Opiates in Chronic Pain

Dr S Vas, Barnsley VTS October 2014

Quiz – True or False

• 1.Deaths for adults aged 35 – 54 yrs of age exceed road traffic collisions and firearms incidents combined in the USA

• 2.55 % of patients prescribed opiates will experience at least 1 side effect

• 3.Patients taking > 100mg of morphine/day are more than 9 times more likely to accidentally over-dose than those taking < 20mg of morphine/day

• 4.There is no evidence for the short term use of opiates in relieving pain

• 5.Medications such as Amitriptyline and Gabapentin should always be used before Opiates for persistent pain

• 6.Modified Release medications are more likely to cause tolerance and problem drug use

Quiz – True or False

• 7.Red flags indicating problem use include:

– A.Earlier prescription seeking

– B.Frequent telephone appointments

– C.Claims of lost medication

– D.Presenting with other symptoms

– E.Intoxication

– F.Admissions to A+E

– G.Frequent missed appointments

– H.Use of other scheduled drugs

Intended Learning Outcomes

• Recognise the potential pitfalls of prescribing opiates in chronic pain

• Describe how to assess patients who will be prescribed opiates for chronic pain

• Understand the barriers to managing patients who use opiates for chronic pain

Why focus on this?

http://www.dailymail.co.uk/health/article-2774300/GPs-creating-nation-hooked-painkillers-Addictions-codeine-morphine-drugs-reached-dangerous-levels.html

Stats• Deaths for adults aged between 35 and 54 yrs of age exceed road

accidents and firearms incidents (Opioids for chronic non-cancer pain A position paper of the American Academy of Neurology, Sep 2014)

• Comparable trends in the UK (http://www.hscic.gov.uk/searchcatalogue?productid=12055&returnid=1683)

• Opioids are prescribed more often and for longer periods than would be predicted by their known efficacy in the management of persistent pain.

• Opioids are often prescribed in doses above which we know that harms outweigh benefits http://www.bmj.com/content/347/bmj.f5108?sso=

Other worrying evidence• 80% of patients taking opioids will experience at least one

adverse effect

• Common side effects directly related to opiates include:– Constipation, nausea, somnolence, itching, dizziness, vomiting

• Serious long term consequences include:– Hypogonadism and infertility, immunosuppression, falls and

fractures in older adults, sleep-disordered breathing, nonfatal overdose hospitalizations and death from unintentional poisoning.

• There is a 9 fold increase in over-doses over 100mg/day of Morphine equivalent dose (MED) compared to doses below 20 mg/day MED. There is 3.7 – 4.6 increase in overdoses for amounts between 50 – 100mg/day.

Efficacy• There is evidence for significant short-term pain relief

(average duration in trials was 5 weeks)

• There is no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence or addiction.

• One study found that patients with chronic pain on opioids reported decreased pain relief, functional capacity, and quality of life vs persons in chronic pain not on opioids, adjusting for severity

Prescribing

• Drugs with demonstrated efficacy for persistent pain syndromes (e.g. tricyclic antidepressants and antiepileptic drugs for neuropathic pain)

should always be prescribed before starting opioids.

• Discuss the risks and benefits with the patient and consider giving them written information

• Modified release preparations at regular intervals should be used

• Immediate release preparations are more associated with tolerance and problem drug use – if they are required for persistent pain then consider pain team referral

Prescribing

• Do NOT use Pethidine – lipid soluble with rapid onset/offset action means a higher risk of problem drug use

• Consider potentially serious drug interaction i.e. Tramadol + TCAs/SSRIs causing Serotonin Syndrome

• Start low and slowly titrate up

• British Pain Society suggest referral if no useful relief of pain symptoms at 120mg Morphine equivalent/24 hrs (I would suggest lower)

Trial of Opioid Therapy

• This is recommended before prescribing opioids for long term use

• Assess mental health, including:– Current/past history of anxiety or depression

– Current/past history of substance misuse

– Family history of substance misuse

• Review should be at least monthly in the first 6 months

• Goals of therapy should be agreed before starting treatment and reviewed at each assessment

• Consider a formal “opioid” contract

Long Term Opioid Prescribing

• Treatment may be continued until:– the underlying painful condition resolves– the patient receives a definitive pain relieving

intervention (e.g. joint replacement)– the patient no longer derives benefit from

opioid treatment– the patient develops intolerable side effects– use of opioids becomes problematic

Opioids and problem drug use• May result in problem drug use, this is influenced by:

– Social, psychological and health related factors

• Consider whether medications are being “diverted” to other people

• Addiction– Characterised by certain behaviours such as impaired control over

drug use, compulsive use, continued use despite harm and craving

• Dependence– Specific withdrawal syndrome that can be produced by abrupt

cessation, rapid dose reduction, decreasing blood level of the drug, or administration of an antagonist.

• Tolerance– diminution of one or more of the drug’s effects over time.

Problem drug use

• “elicit the patient’s thoughts” on how they are using opioid analgaesia

• pattern of use is possibly more important than quantity especially if being used for improving mood

• Other “red flags” which may indicate problem drug use:– earlier prescription seeking– claims of lost medication– intoxication– frequent missed appointments– use of other scheduled drugs

Opiates and driving

• Patients taking prescribed opioids may still drive• Patients cannot drive if their use constitutes misuse or

dependancy• Patients being treated with opioids should be advised to

avoid driving when:– the condition for which they are being treated has physical consequences

that might impair their driving ability– they feel unfit to drive– they have just started opioid treatment– their dose of opioids has been recently adjusted upwards or downwards

(as withdrawal may have an impact on capability)– they have consumed alcohol or other drugs that can produce an additive

sedative effect.

• Patients should be advised to inform the DVLA they are taking opioids

An example of a consultation

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

Questions