2015
Pain in Secure EnvironmentsAddiction to Medicines: Commissioning services after health reforms Prospero House February 2013
Cathy Stannard: Bristol UK
Pain Management in Secure EnvironmentsPresentation overview Introduction and background to the project Process of preparation The guidance
Context Clinical Issues Diagnosis and prescribing Non-pharmacological management
Pathways
Introduction and backgroundPain in Secure Environments
www.britishpainsociety.org
Process of preparationPain in Secure Environments
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
Danny Alba NHS Wakefield DistrictProf Mike Bennett University of Leeds, Faculty of Pain Medicine Royal College of AnaesthetistsDr Iain Brew GP at HMP Leeds and RCGP Secure Environments Group MemberDr Michelle Briggs Senior Research Fellow, University of Leeds (on behalf of the Pain in Prisons NIHR programme development group)Ms Helen Carter Healthcare Inspector, Her Majesty's Inspectorate of PrisonsDr Beverly Collett Consultant in Pain medicine: Chronic Pain Policy Coalition, Faculty of Pain Medicine Royal College of AnaesthetistsMrs Cathy Cooke Chair: Secure Environment Pharmacists GroupDr Annette Dale-Perera Central and North West London NHS Foundation TrustMr Kieran Lynch National Treatment AgencyMr David Marteau Department of HealthMs Jan Palmer Department of HealthDr Mary Piper Department of HealthDr James Robinson Clinical Lead HMP Styal: RCGP Secure Environments Group Mr Mark Warren Avon and Wilts Mental Health PartnershipDr Amanda Williams Reader in Clinical health Psychology University College London; University College London Hospitals Policy ObserversMr Mark Edginton Department of HealthDr Mark PruntySenior medical officer for substance misuse policy: Department of Health
The guidancePain in Secure Environments
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 problemTrends in prescribingAdditional challenges in specific settingsFemale prison estateMale 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 analgesicspersistent pain is hard to treat so something strong is a tempting ideapain sufferers exhibit distressdistress makes clinicians want to do somethingwe know there are risks but think we can handle them
WHO 1986
Why are opioids prescribed?Because…they are strong analgesicspersistent pain is hard to treat so something strong is a tempting ideapain sufferers exhibit distressdistress makes clinicians want to do somethingwe know there are risks but think we can handle them
Figure 4: trends in the prescribing of opiates analgesics in general practice in England (Source: NHS National Treatment Agency May 2011).
Population 56.1 million
Figure 5: variation between Strategic Health Authorities in prescribing ofopioid analgesics (Quarter to March 2010) NHS prescribing services.
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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
Amitriptyline 10-75mg once daily
Nortriptyline 10-75mg once daily
Duloxetine 60-120mg once daily
Carbamazepine 200-1200mg daily in two divided doses
Gabapentin 900-2700mg daily in three divided doses
Pregabalin 150-600mg daily in two divided doses
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)
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 self-management 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 pre-existing persistent pain condition
History suggests •obvious precipitating event (trauma/tissue damage)•evidence of functional impairment
History and examination confirm diagnosis of neuropathic pain
Initiate paracetamol +/- NSAIDs
Initiate amitriptyline 10mg nocte increasing every few days as tolerated to 75mg nocte. If sedation a problem change to equivalent dose of nortriptyline
YesNo
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 active physiotherapeutic strategies (paced increase in exercise) supported by education about meaning and consequences of pain
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
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
Opioid Prescribing Pathway
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
Patient established on methadone complains of pain on dose reduction
Previous healthcare provider confirms pre-existing persistent pain condition
History suggests obvious precipitating event (trauma/tissue damage)evidence of functional impairment
Reassess pain as above with history and examination
No
Yes
Patients on methadone
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