British Medical Associationbma.org.uk
Chronic pain: supporting safer
prescribing of analgesics
March 2017
1British Medical Association Chronic pain: supporting safer prescribing of analgesics
Contents
1 Background ............................................................................................................................................................2
2 Introduction ...........................................................................................................................................................32.1 Definingchronicpain ................................................................................................................................32.2 Prevalenceofchronicpain .....................................................................................................................32.3 Analgesic drugs ...........................................................................................................................................4
3 Analgesicuseforchronicpain .......................................................................................................................53.1 Analgesicprescribingforchronicpain:UKtrends...................................................................... 53.2 Analgesicuseinchronicpain–exploringtheevidence ...........................................................73.3 Potentialharmsassociatedwithlong-termanalgesicuseinchronicpain ...................11
4 Supportingthemanagementofpatientswithchronicpain ........................................................14
5 Roleoftrainingandeducationinimprovinganalgesicusefortreatingchronicpain .......205.1 A focus on undergraduate training .................................................................................................205.2 Promotingguidancetosupportimprovedanalgesicprescribingforchronicpain ...21
6 Conclusionandsummaryofrecommendations ................................................................................ 22
7 Furtherresources ............................................................................................................................................. 24
Appendix1–classificationofchronicpain .................................................................................................... 25
Appendix2–specialisttraininginpainmedicine ...................................................................................... 26
Acknowledgements ................................................................................................................................................. 27
References .................................................................................................................................................................... 28
Abbreviations
ACMD AdvisoryCouncilontheMisuseofDrugs BMA BritishMedicalAssociationBPS BritishPainSocietyCDC Centers for Disease Control and PreventionCQC CareQualityCommissionEPM EssentialPainManagement FPM FacultyofPainMedicineIASP InternationalAssociationfortheStudyofPain ICD InternationalClassificationofDiseasesNHS NationalHealthServiceNICE NationalInstituteforHealthandCareExcellenceNSAID Nonsteroidalanti-inflammatorydrugPHE PublicHealthEnglandRCGP RoyalCollegeofGeneralPractitioners RCOA RoyalCollegeofAnaesthetistsSIGN ScottishIntercollegiateGuidelinesNetworkSNRI Serotonin–norepinephrinereuptakeinhibitorSSRI SelectiveserotoninreuptakeinhibitorTCA TricyclicantidepressantWHO WorldHealthOrganization
ThispublicationwaspreparedundertheauspicesoftheBMAboardofscience.ApprovalforpublicationwasrecommendedbyBMAcouncilon24March2017.
WearegratefultotheFacultyofPainMedicineoftheRoyalCollegeofAnaesthetistsfortheirguidanceinproducingthisdocument.AfulllistofcontributorscanbefoundintheAcknowledgementssectionattheendofthisdocument.
2 British Medical Association Chronic pain: supporting safer prescribing of analgesics
1 Background
Themanagementofpatientswithchronicpaincanpresentsignificantchallenges,1 and thesubstantialpublichealthharmsinrelationtoprescriptionanalgesicsseenintheUnitedStatesandelsewherehaspromptedrenewedeffortstoassesstheroleofmedicinesinpainmanagement.TheBMA’s2016analysisreportonPrescribed drugs associated with dependence and withdrawal,notestheincreaseinanalgesicprescribingforthispatientgroup2andaddstothecurrentconversationaboutwhetherprescribinganalgesicsisalwaysinthepatient’sbestinterestsgiventhat,foropioidsinparticular,thereislimitedevidenceforefficacyintreatinglong-termpain.2,3Thisrepresentsapotentiallysignificantpublichealthissue,andourmembershavecalledfortheexplorationoffactorsthatcouldsupportthesaferprescribingofopioidanalgesics.Suchanapproachwouldensurethatpatientsareonlyprescribedmedicinesfromwhichtheyderivebenefitandwilllimitmedicationassociatedharms.Thisisimportantgiventhecostofopioidprescribing,whichinEnglandisestimatedtototalover£300million,andinScotlandtoover£32million,annually.4,5
Thisbriefingpaperhighlightssomeofthekeyissuessurroundingtheuseofanalgesicsinthemanagementofpatientswithchronicpain;settingoutarangeofrecommendationsforgovernments,policymakersandhealthcareprofessionals,withtheaimofsupportingthesaferprescribingofthesemedicines.Whilstitprovidesanintroductiontothecurrentstateoftheevidenceinthisarea,itisnotintendedtoprovideasystematicreviewoftheevidenceoractasaclinicalguide.Acomprehensiveresourcetosupporttheclinicaluseofopioids–Opioids Aware–hasrecentlybeendeveloped(seeSection 3).
IssuessurroundingtheappropriateuseofanalgesicsareofwiderelevancetoBMAmembersacrossdifferentbranchesofpractice.ThisbriefingfollowsaBMAboardofscienceseminarinSeptember2014,initiatedbyBaronessIloraFinlay(BMApresident2014-15),whichexploredproblemsfacingclinicianswhenprescribingopioidsinpalliativecareandforchronicpain.
3British Medical Association Chronic pain: supporting safer prescribing of analgesics
2 Introduction
Paincanbedefinedasanunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage.6Thecomplexityandprevalenceofpainmakeitamajorclinicalandsocialchallenge.Accordingtothe2015globalburdenofdiseasestudy,chronicpainconditionsareamongstthemostsignificantcausesofsufferinganddisabilityworldwide.7 Pain canoftenco-occurwithemotionalandmentalhealthdifficulties.Paincanbeassociatedwithanxietyanddepressionandmentalhealthdiagnosesandemotionaldifficultiescaninfluencetheexperienceofpainandcomplicatemanagement.Anestimated49%ofpatientsintheUKsufferingfromchronicpainalsosufferfromdepression.8Datafromthe2011HealthSurveyforEnglandindicatethat,aswellasdepression,chronicpainisassociatedwithamultitudeofnegativehealthandsocialoutcomes,includingpoorermentalwellbeing,anxiety,job/incomeloss,impairedfunctionandlimiteddailyphysicalandsocialactivities.9
2.1 Definingchronicpain
TheIASP(InternationalAssociationfortheStudyofPain)defineschronicpainaspainthathaspersistedbeyondnormaltissuehealingtime.Itcanbecontinuousorinterruptedbypain-freeintervals.10Intheabsenceofothercriteria,chronicpainisusuallytakentobepainthathaspersistedforthreemonths.Althoughthistemporaldefinitionmaybemoreusefulforresearchratherthanclinicalpurposes,theBPS(BritishPainSociety)andtheSIGN(ScottishIntercollegiateGuidelinesNetwork)usethethree-monthdefinitionasthebasisfortheirrecommendationsonthetreatmentofchronicpain.11,12
Painhasbeenhistoricallysubdividedaccordingtothepresumednatureofthetissueinjury.Theremaybeanumberofunderlyingmechanismsincludingsomatictissueinjury,damagetonervesandpainfromviscera.Thesecategoriesoftenoverlap.Thereisoftennotanidentifiablecurrentinjury,butpainmayrelatetopreviousinjuryordiseaseorabnormalsensoryprocessing.Theperceivedintensityofpaindoesnotnecessarilyrelatetothedegreeoftissueinjuryandisinfluencedbymanyfactorsincludingthepatient’sunderstandingofandconcernsaboutthepain,anxiety,distress,expectationsandpreviousexperienceofpain. 13,14,15,16 Thereisalsonowincreasingunderstandingofthelongtermhealthimpactofearlyadverseexperiences,andtheassociationbetweenemotionaltrauma,post-traumaticstressdisorderandpainhasbeenwelldescribed.17,18
Therearemultipleclassificationsofchronicpain,andAppendix 1providesanoverviewofthosethathavebeendevelopedbytheIASPforinclusioninthe11threvisionoftheWHO(WorldHealthOrganization)InternationalClassificationofDiseases.
2.2 Prevalence of chronic pain
Ithasbeenestimatedthataround20%ofadultsinEurope,andthat13%ofadultsintheUKexperiencechronicpain,thoughthisvariesdependingonthecriteriaanddefinitionsused.19,20
Ameta-analysisofpopulationstudiesestimatedthatchronicpainaffectsbetweenonethirdandonehalfoftheUKpopulation,andthatbetween10.4%and14.3%ofthepopulationoftheUKreportseverelydisablingchronicpainthatiseither‘moderately’or‘severely’limiting.21 TheNationalPainAuditestimatedthat11%ofadultsand8%ofchildrenintheUKsufferfromseverepain.20Inthe2011HealthSurveyforEngland31%ofmenand37%ofwomenoverallreportedtohavepainordiscomfortthattroubledthemallofthetimeor‘onandoff’formorethanthreemonths;22thisincreasedwithage,from14%ofmenand18%ofwomenaged16-34comparedto53%ofmenand59%ofwomenaged75andover.22
Key message – ThereisasubstantialburdenofchronicpainintheUKpopulation,thoughspecificprevalencefiguresvarydependingonthecriteriaanddefinitionsused.
4 British Medical Association Chronic pain: supporting safer prescribing of analgesics
Theincreasingprevalenceofchronicpaininapopulationwithagrowingproportionofolderpeoplemaybedirectlycontributingtotheincreasedprescribingofanalgesics,includingopioids.Numerousstudieshavesuggestedthatchronicpainismorecommonamongstolderpopulations,althoughnotnecessarilytheveryoldestagegroups.23,24Thisisparticularlythecasewhenrelatedtopaincausedbyconditionssuchasosteoarthritis,25 withtheseverityofchronicpainalsoincreasingwithage.25AsthemedianageoftheUKpopulationhasincreasedsignificantly–from33.9in1974to40.0inmid-2014–and17.6%ofthepopulationisnowover65,26 itwillbeimportanttoconsidertheimpactthismayhaveondemandforpainmanagement.
2.3 Analgesic drugs
Anumberofdrugclasseshaveeffectsonpainprocessingsomeofwhichareusedforotherindicationse.g.depressionandepilepsy,astherearecommonunderlyingbiologicalprocesses.Whilsttheprimaryfocusofthisbriefingpaperisonthesaferprescribingofstrongopioidanalgesics,Figure 1providesasummaryofthevarioustypesofdrugsthatareusedforthetreatmentofpain.Box 1providesabriefoverviewofopioidpharmacology.
Figure1–Summaryofdifferentanalgesicdrugs
Analgesic type Examples
Simpleanalgesics paracetamol,aspirin
NSAIDs(nonsteroidalanti-inflammatorydrugs)
ibuprofen,naproxen,diclofenac,celecoxib,mefenamicacid,etoricoxib,indomethacin,aspirin
compoundanalgesics co-codamol(codeineandparacetamol), co-dydramol(dihydrocodeineandparacetamol),co-codaprin(codeineandaspirin)
weakopioid codeine,dihydrocodeine
strongopioid morphine,buprenorphine,fentanyl,methadone,oxycodone,tapentadol,tramadol
drugswithanti-epilepticaction carbamazepine,pregabalin,gabapentin
tricyclicantidepressants amitriptyline,nortriptyline
serotonin-noradrenalinereuptakeinhibitors
duloxetine
Source:BritishNationalFormulary(availableat:www.evidence.nhs.uk/formulary/bnf/current)
Box 1 – Basic opioid pharmacology
Opioiddrugsproducetheireffectsbyactivatingopioidreceptors,locatedinthecentralnervoussystem,peripheralnervoussystemandperipheraltissues.Activation,27 results in areductionofneuronalcellexcitabilitythatinturnreducestransmissionofnociceptiveimpulses.
Opioidscanbenatural,syntheticorsemi-synthetic.Naturalopioidsarethosederivedfromthealkaloidsfoundinopium,suchasmorphineandcodeine.Semi-syntheticopioidsarederivedfromnaturalopioids,andincludeoxycodone(derivedfromthebaine),hydrocodone(derivedfromcodeine)anddihydromorphine(derivedfrommorphine).Syntheticopioidsaresynthesisedfromchemicalsandmoleculesthatdonotcomefromthealkaloidsfoundinopiumbutsharetheabilitytobindtoandactivateopioidreceptors.Examplesofsyntheticopioidsincludemethadone,fentanylandtramadol.28Someopioids–includingcodeine–areprodrugsthatexerttheiranalgesiceffectaftermetabolism.
5British Medical Association Chronic pain: supporting safer prescribing of analgesics
3 Analgesic use for chronic pain
Theprescribingofopioidshasincreasedmarkedlyoverrecentyears,althoughtheevidencefortheirefficacyinthetreatmentofchronicpainconditionsremainsweak,andourincreasingknowledgeoftheirshortandlong-termsideeffects,raisesquestionsovertheiruse.2,3Thefollowingsectionshighlightrecenttrendsintheprescribingofopioidandotheranalgesics,andexploretheevidencefortheefficacy,safetyandpotentialharmsassociatedwiththeiruseinpeoplesufferingfromchronicpain.
3.1 Analgesic prescribing for chronic pain: UK trendsInrecentyearstherehasbeenasubstantialincreaseinthenumberofopioidanalgesicsprescribedforthemanagementofchronicnon-cancerpain,withincreasesoccurringinallpartsoftheUK,significantlyinexcessofanypopulationincreases(seeBox 2).Whileitisnotpossibletodetermineifitemswereprescribedforchronicpain,orwhethertheywereusedinpalliativecare,researchindicatesthatthemajorityofprescriptionsforopioidanalgesicsareforpatientswithchronicnon-cancerpain.29
Box 2 – Opioid prescribing trends in the UK
England – Therewasayearonyearincreaseinopioidprescribinginthecommunityfrom228millionitemsin1992to1.6billionin2009.30
– ThenumberofopioidanalgesicsprescribedingeneralpracticeinEnglandincreasedby1.5millionbetween2008and2013.22
– ThemostcommonlydispensedopioidanalgesicinEnglandisco-codamol,acompoundanalgesicofcodeineandparacetamol,withnumbersofprescribeditems–bychemicalname–increasingby5%from14.89millionto15.58millionbetween2010and2014.31,32 Overthesametimeperiodtheuseofmorphineroseby66%from2.44millionprescribeditemsto4.05million; buprenorphineuseroseby53%(1.19millionto1.83million);oxycodoneby44%(0.89millionto1.28million);codeineby37%(3.03millionto4.16million)andfentanylprescribingroseby22%(0.99millionto1.21million).32
Scotland – Theprescribingofanumberofopioidsincreasedbetween2010and2015.Thefastestincreaseswereseenforcodeineandmorphine.
– Over50%moremorphinewasdispensedin2014/15thanfouryearsearlier,upfrom280,351to440,472items.Codeineuseroseevenmorerapidly,witha64%increasefrom89,159to146,561items.Tramadoluserose12%from972,922to1,091,237items.Therewasalsoa33%increaseinoxycodoneuseanda23%increaseforfentanyl.33
Wales – Between2010and2014theprescribingofmorphineincreasedby105%,from168,736to345,808items,andcodeinefrom63%from85,528to120,257items.Tramadoluseroseby5%overtheperiod(563,071to592,678),buprenorphineby22%(93,843to114,559)andoxycodoneby23%(72,139to88,997).
Northern Ireland – AvailabledatafromNorthernIrelandindicatethatanalgesicuseoverallincreased by9.7%between2010and2014andby36.4%between2004and2014.34
Key message – AllpartsoftheUKhaveseensubstantialincreasesintheprescribingofopioidsoverrecentyears.
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3.1.1 Other analgesics
Gabapentin and pregabalin TherehasbeenasteepriseinthenumberofprescriptionsofgabapentinandpregabalinforthemanagementofchronicpainingeneralpracticeinEngland.22In2012,nearlythreemillionitemsofpregabalin,andthreeandahalfmillionitemsofgabapentinwereprescribed,representinga350%and150%increaseinprescribingofthesedrugsrespectively,since2007.35,36In2013,thetotalcostforthesemedicinesinEnglandwas£237.9m,mostofwhichwasaccountedforbypregabalin,whichisstillunderpatentforuseinpain,andcostatotalof£211.2min2013.37
Scotlandhasseenasimilarlyrapidincreaseintheprescribingofgabapentinandpregabalin.Between2010/11and2014/15,thenumberofitemsdispensedforeachdrugmorethandoubled,withgabapentinrisingfrom302,736itemsto629,741,andpregabalinrisingfrom133,985to364,111items.34InWales,pregabalinitemsdispensedmorethandoubledbetween2010and2014,increasingfrom121,495to282,183,andgabapentinuserosefrom192,767to395,109items.42InNorthernIreland,pregabalinappearstobeprescribedmuchmorereadilythanintherestoftheUK,38withthecombinednumberofitemsofgabapentinandpregabalinprescribedtotalling352,000for2013,a29%riseintwoyears.39Asthesefiguresdonotbreakdowndispenseditemsbyindicationitisnotpossibletodeterminepreciselytheproportionprescribedforthetreatmentofpaincomparedto,forexample,thoseprescribedtotreatepilepsy.However,manufacturersofpregabalinhaveestimatedthatapproximately80%oftotalUKpregabalinprescriptionsareforthetreatmentofneuropathicpain.40
AntidepressantsTherehasbeenanincreaseintheuseofantidepressantsthataremostcommonlyusedorrecommendedforthetreatmentofpain.Totalprescriptionsforamitriptylineincreasedby36.1%andforduloxetineby131.3%,to11.85millionand1.36millionitemsrespectivelyinEnglandbetween2010and2014.31,32Althoughnotbrokendownbyindication,amitriptylineisnowusedmorecommonlyfortreatingpainthanitisfordepression.41InScotland,between2010/11and2014/15,amitriptylineprescriptionsincreasedby25.6%from931,799to1,169,917itemsandduloxetineby150%from60,279to150,790items.33InWales,amitriptylineincreasedby50.6%from575,196itemsto866,025items,andduloxetine108.7%from88,883to185,425items.42InNorthernIreland,prescribedamitriptylineitemsincreasedby76.2%from222,358to391,720andduloxetinefrom58,284to106,980items,or83.5%.34
NSAIDsItisnotclearwhatproportionofNSAID(nonsteroidalanti-inflammatorydrug)prescribingisforindividualswithchronicpain.TheprescribingofdiclofenacinthecommunityinEnglandhasreducedsignificantlyinrecentyears,fromover8.6millionitemstolessthan3million,nowaccountingforapproximately10%ofNSAIDprescriptions.43 ThesedatareflecttrendsthroughouttherestoftheUKwheretheprescribingofdiclofenachasdecreasedoverrecentyears.33,34,42Thishasmostlikelyresultedfromupdatedguidanceonitscardiovascularrisk(seeSection 3.3),andmayhaveimportantimplicationsfortheprescribingofopioidanalgesics.Incontrast,theprescribingofNaproxeninEnglandincreasedfrom1.1millionitemsin2005to7.6millionin2015.43 OverthesametimeperiodtheprescribingofIbuprofenincreasedfromapproximately6millionitemsto7.3million.InScotlandtheprescribingofibuprofeninthecommunityincreasedby79%between2014/15and2015/16,withNaproxenprescribingincreasingby18%.33
7British Medical Association Chronic pain: supporting safer prescribing of analgesics
3.2 Analgesic use in chronic pain – exploring the evidence
Thefollowingprovidesabriefintroductiontotheevidencesurroundingtheeffectivenessofopioidsandotheranalgesicsfortreatingchronicpain,aswellasthepotentialharmsassociatedwiththesedrugs.
3.2.1 EfficacyofopioidsforchronicpainAshighlightedbyOpioids Aware,thereisalargebodyofevidence–includingrandomisedcontrolled trialsaandsystematicreviews–thathasconcludedthatopioidsmayreducepainforsomepatientsintheshortandmediumterm(lessthan12weeks).44Theiruseinacutepainandforpainattheendoflifeiswellestablished.Thereis,however,alackofconsistentgood-qualityevidencetosupportastrongclinicalrecommendationforthelong-termuseofopioidsforpatientswithchronicpain.Meta-analysesassessingevidenceoftheeffectivenessofopioidsforpatientswithchronicpainofwhateveraetiology,havesuggestedthattheyareonlyeffectiveinaminorityofpatients.4,45,46,47,48,49,50,51,52,53
Alimitingfactoristhatmostclinicaltrialsofchronicpainmedicinesareconductedovera12-weekperiod,andthereareverylimiteddatathatprovideevidencefortheiruseforperiodsoflongerthansixmonths.Giventhelimiteddurationofmostclinicaltrialsforopioidanalgesics,andtheimpracticabilityofusingplacebocontrolsoverprolongedperiods,dataontheefficacyoflong-termusehasbeenlimitedtoassessmentincaseseriesandopen-labelextensionsofcontrolledtrials,bratherthanplacebo-controlledstudies.44Analysisofthesedatadoesnotallowfirmconclusionswithregardstofunctionalimprovementorimprovementinapatient’squalityoflife.A2015meta-analysis–assessingtheefficacy,tolerabilityandsafetyofopioidanalgesicsinopen-labelextensiontrialsoveradurationofsixmonthsormore–highlightedthatonlyaminorityofpatientsselectedforopioidtherapycompletedthestudies,yetsustainedeffectsofpainreductioncouldbeseeninthesepatients,includinginthosewithneuropathicpain.54Longtermcohortdatamayprovidefurtherinformationontheexperiencesofpatientsusingopioidslong-terminclinicalpractice.55Similarly,ithasbeensuggestedthat‘pragmatictrials’measuringawiderangeofpatientoutcomesshouldbeutilisedforassessingtheeffectivenessofpainmedications.56
Onedifficultyinassessingtheeffectivenessofopioidtreatmentarisesfromthenumberofpossibleadverseeffects,includingnausea,headache,somnolence,urinarycomplicationsandconstipation(seeSection 3.3).Manystudiessufferfromlow-compliancerates,57withpatientsdiscontinuingtreatmentduetoadverseeffectsorwithinsufficientpainrelief.
Ina2009evidencereviewbytheAmericanPainSociety,itwashighlightedthatwhilstrecommendationsfortheuseofopioidsinchronicpainhavebeenmadeonthebasisofasystematicreview,thesearerarelysupportedbyhighquality,orevenmoderatequalityevidence.Instead,theyrelyonexpertconsensustoovercomenumerousresearchgapsinareassuchasbalancingtherisksandbenefitsofopioidtherapy.58
Key messages – Thereisalackofgood-qualityevidencetosupportastrongclinicalrecommendationforthelong-termuseofopioidsforpatientswithchronicpain
– Thereareonlylimiteddatathatprovideevidencetosupporttheuseofopioidsforperiodsoflongerthansixmonths
– Manyclinicalstudiesofopioidsforchronicpainsufferfromlow-compliancerates,withpatientsdiscontinuingtreatmentduetoadverseeffectsorwithinsufficientpainrelief.
a Randomisedcontrolledtrialsarestudiesinwhichpeoplearerandomlyassignedto2(ormore)groupstotestanintervention.Onegrouphastheinterventionbeingtested,theother(controlgroup)hasanalternativeintervention,adummyintervention(placebo)ornointerventionatall.
b Open-labelextensionstudiestypicallyfollowonfromrandomisedcontrolledtrials,toallowassessmentoveralongerperiodoftime.Theyarenotplacebocontrolledandbothresearchersandparticipantsknowwhattreatmentisbeingadministered.
8 British Medical Association Chronic pain: supporting safer prescribing of analgesics
Current guidance on opioid prescribing for chronic pain Despitelimitationsintheevidence,guidanceisavailableforprescribersintheUKontheuseofopioidsfortreatingpain.ClinicalguidancefromNICE(NationalInstituteofHealthandCareExcellence)ondrugtreatmentforneuropathicpainrecommendstheuseofmorphineortramadoltotreatneuropathicpainonlywhenadvisedbyaspecialist.59Ithasgradedmostoftheavailableevidenceasloworverylowduetoinsufficientfollow-upperiods.59Separately,guidancefromtheIASPNeuropathicPainSpecialInterestGroup(NeuPSIG)–basedonsystematicreviewandmeta-analysis–madeonlyweakrecommendationsfortheuseoftramadolandotherstrongopioidsassecondandthird-linetreatments,respectively,forneuropathicpaininadults.46Originallydevelopedtoassistthetreatmentofcancer-relatedpain,theWHO’sanalgesicladderisoftenusedasaguidetothetreatmentofchronicpainbutithasneverbeenvalidatedinthissetting.Theanalgesicladdersuggeststhatwithincreasingreportedpainintensity,increasinglystronganalgesicsshouldbeprovidedanddosesofstrongopioidsincreaseduntilpainiscontrolled.Chronicpainisacomplexentityreflectingfactorsbeyondtheoriginal,orongoing,stimuli.Furthermore,theevidencethatescalationofopioiddosesinthissettingconfersanimprovementinpainorfunctionisweakandthereisstrongevidencethatharmfromopioidsisdoserelated. IthasbeensuggestedthatuseoftheWHOladderinpatientswithlongtermpainfailstorecognisethecomplexityofthechronicpainexperience,andmaycontributetoinappropriateprescribing.60
In2010,theBPSproducedgoodpracticeguidelinesonopioiduseinpersistentpain,statingthat,whileopioidscanbeeffective,otherevidence-basedinterventionsshouldbeusedifavailable.11 Opioids Awarereplacesandsupersedesthe2010guidanceandplacesemphasisongeneralprinciplesofgoodprescribingpracticeunderpinnedbyanunderstandingoftheconditionbeingtreated,appropriatepainassessmentandmonitoringofprescribingtoensurethatmedicinesthatareineffectivearestopped(seeBox 3).61
Box 3 – ‘Opioids Aware’ prescribing resource
Opioids AwareisaprescribingresourcefundedbyPHE(PublicHealthEngland)andproducedbytheFPM(FacultyofPainMedicine)inconjunctionwithNHSEngland,othermedicalRoyalColleges,NICE,theCQC(CareQualityCommission),NHSBSA (NHSBusinessServicesAuthority),theRoyalPharmaceuticalSocietyandtheBritishPainSociety.Theresourceaimstosupportallhealthcareprofessionals,patients,andcarersinunderstandingthepotentialbenefitsandharmsofopioidtreatment.
Recognisingthatexistingguidancehasbeenrelativelyunsuccessfulininfluencingtheuseofanalgesics,ithastakenadifferentapproach.Itinsteadbreaksdowntheavailableevidenceintosmallersections,makingitmoreaccessibleandplacingopioidsinthewidercontextofpainmanagement.Itprovidesguidanceinthefollowingareas:
– Bestprofessionalpractice; – Thecondition,thepatient,thecontext – Clinicaluseofopioids – Astructuredapproachtoopioidprescribing – Informationforpatients
Theresourcecoversissuessuchasopioidsandthelaw;writingprescriptions;reportingharms;theroleofpharmacistsinsafeprescribing;assessingandmanaginglong-termpain;theroleofmedicines;effectivenessofopioids;sideeffectsandharms;prescribingtrends;problemdruguseandspecialcircumstances.
9British Medical Association Chronic pain: supporting safer prescribing of analgesics
Adetailedexplanationoftherisksandbenefitsmustbeundertakenwiththepatientbeforeopioidsarestarted.Asmallproportionofpeoplemayobtaingoodpainreliefwithopioidsinthelongtermifthedoseiskeptlowandespeciallyiftheiruseisintermittent.Thesepatientscanbemanagedwithregularmonitoring.Toomanypeoplewithchronicpainareprescribedopioidsathighdoses.Theriskofharmincreasessubstantiallyathighdose.Aboveanoralmorphineequivalentdailydoseof120mg,furtherbenefitisunlikely.Ifbenefitinpainreductionandimprovedfunctionisnotachievedatlowdose,opioidsshouldbediscontinued,evenifnoothertreatmentisreadilyavailable.
Chronicpainisverycomplexandifpatientshavedisablingsymptomsthatdonotrespondtotreatment,adetailedassessmentofthemanyemotionalinfluencesontheirpainexperienceisnecessary.ThismaybedonebyaGPorinapainmanagementservice.Patientswithchronicpaininhighdoseopioidsshouldbereferredtospecialistpainmanagementservices,andifpossiblejointpainandaddictionservices.Theidealpracticeisthentoreducetheopioiddose.FurtherguidanceisavailablefromOpioids Aware
Recommendation:Tobetterinformclinicalpracticemoreresearchisrequiredintotheeffectsoflong-termprescribingofopioidsforpainrelief,includingtheirefficacy &safetyforperiodslongerthansixmonths.
3.2.2 Efficacyofotheranalgesicsforchronicpain
Gabapentin and pregabalinGabapentinandpregabalinarelicensedintheUKforthetreatmentofneuropathicpainandrefractoryepilepsy.Pregabalinisalsolicensedforthetreatmentofgeneralisedanxietydisorder.Theevidencefortheuseofgabapentinandpregabalinforthetreatmentofneuropathicpainismorecomprehensivethanthatofopioids,asreflectedintheirindicationsandtheirrecommendeduseinguidelines.NICEclinicalguidanceforprimarycareprofessionalsondrugtreatmentforneuropathicpainrecommendstheuseofgabapentinorpregabalin(aswellastheanti-depressantsduloxetineoramitriptyline)asinitialtreatment,withdueconsiderationofapatient’sco-morbiditiesandcontext.59,62 Thisrecommendationisbasedonevidencefromrandomisedcontroltrialsshowingthatbothreducepainincomparisontoaplacebo.59Separately,asystematic-reviewandmeta-analysisfromtheNeuPSIGoftheIASPrecommendedgabapentinandpregabalinforfirst-lineuseinadultswithneuropathicpain.46Despitetheserecommendations,a2014systematicreviewconcludedthatoverhalfofpatientstreatedwithgabapentinforchronicneuropathicpainorfibromyalgiacwillnothavesubstantialpainrelief,determinedasareductioninpainintensityofatleast50%.63Sixineverytenpatientscanexpecttohavesomeadverseeffects,suchasdizziness,somnolence(drowsiness),peripheraloedema(swelling)orgaitdisturbance.63
Aseparate2009systematicreviewconsideringtheuseofpregabalinsimilarlyfoundnousefulbenefittoasignificantproportionofpatients.64However,inbothcases,asmallnumberofpatientswerefoundtobenefitsubstantially,includingwithmarkedimprovementsintheirqualityoflife,whilemorebenefittedmoderately. Thereisnogoodevidenceforeffectivenessofgabapentinandpregabalinforacutepainorforlong-termpainthatisnotofneuropathicorigin.Moreresearchisrequiredtoensuregabapentinandpregabalinareusedinthebestpossibleway,tomaximisethepotentialbenefittopatientswithchronicpain,whilstminimisingtheriskofharm.50
c Fibromyalgiaisalong-termconditionthatcancausewidespreadpainandsymptomsinmanyotherbodilysystems.
10 British Medical Association Chronic pain: supporting safer prescribing of analgesics
AntidepressantsThereisevidencethatsomeantidepressantsmaybehelpfulforsomepatientswithchronicpain.A2007systematicreviewsuggestedthatanumberofantidepressants–in-particulartricyclicantidepressants–canbeeffectiveinthetreatmentofchronicpain.65However,a2015systematicreviewassessingtheuseofthetricyclicantidepressantamitriptylineforthetreatmentofneuropathicpainconcludedthat,despiteitswidespreaduseandsuccessfultreatmentinmanypeoplewithneuropathicpain,thereisalackofsupportiveunbiasedevidenceforitsbeneficialeffect,withfewstudiesmeetingthemostrecentresearchstandards.66
Inareviewof19studiesconsideringtheanalgesiceffectofSNRIs(serotonin-noradrenalinereuptakeinhibitors),12foundthattheyprovideclinicallyimportantpainreliefandareassociatedwithfewerside-effectsthantricyclicantidepressants.67Thereismoderatelystrongevidence–basedontheGradeProsystemofassessingevidenced–thattheSNRIsduloxetinereducespainindiabeticneuropathyandfibromyalgia.Asystematicreview,consideringsixrandomisedcontrolledtrials,concludedthatduloxetineisusefulforrelievingpainfromfibromyalgiaanddiabeticneuropathy,andaboutaseffectiveasotheravailabledrugs.68Althoughonesystematicreviewsuggeststhatamitriptylinedemonstratessuperiorefficacytoduloxetine.69Asystematic-reviewandmeta-analysisfromtheNeuPSIGoftheIASPrecommendedSNRIsortricyclicantidepressantsasfirst-linetherapyforneuropathicpain.46
NICEguidanceforthetreatmentofneuropathicpainrecommendstheuseofamitriptylineandduloxetineasfirstlinetreatmentsforneuropathicpain,alongsidegabapentinandpregabalin.Switchingbetweenthesefourisrecommendedifthefirstisnotsuccessful.62 SIGNguidanceforthetreatmentofchronicpainrecommendstheuseofamitriptylineforneuropathicpainandfibromyalgia,andtotryalternativetricyclicantidepressantsifthere isaneedtoreducesideeffects.
NSAIDsA2015systematicreviewconcludedthatthereisnoevidencetosupportorrefutetheuseofNSAIDsinneuropathicpainconditions,70whichisreflectedintheguidanceavailableforthetreatmentofneuropathicpain.A2015reviewofNSAIDsforchroniclowbackpainconcludedthattherewaslowqualityevidencethattheyareslightlymoreeffectivethanplacebo.71 AseparatereviewoftopicalNSAIDsforchronicmusculoskeletalpainindicatedthattheyprovidedsignificantlymoretrialparticipantswhohadosteoarthritisofthekneeorhandwithgoodlevelsofpainreliefthanplacebo,butthattherewasnoevidencefortheeffectivenessoftopicalNSAIDsinotherchronicpainfulconditions.72
d GradeProistheofficialsoftwareoftheGradingofRecommendationsAssessment,DevelopmentandEvaluation(GRADE)WorkingGroup,withthegoalofcreatingacommonapproachtogradingqualityofevidence.IthasbeenupdatedforusebyCochranereviewauthorstocreatesummaryoffindingstables. http://tech.cochrane.org/revman/other-resources/gradepro/about-gradepro
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3.3 Potential harms associated with long-term analgesic use in chronic pain
Therearesignificantpublichealthconcernsabouttheharmfuleffectsofanalgesics,particularlyregardingtheirlong-termuse.Thefollowingbrieflyexploresthepotentialharmsassociatedwiththeuseofopioids,andotheranalgesics,forthetreatmentofchronicpain.
Box 4 – Opioid prescribing in the USA
ConcernsabouttheharmscausedbyextensiveprescribingofopioidshavebecomeparticularlypertinentasaresultoftheirextensivemisuseintheUSA.
AccordingtotheCDC(CentersforDiseaseControl),theannualnumberofopioidprescriptionsintheUSAquadrupledbetween1999and2014.73Thisincreasehasbeenmatchedbyasteepincreaseinopioid-relatedmortality.74Mortalitytrendsindicatearapidincreaseinthenumberofdeathsfromunintentionaldrugpoisoningwithopioidanalgesics,withdeathsinvolvingopioidsrisingfrom4,041in1999to14,459in2007.44Seventy-fivepercentofallpharmaceuticaloverdosedeathsintheUSAin2010involvedopioids.75In2014,morethan14,000peoplediedfromoverdosesinvolvingprescriptionopioids.74AccordingtodatafromtheCDC,prescriptiondrugoverdosesintheUSAoccurdisproportionatelyamongstpatientswhoareseeingmultipledoctors,orseeingonedoctorandreceivingahighdosage.76
IntheUK,therehasbeenafocusonunderstandingthelessonsthatcanbelearnedfromthesignificantprescriptionopioidmisuseintheUSA.Thishasincludedexplorationoftheextenttowhichthesituationiscomparablebetweenthetwocountries,andidentifyingwhichcontributoryfactorsmaybeuniquetotheUSA.77,78 Ithas,forexample,beensuggestedthatpharmaceuticalcompanymarketingpracticesintheUSAhaveservedtoinflatethebenefitsandobscuretheharmsofprescriptionopioids.78IthasalsobeenhighlightedthatspecificdifferencesinthehealthcaresystemsofthetwocountriesmayinfluencetherelativeharmsassociatedwithopioidmisuseintheUSAandUK,77,78asmayeachcountry’swiderpolicyonillicitdrugs.77
3.3.1 Harms associated with opioids
Mortality AshighlightedinSection 3.1,prescribingdataindicatesthattheuseofopioidshasincreasedsubstantiallyintheUK.TodatethishasnotresultedinthesamesignificantincreaseinopioidrelateddeathsthathasbeenseenintheUSA(seeBox 4).77TheUKhas,however,seenanincreaseindeathsinvolvingopioidswithheroin,methadoneandmorphine(thislatternotedatpostmortemasametaboliteofheroin)beingthebiggestcontributors.AlthoughthetotalnumbersaresubstantiallylowerthanintheUSA,theoveralltrendsaresimilar.ThoughitshouldbenotedthatintheUSAprescriptionopioiddeathssignificantlypredominateoverheroin.79EnglandandWalesexperiencedadoublingofannualdeathsinvolvingcodeinebetween2005and2009,80andtherewereatotalof128deathsinvolvingcodeinein2015.81 Therehasalsobeenasignificantincreaseinthenumberofdeathsrelatedtotramadol,risingfromonerecordedinEnglandandWalesin1996,to208in2014althoughmostrecent(2015)datashowafallinthelast12months.81Thesemortalitydatapromptedschedulingofthedruge in 2014.82Mosttramadoldeathswereinconjunctionwithotherdrugsanditisnotknownwhetherthetramadolwasorwasnotprescribedforthosepatientsinwhomthedrugwasmentionedonthedeathcertificate.InScotland,tramadol-relateddeathsincreasedfromeightin2001to34in2011.55 StatisticsfromNorthernIrelandalsoshowanincreaseindeathsfromarangeofopioids.Between2003and2013,thenumberofdeathsinwhichtramadolwasmentionedonthedeathcertificaterosefrom0to20,althoughthisisdownfromahighof31in2012.Deathsinvolvingcodeinerosefrom2to22overthesameperiod.83
e FurtherinformationfromNICEaboutcontrolleddrugsisavailablehere.
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Respiratory depressionOpioidscanhaveaneffectonrespirationviaanumberofmechanisms,84andrespiratorydepressionhasbeenhighlightedasaparticularprobleminacutepainmanagement–wherepatientshavenotdevelopedtolerance.44 Inpatientswithchronicpain,therearespecificconcernsoverdisturbanceofnocturnalrespiratorycontrol.85Forexample,therehavebeenreportedfatalitiesinpatientswithsleepapnoeawhoareprescribedopioids,andparticularrisksarisewhenopioidsareprescribedwithothersedativedrugs,particularlybenzodiazepines.44
Endocrine and immune effects Thereisevidencethatopioidusecanadverselyimpactuponarangeofendocrinefunctions.86AshighlightedinOpioids Aware,opioiduseisassociatedwithhypogonadismandadrenalinsufficiencyinbothsexes.61 Ithasalsobeendemonstratedinanimalandhumanstudiesthatopioidscanhaveasuppressiveeffectonimmunefunction,butthatthismaydifferfordifferentopioidanalgesics.61,87
Hypersensitivity to pain (hyperalgesia)Anumberofstudieshaveindicatedthat,paradoxically,prolongeduseofopioidscanresultinhypersensitivitytopain(hyperalgesia).A2006systematicreviewofopioid-inducedhyperalgesiahighlightedthatopioidanalgesicscanrenderpatientsmoresensitivetopainandpotentiallymayaggravatepre-existingpain.88 Opioids Awarestatesthathyperalgesiahasbeendemonstratedinpreclinicalstudies,inpatientsreceivinghighdosepotentopioidsasacomponentofgeneralanaesthesiaandinexperimentalstudiesofpatientsmaintainedonmethadoneforthetreatmentofopioidaddiction.Theclinicalsignificanceofthesefindingsinroutineprescribingisnotknown.61
Dependence and withdrawal The2016BMAanalysisreportonPrescribed drugs associated with dependence and withdrawalhighlightedthepotentialthatopioids,prescribedtotreatchronicpain,willleadtotoleranceandphysicaldependence,especiallywithprolongedtreatmentandathigherdoses.2Thereportalsonotedthatwithdrawalsymptomscanbesevereanddisabling.2It shouldbenotedthattoleranceandtheexperienceofwithdrawalsymptomsonopioidcessationarenormalpharmacologicaleffectsofopioidtreatmentandshouldnotbeconfusedwithaddictionoropioidmisuseorabuse.Therearecertainriskfactors–includingco-morbidmentalhealthdisordersandsubstancemisusedisorders–thatlong-termepidemiologicaldataindicateareassociatedwithindividualsbeingmorelikelytoreceiveopioidprescriptionsforpain.Patientswiththeseriskfactorsaremorelikelytobeprescribedhigherdosesofopioidsandmorelikelytobeco-prescribedothercentrallyactingdrugsincludingbenzodiazepines–aphenomenondescribedas‘adverseselection’.44
3.3.2 Harms associated with other analgesics
Gabapentin and pregabalin Aswithopioids,gabapentinandpregabalinhavebeenassociatedwithincreasingmortalityintheUK.Instancesofgabapentinbeingmentionedondeathcertificatesincreasedsignificantly,from4in2010to49in2015.81Pregabalinhasshownanincreasingtrendintermsofprescriptionlevels,positivepost-mortemtoxicologyfindings,andinthemisuseofthedrugbeingimplicatedindeath.59Instancesofgabapentinbeingmentionedondeathcertificatesincreasedfrom4in2010to90in2015.81
ThedependencepotentialassociatedwithgabapentinandpregabalinhasalsoledtoconcernsthatthenumberofpeoplemisusingtheseprescriptionmedicinesmayberisingintheUK. PHEandNHSEnglandhaveproducedadviceforprescribersonthepotentialformisuseofgabapentinandpregabalin,warningofthedangersofdependenceandthediversionofprescribeddrugs –wherebydrugsareunlawfullytransferredfromtheirintendedrecipienttoanotheruserordistributor.37Highlevelsofmisuse,particularlyofpregabalin,havebeenreportedinprisonpopulations,and, inJanuary2016,theACMD(AdvisoryCouncilfortheMisuseofDrugs)recommendedthat–duetotheharmsassociatedwiththesedrugs–gabapentinandpregabalinshouldbecontrolledundertheMisuseofDrugsAct1971.89
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AntidepressantsDatafromtheOfficeforNationalStatisticsindicatethat,in2013,therewere466deathsinEnglandandWalesassociatedwithantidepressants,withthenumberofdeathsassociatedwithamitriptylinerisingby12%since2012.90Thoughavailabledatadoesnotallowforadistinctionbetweenpatientswhoweretakingantidepressantsfordepressionandthosetakingthemforthereliefofpain.
TCAs(tricyclicantidepressants)areassociatedwithanumberofadverseeffects,includingdrymouth,constipation,tachycardia,cardiacarrhythmia,andblurredvision.Overdosewiththesedrugsisassociatedwithahighrateoffatality.91IncomparisontoTCAs,SSRIs(selectiveserotoninreuptakeinhibitors)havemoretolerablesideeffectsandgreaterrelativesafetyinoverdose,92,93butareassociatedwithgreaterwithdrawalsymptomsinpeoplediscontinuinguse.94A2009systematicreviewoftheuseoftheSNRIduloxetineindicatedthatmostpeopletakingitwillhaveatleastonesideeffect,butthesearemostlyminor.Neverthelessaboutoneinsixpeoplediscontinueduloxetineasaresultofsideeffects.68
NSAIDs TherearespecificissuesaroundtheuseofNSAIDs,includinglong-standingandwell-recognisedgastrointestinal,cardiovascularandrenalsafetyconcerns,whichhavebeensummarisedinNICEprescribingguidance.95ThishighlightsthatadecisiontoprescribeNSAIDsshouldbebasedonanassessmentofaperson’sindividualriskfactors,includinganyhistoryofcardiovascularandgastrointestinalillness.95ConcernsoverthecardiovascularandgastrointestinalsafetyofNSAIDsmayhavecontributedtoincreasedprescribingofotheranalgesic classes.
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4 Supporting the management of patients with chronic pain
Overthelastfewdecades,opioidshavebeenincreasinglyusedintheUKtomanagechronicpain.Potentialreasonsforthisincludetheavailabilityofnewpreparationsandformulationsofopioids,changesinpatientexpectation,prescribingpractice,andsocietalattitudes.12Otherstudieshaveidentifiedalackofconsensusregardingappropriateuseofmedicines,alackofsuitablealternatives,thedifficultystoppingorreducingapatient’sopioidprescription,andpatientdemandforopioidtreatments(includingfromthosewhomaybeaddictedoraredivertingprescriptionmedicines).96Afurthercontributoryfactoristhehistoricunder-treatmentofpain,whichmayhavemotivatedwell-intentionedeffortstoenhancetheavailabilityofprescriptionanalgesics,includingopioids.96Giventheweakevidencebaseandpotentialharmsassociatedwithlongtermanalgesicusediscussedintheprecedingsection,thereisaneedtoexploretherangeofsupportrequiredforpatientssufferingfromchronicpain.
Thefollowingsectionsfocusonthestepsrequiredtoensurethatallpatientswithchronicpainhaveaccesstothemostappropriatetreatment,andtoensuredoctorsareadequatelysupportedinthemanagementofthesepatients.
4.1.1 Attitudes towards the use of opioidsfor chronic painAnalysisoftheattitudestoopioidprescribingintheUSAhassuggestedthat,historically,concernsaboutaddiction,thepotentialforincreaseddisabilityandlackofefficacyoverlongertime-periodslimitedtheiruseinthetreatmentofchronicpain.97Inthe1980s,reportsandarticlesbegantoemergethatsuggestedopioidscould,orshould,beusedtotreatchronicpain,basedonearlierexperiencestreatingcancerpatients. Twopapershavebeenidentifiedasbeingparticularlyinfluentialinthisregard.97In1986,PortenoyandFoleypublishedapaperdescribingtheirexperiencesoftreatingpatientswithnon-malignantpainthatstronglyadvocatedtheuseofopioidsoverlongerperiodsoftime.98In1990,Melzackwrote‘TheTragedyofNeedlessPain’,97,99whichcalledformoreresearchintotheuseofopioidsfornon-cancerchronicpain,arguingthatpeoplewereunnecessarilysufferingfrompainbecauseoffearsofaddiction.
Prescribingbehaviourinrelationtoopioidsmaybesubjecttoarangeofinfluences.A2007surveyofGPs’attitudesfoundthat53%ofthosewithoutspecialisttrainingfeltthatboththeirmedicalschoolandprimarycaretrainingwereinadequatewithregardtopainmanagement.100Evensoitsuggestedthatthepresenceofguidelinesandthelevelofspecialisttraininghadlittleimpactontheprescribingofopioids.InthestudyGPswhodidnotcommonlyprescribeopioidswerefoundtobeolder,andtohavebeenpracticingforlonger,thanthosewhodid.100 Aseparate2008surveyofGPsintheUKindicatedthatthelikelihoodofprescribingopioidsmaybeinfluencedbyapractitioner’sage,genderanddegreeofspecialisttraining.101AfurthersmallqualitativestudyoftheattitudesofGPstoprescribingsuggestedthattheyhadamorecautiousapproachtoprescribingopioidsforchronicnon-cancerpainthanforcancer-relatedpain.102
A2015qualitativestudyofopioidprescribinginprimarycarehighlightedarangeoffactorsidentifiedbypatientsanddoctorsthatinfluencedprescribinginthissetting.Theseincludedthedifficultiesofshort-term,oftenemotionallychargedconsultations;highlightingtheimportanceofcontinuityinthedoctor-patientrelationship.103
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4.1.2 Challenges when stopping opioid treatment Doctorscanfacesignificantchallengesinstoppingopioidtreatmentforpatientsinwhomthesemedicationshavenotprovidedeffectivepainrelief.Thismayresultinpatientsbeingprescribedopioidsdespitethefactthattheyarereceivingnobenefitfromthem.Assetout in Opioids Aware (seeSection 3.2), ifitisthoughtopioidtherapymayplayaroleinapatient’spainmanagement,atrialshouldbeinitiatedtoestablishwhetherapatientachievesareductioninpainwiththeuseofopioids–ifnottheyshouldbestopped.44Thedifficultiesinceasingopioidtreatmentifnoteffectivehavebeenacknowledged.3Itcan,forexample,beverydifficulttotellapatientthattheirtreatmentisnotworkingwhentheyareclearlyinpain,andthereareoftenfewalternativestousingopioidsinattemptingtoreducechronicpain.3
Guidanceontheuseofopioidsforchronicpaindoesrecommendstrategiestomanagethis.Forexample,theSIGNpathwayforusingstrongopioidsinpatientswithchronicpainrecommendsatrialofopioidswithstoppingrulesagreedwiththepatient,suchasiftreatmentgoalsarenotmet,orifthereisnoclearevidenceofdoseresponse.104Ithasbeenhighlightedthatwhileopioids,aswellasotheranalgesicsincludinggabapentinandpregabalin,canworkeffectivelytorelievepain,thisisonlyachievedinasmallpercentageofpatients,andprescribersmustexpectanalgesicstofailforthemajorityofpatients.105Itisunusualforanyanalgesic,includingopioids,tocompletelyeliminatepain,andthatthefocusoftreatmentshouldbeonreducingapatient’spainwithaviewtoimprovingtheirqualityoflife.
Recommendation:Considerationshouldbegiventotherangeofsupportthatisrequiredfordoctorsandpatientsduringtheprocessofassessment,trialandreviewofopioidtreatmentforchronicpain.Thisshouldincludesupportforstoppingopioidtreatmentthatisnotworking.
4.1.3 SupportingtheeffectivemanagementofchronicpaininprimarycareMostpatientswithchronicpainfirstcontacthealthservicesthroughprimarycare,andaresubsequentlymanagedinthissetting.AccordingtotheRCGP(RoyalCollegeofGeneralPractitioners),peoplewithchronicpainconsulttheirGParoundfivetimesmorefrequentlythanthosewithout,andchronicpainisapresentingconditioninaround22%of consultations.106Itisgenerallyacceptedthatmorestraightforwardpainproblemscanbeassessedandmanagedbynon-specialistsinaprimarycaresetting,withspecialistcarerequiredforcomplexpain,andevenwhenpatientsarereferredtospecialisttreatment,theirongoingcareislikelytoreturntotheirGP.107Ina2015parliamentaryreport,theChronicPainPolicyCoalitioncalledforaminimumstandardofyearlyassessmentofpatientsbeingtreatedwithopioidsfortheirchronicpain.108
Supportingactioninthisareaisdependentuponadequateresourcingofgeneralpractice.AshighlightedintheBMA’s2015visionforgeneralpractice–Responsive, safe and sustainable: towards a new future for general practice–havingsufficienttimetospendwithpatientsisoneoftheleadingfactorsidentifiedbyGPsthatcouldhelpthemtobetterdelivertheessentialsofgeneralpractice.109Thevalueofadequateconsultationtimesisparticularlyimportantforpatientsthathavecomplexconditionswhichmayrequiregreaterexploration,asisoftenthecaseforpeoplesufferingfromchronicpain.Sufficientresourcesarealsonecessarytosupportregularreviewsofmedicationuse.Furtherconsiderationshouldbegiventotheroleofpharmacistsinpainmanagementinprimarycaresettings.110,111
Recommendation:Sufficientinvestmentandresourcesforprimarycare,includinglongerconsultationtimes,arerequiredtosupportimprovementsinanalgesicprescribingforpatientswithchronicpain.
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4.1.4 Supporting the development of specialist chronic pain servicesSomepatientswithchronicpain,includingthosewithcomplexco-morbidities,willrequirethesupportofspecialistservices.115Specialistsinpainmedicineplayacentralroleinpainmanagementascompetentphysicianswiththetrainingandexpertisetounderstandandmanagepainfulmedicalconditions,diagnosetreatableunderlyingcausesofpainandhighlightunmetphysicalandmentalhealthneeds.Referraltospecialistpainservicesisindicatedwherepainisassociatedwitheitherorbothhighlevelsofdistressand disabilityorwhenseverepainremainsrefractorytotreatment.Improvingaccesstospecialistserviceswouldbettersupportpatientstocopewithpain,andmayreduceinappropriateprescribingofstronganalgesics.Amultidisciplinary/multiprofessionalapproachisrecognisedasthemainrequirementforthisandthereshouldbereadyaccesstopainmanagementprogrammesforpatientswhoarelikelytobenefit(seeBox 5).112Multidisciplinarychronicpainservicesaremoreeffectivethannotreatment,ortreatmentasusual,forarangeofpatientoutcomes,includingpainexperience,moodandactivitylevels.115Therearearangeoffactorsthatimpactuponaccesstospecialistservices,including:thegeographicaldistributionofclinics;whetherservicesmeettheminimumstandardsforamultidisciplinaryservice;andreferraltopainmanagementservicesandthewaitingtimestoaccessthem.113 Thedevelopmentofspecialistservicesnecessitatessufficientavailabilityofappropriatelytrainedhealthcareprofessionals.Ithas,forexample,beenhighlightedthatthereisalackofpainmedicinespecialistsinsomepartsofEnglandandWales,andasawholeEngland&Walescurrentlyhavefewerchronicpainconsultantsper100,000populationthanScotlandandNorthernIreland–equatingtoatotalshortfallof118chronicpainspecialists.114
Box 5 – Pain management programmes
TheBPShaveproducedguidelinesforpainmanagementprogrammesforadults.Thesehighlightthattheprincipleofpainmanagementprogrammesisto“enablepeoplewithchronicpaintoachieveasnormalalifeaspossiblebyreducingphysicaldisabilityandemotionaldistress,andimprovingtheindividual’sabilitytoself-managepain-associateddisabilityandreducerelianceonhealthcareresources”.115
Thoughtheyshouldnotnecessarilybeexpectedtoachieveareductioninapatient’spain,thereisgoodevidencefortheefficacyofpainmanagementprogrammesinimprovingpainexperienceandphysicalfunctioningandfortheirpotentialtoreducemedicationuse.115
Psychologicalinterventionsmayhaveanimportantroleinthetreatmentofsomepatientswithchronicpain.Thereismoderateevidencethatpsychologicaltherapiescanhelppeoplewithchronicpainreducenegativemood(depressionandanxiety),anddisability.116 Thoughforsometypesofpain–forexampleneuropathicpain–thereisalackofstudiesassessingtheeffectivenessofthesetherapies.117Researchalsosuggeststhatpatient’sattitudestowardstheirpaincanhaveaninfluenceontheirqualityoflife.Forexample,fearofmovementasaresultofthepain,andotherpain-relatedfearscanbemoredisablingthanthepainitself,sotacklingsuchissuesisavitalconsiderationofanytreatment.118
Itisveryimportantthatco-morbidmentalhealthdisordersareidentifiedandmanagedappropriately.Oneapopulation-basedcase-controlstudyfconductedinManchesterfoundthatpatientswithchronicpainwerethreetimesmorelikelytosufferfromamentaldisorder,withmostpatientssufferingfrommoodandanxietydisorders.119
f Case-controlstudiesareobservationalstudiesthatcomparegroupsofpeoplewithandwithoutaparticulardisease or condition.
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Patientswithcomplexmultiplemedicalsymptoms,particularlyiftheyarefindingitdifficulttoreducehighharmfuldosesofopioids,needtobemanagedinteamswithmentalhealthexpertiseindiagnosingandmanagingcommonmentalhealthdisordersincludingsignificantdepression,personalityvulnerabilities,post-traumaticstressdisorder,somatisationdisorder,addiction,andinmanagingtheemotionaleffectsofprevioustraumaticexperiences.
Access to servicesThereishighvariationinaccesstomultidisciplinarycare,withmanypainclinicsnothavingadequateaccesstoapsychologist,physiotherapistandphysician.20The2012NationalPainAuditfoundthatonly40%ofpainclinicsinEngland,and60%inWales,mettheminimummultidisciplinarystandard–thepresenceofapsychologist,physiotherapistandphysician–comparedto64%and80%respectivelythatself-identifiedasmultidisciplinary.Thereportrecommendedbetteraccesstophysiotherapyandpsychologygiventhehighrateofanxietyanddepression,andthelinkwithpoorphysicalfunctioning.20Italsohighlightedthatpainclinicsshouldbeabletotreatawidevarietyofconditions;theaudit,forexample,indicatedthatsomeclinicsappeartofocusmainlyonspinalpainorothermusculoskeletalcomplaints,despitetheneedfortreatmentforconditionssuchaspelvicpainornon-musculoskeletalneuropathicpain.20FreedomofinformationrequestsfromtheChronicPainPolicyCoalitioninJune2013indicatedthat,ofall211CCGsinEngland,28%hadnonamedclinicalleadforpainservices,27%couldnotprovideanamedmanageriallead,and29%ofdidnotcommissionmultidisciplinarypainservices.120
Closerworkingbetweendifferentpartsofthehealthcaresystemisessential.Integratedworkingbetweenprimarycareandthespecialisttreatmentprovidedbysecondarycare,orspecialistcommunity-basedservices,isincreasinglyseenasthemoreappropriatemodelofcareforachievingthebestpatientoutcomes.112,121Patientsshouldbeabletomoveseamlesslybetweendifferentpartsofthesystemandbetweendifferentproviders,toensurethattheyreceivetimelyaccesstotheservicesrequired.112
WaitingtimesforspecialistservicesarenotconsistentacrosstheUK,withsomepatientshavingtowaitconsiderablylongerforspecialisttreatment.A2014reportbyHealthcareImprovementScotlandhighlightedsignificantvariationinwaitingtimesforspecialistservices,in-particularinaccesstopainpsychologyservices.122TheNationalPainAudit’sfinalreport–whichfocusedonEnglandandWales–suggestedthattheRCoA(RoyalCollegeofAnaesthetists)shouldadopttheIASPswaitingtimeguidanceforitsgoodpracticeguideforpainservices.Thisrecommendsthatpatientsshouldbeseenwithineightweeksforroutineorregulartreatment,onemonthforurgentorsemi-urgentcases,andoneweekforthemosturgent cases.20
Service provisionThereisavarietyofguidanceavailableontheprovisionofservices.SpecificguidanceonthecommissioningofchronicpainserviceshasbeenpublishedbytheRCGP,andendorsedbytheBPS,ChronicPainPolicyCoalitionandFPM.112Itexploreshowthecommissioningprocesscanbettersupportchronicpainpatientsandhowdoctorscanengagewithcommissionersmoreeffectively.Itskeypointsincludethat:
– painmanagementisbestdeliveredbymultidisciplinaryandmultiprofessionalteams; – thereshouldbeequityofprovisionacrosssocioeconomicscales,withservicesmeetingtheneedsoflocalpopulations;
– clinicalprofessionaladvicetocommissionersiskeytodeliveringthebestvalueservices – peopleshouldbeatthecentreofamulti-morbiditiesapproach,andinvolvedinservicedesignanddelivery.
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TheFPMhavepublishedcorestandardsforpainmanagementservicesintheUK,whichareintendedtoprovideaclinicalguidelineandaframeworkforthoseplanningservices.113
Thesesetoutcorestandardsforpainmanagementservicesincommunity,secondarycare,andspecialistsettings.Theyhighlightthatspecialistpainmanagementservicesinthecommunityorsecondarycareshouldalwaysinvolveamultidisciplinaryteam,andthatamultidisciplinaryteammustinclude:
– medicalconsultants – nurses – physiotherapists – psychologists – pharmacists
Oftenthiswillalsoincludeoccupationaltherapists,andwhereavailable,suitablytrainedGPsaswellasSAS(specialtyandassociatespecialist)doctors.113 Thereneedtobecloseworkingrelationshipsinrelatedmedicaldisciplinesincludingorthopaedicsurgery,neurosurgery,neurologyandpsychiatry.
Somepainmanagementservicesholdcombinedpainandsubstancemisuseclinicswherepatientswhohavepainandwhoareusinghighdosesofprescribedopioidsorrecreationaldrugsandalcoholcanbeassessedandmanaged.
TheBPSguidelinesonpainmanagementprogrammesoutlinetheevidenceformultidisciplinaryservices,howpatientsshouldbereferredandtheresourcesthataserviceshouldhaveaccessto.Theyhighlighttheimportanceofpainmanagementprogrammesbeingproperlyresourcedwithadequatetime,personnelandfacilities,andrecognisetheneedtoimproveaccesstotheseprogrammestosupportearlyinterventionaswellascomprehensiverehabilitation.115TheBPShasalsodevelopeda‘commissioninghub’,whichisintendedtoprovideasourceofinformationondifferentservicemodels,commissioningissuesandoutcomesfromacrossthecountry.
Key messages – Painmanagementisbestdeliveredbymultidisciplinaryandmultiprofessionalteams. – ThereishighvariationinaccesstomultidisciplinarycareandwaitingtimesforspecialistpainservicesarenotconsistentacrosstheUK
4.1.5 Non-pharmacological interventions for chronic pain Non-pharmacologicaltreatmentmaybeeffectiveinreducinglong-termpainanddisabilityinsomepatientswithchronicpain.123Thesetreatmentoptionscanalsoaugmentandcomplementanalgesicuse.123Itisthereforeimportantthatpatientshaveaccessto,andopportunitytobenefitfrom,arangeofeffectivenon-pharmacologicaltreatmentoptionswhereappropriate.Non-pharmacologicalinterventionsforchronicpainincludepsychologicallybasedinterventions,suchasbehaviouraltherapies,aswellasphysicaltherapies.12 Thecorestandardsforpainmanagementservices,publishedbytheFPM,recommendthatpainmanagementprogrammesshouldutilisepharmacologicalandnon-pharmacologicaltreatmentoptions,andthatpatientswithchronicpainshouldhaveaccesstoclinicalpsychologyandspecialistphysiotherapyearlyintheirtreatmentpathway.115 As highlightedintheBPSguidelinesforpainmanagementprogrammes,thereisevidencefortheefficacyofcognitivebehaviouraltherapypainmanagementprogrammesinimprovingpainexperience,mood,coping,negativeoutlookonpain,andactivitylevels.115 Thoughthereremainsalackofstudiesassessingtheefficacyofpsychologicalapproachesforsometypesofpain.117 Furtherworkisalsorequiredtodeveloptheevidencebaseforinvasiveinterventionsinthetreatmentofchronicpain.124
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Recommendations: – Allrelevantcommissioningandproviderorganisations–includingCCGsinEngland,healthboardsinScotlandandWales,andtheHealthandSocialCareBoardinNorthernIreland–shouldensurethatmultidisciplinarypainmanagementservicesareavailableforpatientsintheirareaandthatthesearecommissionedaccordingtoavailableguidance.Theseorganisationsshouldalsoworktoensuretimelyaccesstopainmanagementprogrammes,tosupportearlyinterventionandcomprehensiverehabilitationforpatientswithchronicpain.
– Allhealthcareprovidersthatareresponsibleforthemanagementofpatientswithchronicpainshouldbefamiliarwiththerangeofnon-pharmacologicalinterventionsthatmaybeeffectiveforthemanagementofchronicpain–includingphysicalandpsychologicaltherapies.Healthcareprofessionalsshouldalsobeawareofthelocalavailabilityoftheseservices.
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5 Role of training and education in improving analgesic use for treating chronic pain
Thefollowingsectionexplorestheroleoftrainingandeducationinsupportingimprovementsinanalgesicprescribing.Itparticularlyfocusesonthestepsrequiredtoensureallnon-specialistshavethebasicknowledgeandskillstosupporttheappropriatemanagementofpatientswithchronicpain.ForinformationAppendix 2 providesanoverviewofthetrainingpathwayforpainmedicinespecialistsintheUK.Thereisaneedtoensurethattraininginmedicalschools,aswellaspostgraduatetraining–bothingeneralpracticeandforsecondarycaredoctorswhoarenotspecialistsinpainmedicine–equipsclinicianswiththeknowledgeandskillstosupporttheappropriatemanagementofpatientswithchronicpain.Trainingontheprinciplesofpainmanagementshouldensureallclinicianswhoarenon-specialistsinpainmedicineare:
– awarethatitisoftenunlikelythatanalgesics,includingopioids,willcompletelyeliminatepainandthattheyarelikelytobeeffectiveinonlyaminorityofpatients;
– awarethataswellasbeingacomponentofotherconditions,chronicpainisalong termconditioninitsownright,andlikemanyotherlongtermconditionsitusually cannotbecured;
– abletoeffectivelymanagetheexpectationsthatpatientsmayhaveabouttheirtreatment,forinstance,withregardtothelikelihoodthattreatmentwillsuccessfullyreducetheirchronicpainandthedegreeofpainreductionitcanberealisticallyexpectedtoachieve;
– comfortablehighlightingthatthefocusoftreatmentislikelytobeonreducingratherthaneliminatingpain,andmaintainingfunction,withaviewtoimprovingqualityoflife;
– abletoaccessspecialistinputandadvicetosupporttheseconversationswithpatients.
Aswellasthesebasicprinciples,theroleofdoctorsinassistingthosewithchronicpaintomanagetheimpactoftheirconditionandliveindependentlyhasbeenspecificallyhighlightedasanareathatwouldbenefitfromimprovedtraining.TheChronicPainPolicyCoalitionhavesuggestedthathealthcareprofessionalsshouldbe‘trainedtoencouragepeoplelivingwithchronicpaintoparticipateineducationandpeersupportprogrammestoaidindependentliving’.108Healthcareprofessionalsshouldalsobecomfortableinprovidinginformationregardingsupportedself-managementofchronicpain.113
5.1 A focus on undergraduate training
In2008,theChiefMedicalOfficer’s150thannualreportrecommendedthattraininginchronicpainbeincludedinthecurriculaofallhealthcareprofessionals.8Itnotedatthetimethatteachingatundergraduatelevelwaspatchyandinconsistent.ResearchintotheprovisionofpaineducationinmedicalschoolsacrossEurope–basedoninformationonthecontentofcurriculain2013–foundthattherewerecompulsorydedicatedmodulesinpaininonly4%ofUKmedicalschools,andonly11%offeredcompulsoryorelectivemodules.125 FiftypercentofmedicalschoolsintheUKdocumentedpain-specifictopicswithintheircurricula,eitheraspartofcompulsorydedicatedpainmodules,orpainwithinothercompulsorymodules–thelowestlevelof15Europeancountries,althoughtheresearchersdidindicatethatthelevelofdetailavailablewastoovariabletoallowcomprehensiveanalysis.125AdvancingtheProvisionofPainEducationandLearning(APPEAL)–aEuropewidereviewofundergraduatepaineducation–calledonmedicalschools,painspecialists,medicalstudentsandpolicymakerstoensurethatundergraduatestudentsreceivepaineducationtoallowthemtoadequatelytreatpain,inlightoftherelativelylittlecoverageitreceivesatpresent.126
TheGMC’s(GeneralMedicalCouncil)Outcomes for graduatesincludestherequirementtobeabletoprescribedrugssafelyandeffectively,andtoplandrugtherapyforcommonindications,includingpain.127Itisimportantthatthereisclearguidanceontheknowledgeandskillsinpainmanagementthatstudentsshouldbeexpectedtoacquireoverthecourseoftheirundergraduatequalifications.Medicalschoolsshouldconsiderhowtoincorporate
21British Medical Association Chronic pain: supporting safer prescribing of analgesics
existingresourcesintotheirindividualcurricula.DespitetheproductionofpaincurriculabyIASP,128evidenceoftranslationintomoreeffectiveundergraduateeducationinpainislimited.
Arecentinternationalconsensushassetoutthecorecompetenciesinpainassessmentandmanagementthatshouldbeincludedinthecurriculaofallmedicalschoolsworldwide.129Thesecompetenciesareintendedtodriveimprovementsindeliveryofpaineducationandhelpshiftemphasistowardspainasadisease.Itisrecommendedthatthesecompetenciesareassessedwithintheexaminationprocessforgraduation.Inanotherinitiative,theFPMiscurrentlysupportingtheintroductionofapainmanagementcourse‘EssentialPainManagement-lite’tomedicalschools(seeBox 6)withemphasisondeliveryofpre-determinedpaincontent.TheFPMhasalsoproducedguidanceonthecompetenciesrequiredforarangeofpaininterventions,aswellasguidancespecifictothemanagementofpaediatricpain.130
Box 6 – Essential Pain Management (EPM-lite)
EPM-liteisascaleddownessentialpainmanagementcoursedesignedtobedeliveredtomedicalundergraduatesinhalfaday,withtheaimofexpandingthelevelofpainmanagementknowledgetaughtatundergraduatelevel.In2014,theFPMbeganaprojectofintroducingEPM-lite,andithasnowbeendeliveredinseveralUKmedicalschools.131
Recommendations: – Paincompetenciesshouldbeincludedinthecurriculaofallmedicalschoolsandbeassessedingraduationexaminations
– Medicalschoolsshouldensurethatexistingresources–suchastheIASP’scurriculumoutlineonpainandtheFPM’sEPM-liteprogramme–areusedeffectivelytoensuresufficienthighqualityundergraduateteachingonthebasicsofpainmanagement.
5.2 Promoting guidance to support improved analgesic prescribing for chronic pain
Topromotetheappropriatemanagementofchronicpain,renewedemphasisisrequiredontheutilisationofexistingguidance,andthedevelopmentoftoolstoassisthealthcareprofessionalswhenprescribinganalgesics.Aconsiderableamountofguidancehasalreadybeenproducedsettingouttherecommendedwaysofmanagingpainforpatientssufferingfromchronicpain(seeSection 3.2).Althoughawiderangeguidanceisavailabletosupportprescribing,thecontinuedincreaseinthelong-termuseofopioidstotreatchronicpain–despitethelackofevidenceoftheirlong-termeffectivenessinmostpatients–indicatesanongoingneedtopromotebestpractice,andtomonitorcloselycurrentprescribingtrends.
Recommendation: Existingguidanceonthemanagementofchronicpainandtheappropriateprescribingofanalgesicsneedstobepromoted,andconsiderationgivenhowitcanbemaximisedtosupportmoreappropriateuseofanalgesics,includingamongstclinicianswhoarenotspecialistsinpainmedicine.
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6 Conclusion and summary of recommendations
Overrecentyearstherehasbeenasubstantialincreaseintheprescribingofopioids,leadingtosignificantpublichealthconcernsthattheharmsassociatedwiththesemedicationsareincreasing.Muchofthisincreasedprescribingislikelyassociatedwiththeiruseforthetreatmentofchronicpainbut,thereislimitedevidencetosupporttheirlong-termuseformostpatients.
Chronicpainisacomplexcondition,whichhasasubstantialimpactonthelivesofthoseaffected.Thereliefofpainshouldbeseenasaclinicalpriority,yettheprescribingofopioidsisoftennotthemostappropriateoreffectivetreatmentoptionformanypatientswithchronicpain,andcanriskexposingpatientstounnecessaryharm.Ifitisthoughtopioidtherapymayplayaroleinapatient’spainmanagement,atrialshouldbeinitiatedtoestablishwhetherapatientachievesareductioninpainwiththeuseofopioids–ifnottheyshouldbestopped.Patientsshouldbefullyinformedofpotentialbenefitsandharmsfromthistrial.Doseescalationshouldbelimitedasriskofharmrisesasdoseincreases,especiallyifthereisinadequatereliefofpain.Analgesicusebypatientswithchronicpainshouldbereviewedregularly.Bettersupportisrequiredforbothdoctorsandpatientsinstoppingopioidtreatmentwherethishasnotprovidedeffectivepainrelief.Adequateresourcesarerequiredtomoveawayfromprescribingasa‘default’option,towardsacomprehensive,multidisciplinaryapproachtothemanagementofchronicpain,whichisnowrecognisedasalong-termconditioninitsownright.Theneedtoavoidtreatmentsorproceduresthatareunlikelytobeofbenefithasbeenrecognisedacrossdifferentbranchesofmedicine,includingthroughthe‘choosingwisely’initiativefromtheAcademyofMedicalRoyalColleges.132
Supportingimprovementsinthetreatmentofchronicpain,andtheuseofanalgesics,necessitatesactionacrossarangeofareas,includingtheprovisionofservices;research;training;continuededucationandprofessionaldevelopment,andthedevelopmentandpromotionofguidance.Thisreportsetsoutarangeofrecommendationsforactionintheseareasthatneedtobetakenforwardbygovernments,policymakersandprofessionalsacrosstheUK.
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Summary of recommendations
Developing the evidence base – Tobetterinformclinicalpracticemoreresearchisrequiredintotheeffectsoflong-termprescribingofopioidsforpainrelief,includingtheirefficacy&safetyforperiodslongerthansixmonths.
Pain management – Considerationshouldbegiventotherangeofsupportthatisrequiredfordoctorsandpatientsduringtheprocessofassessment,trialandreviewofopioidtreatmentforchronicpain.Thisshouldincludesupportforstoppingopioidtreatmentthatisnotworking.
– Sufficientinvestmentandresourcesforprimarycare,includinglongerconsultationtimes,arerequiredtosupportimprovementsinanalgesicprescribingforpatientswithchronicpain.
– Allrelevantcommissioningandproviderorganisations–includingCCGsinEngland,healthboardsinScotlandandWales,andtheHealthandSocialCareBoardinNorthernIreland–shouldensurethatmultidisciplinarypainmanagementservicesareavailableforpatientsintheirareaandthatthesearecommissionedaccordingtoavailableguidance.Theseorganisationsshouldalsoworktoensuretimelyaccesstopainmanagementprogrammes,tosupportearlyinterventionandcomprehensiverehabilitationforpatientswithchronicpain.
– Allhealthcareprovidersthatareresponsibleforthemanagementofpatientswithchronicpainshouldbefamiliarwiththerangeofnon-pharmacologicalinterventionsthatmaybeeffectiveforthemanagementofchronicpain-includingphysicalandpsychologicaltherapies.Healthcareprofessionalsshouldalsobeawareofthelocalavailabilityoftheseservices.
Training and education – Paincompetenciesshouldbeincludedinthecurriculaofallmedicalschoolsandbeassessedingraduationexaminations.
– Medicalschoolsshouldensurethatexistingresources–suchastheIASP’scurriculumoutlineonpainandtheFPM’sEPM-liteprogramme–areusedeffectivelytoensuresufficienthighqualityundergraduateteachingonthebasicsofpainmanagement.
– Existingguidanceonthemanagementofchronicpainandtheappropriateprescribingofanalgesicsneedstobepromoted,andconsiderationgivenhowitcanbemaximisedtosupportmoreappropriateuseofanalgesics,includingamongstclinicianswhoarenotspecialistsinpainmedicine.
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7 Further resources
Please note: this listing of publications is intended for further information only. The BMA is not responsible for the content or accuracy of external websites, nor does it endorse or otherwise guarantee the veracity of statements made in non-BMA publications.
Supporting individuals affected by prescribed drugs associated with dependence and withdrawal – BritishMedicalAssociationAvailableat: https://www.bma.org.uk/collective-voice/policy-and-research/public-and-population-health/prescribed-drugs-dependence-and-withdrawal
Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain–HostedbytheFacultyofPainMedicineAvailableat:https://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware
Core Standards for Pain Management Services in the UK–FacultyofPainMedicineAvailableat:http://www.rcoa.ac.uk/system/files/FPM-CSPMS-UK2015.pdf
The hidden suffering of chronic pain–TheChronicPainPolicyCoalitionAvailableat:http://www.policyconnect.org.uk/cppc/research/hidden-suffering-chronic-pain-booklet-parliamentarians
Pain Management Services: Planning for the future: Guiding clinicians in their engagement with commissioners – RoyalCollegeofGeneralPractitioners Available at: http://www.rcoa.ac.uk/system/files/FPM-Pain-Management-Services.pdf
National Pain Audit Final Report 2010-2012(EnglandandWales)Availableat:http://www.nationalpainaudit.org/media/files/NationalPainAudit-2012.pdf
Guidance on the management of pain in older people (2013) – BritishGeriatricsSocietyAvailableat:http://www.bgs.org.uk/pdfs/pain/age_ageing_pain_supplement.pdf
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Appendix1–classificationofchronicpain
ThebelowtablehighlightstheclassificationsofchronicpainthathavebeendevelopedbytheIASPforinclusioninthe11threvisionoftheWHOInternationalClassificationofDiseases.
ClassificationofchronicpainforICD-11
ThecurrentversionoftheWHO’sInternational Classification of Diseases(ICD-10) includesdiagnosticcategoriesforchronicpainconditions.Forthe11threvisionoftheICDataskforceledbytheIASPhasdevelopedanewclassificationofchronicpain,dividedintothefollowingsevengroups.
1. Chronic primary pain –Chronicprimarypainispainin1ormoreanatomicregionsthatpersistsorrecursforlongerthan3monthsandisassociatedwithsignificantemotionaldistressorsignificantfunctionaldisability(interferencewithactivitiesofdailylifeandparticipationinsocialroles)andthatcannotbebetterexplained byanotherchronicpaincondition.
2. Chronic cancer pain – Chroniccancerpainincludespaincausedbythecanceritself(theprimarytumorormetastases)andpainthatiscausedbythecancertreatment(surgical,chemotherapy,radiotherapy,andothers).
3. Chronic post-surgical and post-traumatic pain – Painthatdevelopsafterasurgicalprocedureoratissueinjury(involvinganytrauma,includingburns)andpersistsatleast3monthsaftersurgeryortissuetrauma.
4. Chronic neuropathic pain –Chronicneuropathicpainiscausedbyalesionordiseaseofthesomatosensorynervoussystem.
5. Chronic headache and orofacial pain – Chronicheadacheandchronicorofacialpainisdefinedasheadachesororofacialpainsthatoccuronatleast50%ofthedaysduringatleast3months.
6. Chronic visceral pain – Chronicvisceralpainispersistentorrecurrentpainthatoriginatesfromtheinternalorgansoftheheadandneckregionandthethoracic,abdominal,andpelviccavities
7. Chronic musculoskeletal pain – Chronicmusculoskeletalpainisdefinedaspersistentorrecurrentpainthatarisesaspartofadiseaseprocessdirectlyaffectingbone(s),joint(s),muscle(s),orrelatedsofttissue(s).
Source:TreedeRD,RiefW,BarkeA(2015)AclassificationofchronicpainforICD-11.Pain 156(6):1003–1007
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Appendix 2 – specialist training in pain medicine
TheFPMistheprofessionalbodyresponsibleforthetraining,assessment,practiceandcontinuingprofessionaldevelopmentofpainmedicinespecialistsintheUK. Itdescribestheroleofpainmedicinephysiciansasundertaking“[…] the comprehensive assessment and management of patients with acute, chronic and cancer pain using pharmacological, interventional, physical and psychological techniques in a multidisciplinary setting.”
Traineeanaesthetiststhatwishtospecialiseinpainmedicinemustundertake 12monthsormoreofadvancedpaintrainingindesignatedspecialistcentres.Successfulcompletionofthistraining,alongsidecontinuousassessmentandpassingoftheFPMexaminationleadstotheawardofFFPMRCA(FellowshipoftheFacultyofPainMedicineoftheRoyalCollegeofAnaesthetists)ortheDiploma(DFPMRCA)forthosetraineeswhohaveaqualificationthatisequivalenttoFRCA.133,134
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Acknowledgements
Editorial boardBoard of science chair ProfessorParveenKumarPolicy director RajJethwaHead of public health and healthcare LenaLevyHead of science and public health GeorgeRoycroftResearch and writing RobertWilson ThomasAndrews
Board of science ThisreportwaspreparedundertheauspicesoftheBMAboardofscience,whosemembershipfor2016-17wasasfollows:Professor Pali Hungin PresidentDrMarkPorter CouncilchairDrDavidWrigley CouncildeputychairDrAndrewDearden TreasurerDrAntheaMowat Representativebodychair
ProfessorParveenKumar BoardofsciencechairDrPaulDarragh BoardofsciencedeputychairDrJSBamrahProfessorPeterDangerfieldDrShreelataDattaDrKittyMohanMrRamMoorthyDrMelodyRedmanProfessorMichaelRees(deputymember)DrPenelopeToffDr Ian Wilson
JacquelineAdams(BMAPatientliaisongrouprepresentative)DrIainThomasRobertKennedy(BMApublichealthmedicinecommitteerepresentative)
TheAssociationisgratefulforthehelpprovidedbytheBMAcommitteesandoutsideexperts.Wewouldparticularlyliketothank:
– DrBeverlyCollettOBE(FacultyofPainMedicine) – DrCathyStannard(FacultyofPainMedicine) – DrPaulWilkinson(FacultyofPainMedicine) – ProfessorAndrewRice(ImperialCollegeLondon) – ProfessorRogerKnaggs(UniversityofNottingham) – DrMartinJohnson
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