Opioids for persistent non-cancer painBritish Pain Society Recommendations

Karen H SimpsonConsultant in Pain ManagementLeeds

Need for recommendations for use ofopioids in persistent non-cancer pain

Persistent pain is being increasingly recognised as a medical and social problem

Large surveys from Europe suggest10% population have persistent severe pain

4600 patients in Scotland in primary care16% moderately/severely disabled by persistent pain

 2000 patients in primary care79% still had pain after 4 years

 

Pain – a widespread problem

– One in five people in UK suffer from chronic pain

– Total of 7.5 million people

– One-third of UK households affected by chronic pain

3

9

20

26

17

4

21

0

5

10

15

20

25

30

6 Months to <1 Year

1 to <2 Years

2 to <5 Years

5 to <10 Years

10 to <15 Years

15 to <20 Years

20 Years or More

Patients Living in PainDuration of Pain (n=300)

Chronic pain present average 6 y

A fifth had pain for more than 20 y

%

6

5

4

3

3

40

18

15

8

0 5 10 15 20 25 30 35 40 45

Arthritis/osteoarthritis

Traumatic injury

Herniated/deteriorating discs

Rheumatoid arthritis

Nerve damage

Surgery

Fracture/deterioration of spine

Migraine headaches

Break/fracture that never healed correctly

Causes of chronic pain

Most frequently arthritis Most commonly low back pain

Need for recommendations for use ofopioids in persistent non-cancer pain

Persistent pain affects lots of people

UK 2-6 million people with persistentsevere non-cancer pain

 England and Wales 1.3-1.75 million osteoarthritis

0.25-0.5 million rheumatoid arthritis

The problem is large and likely to grow as the population ages

Need for recommendations for use ofopioids in persistent non-cancer pain

Persistent pain is expensive

900,000 hospital bed days12 million GP consultations119 million days certified incapacityUK direct health care cost back pain £1632 millionInformal care/lost production cost £10668 million

The public and government are interested

Need for recommendations for use ofopioids in persistent non-cancer pain

There are an increasing number of strong opioids withmarketing authorisation for persistent non-cancer pain

There is increased use of strong opioids for this indication inprimary and secondary care

There is strong pressure from industry to use these drugs more freely

There is little training for health care professionals aboutopioid use for this indication

Need for recommendations for use ofopioids in persistent non-cancer pain

Patients and carers are becoming more aware of the use ofstrong opioids for non-cancer pain

In some European countries and USA there is intense pressure on doctors to provide opioids for non-cancer pain

This is balanced by concerns about medical use of opioids

Doctors accused on heroin advice Steven MorrisTuesday February 24, 2004The Guardian

Development of recommendations

2 years ago Pain Society consensus group developedProvisional recommendations for the appropriate use of opioids in patients with chronic non-cancer related painThere was an accompanying patient information leaflet

This was developed after literature review and consensus opinion from experts from a number of disciplines and patient’s representatives

During the 12 month consultation period over 300 responses from individuals and professional organisations have been received and considered

Consensus group

Joint chair and co-editorsDr Alf Collins UK Pain SocietyDr Karen Simpson UK Pain SocietyMembersDr Douglas Justins Royal College of AnaesthetistsProf Bruce Kidd Royal College of Physicians Dr Richard Potter Royal College of General PractitionersDr Marian de Ruiter Royal College of PsychiatristsDr Cathy Stannard Pain SocietyMr Phil Wiffen Royal Pharmaceutical SocietyDr Amanda Williams UK Pain Society Advice given by the following individuals:Mrs Jean Gaffin UK Pain Society Patient Group Chair Dr Mike Bennett Association for Palliative Medicine

Prof Antony Franks NHS Trust Risk Management Chair

Recommendations endorsed byAssociation of AnaesthetistsRoyal College of AnaesthetistsRoyal College of General PractitionersRoyal College of Psychiatrists/Faculty of Addiction Medicine

Recommendations reviewed byRoyal College of PhysiciansLiam Donaldson – Chief Medical OfficerBritish Pharmaceutical SocietyBritish Medical AssociationAssociation for Palliative MedicineMedical Defence Organisations and Hempsons SolicitorsBritish Medical AssociationComments invited from all Pain Society Members

What issues have been raised?Are opioids effective?

What type of pain?Appropriate patients?

Which drugsSide effects and toxicity?

Modified and transdermal vs. immediate release?Breakthrough pain?

Which routes?Monitoring?

Problem drug use?Drug diversion?

Withdrawal?Patient contracts?

Advantages of opioids

Strong opioids can provide analgesia

? improve quality of life

Problem drug use uncommon

Few long term randomised controlled trials

Unanswered questions about opioids

Adverse effects

Opioids not organ toxic

Patients must be carefully monitored

Side effect must be discussed and managed

Concerns about problem drug and diversion must be addressed

Long term studies?

Many unanswered questions about opioid use

Patients with persistent pain can be challenging often with poorly defined pathology and behavioural and social problems

Most studies are short-term and exclude patients with such problems

The use of opioids must be carefully considered and appropriate in this context

Indiscriminate prescribing must not be encouraged

Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003 Nov 13;349(20):1943-53.

Efficacy and adverse effects

Chou R, Clark E, Helfand M. Comparative efficacy and safety of long-acting oral opioids for chronic non-cancer pain: a systematic review.

J Pain Symptom Manage 2003 Nov;26(5):1026-48. (Oregon)

A total of 16 randomised trials until October 2002Efficacy and adverse effects n=1427 patientsNone rated as good quality evidence

Insufficient evidence that different long-acting opioids associated with different efficacy or safety

Insufficient evidence whether long-acting opioids as a class are more effective or safer than short-acting opioids

Recommendations – future plans

Pain Society will establish an implementation group

Dissemination of information to primary and secondarycare providers of pain management

Liaison with PCTs and Trusts

Data collection and surveillance – ongoing audit

Monitoring of emerging evidence base

Liaison with other European centres