pain and dependency / pain management in the prison population dr colin baird consultant in...
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Pain and Dependency / Pain Management in the Prison Population
Dr Colin BairdDr Colin Baird
Consultant in Anaesthesia & Pain MedicineConsultant in Anaesthesia & Pain Medicine
Western General HospitalWestern General Hospital
Leith Community Treatment CentreLeith Community Treatment Centre
Dr Rebecca LawrenceConsultant in Addictions PsychiatryRitson UnitRoyal Edinburgh Hospital
Dr Lesley ColvinConsultant / Honorary Reader in Anaesthesia and Pain MedicineUniversity of Edinburgh
Summary
Pain and Dependency – an overview•Dr Rebecca Lawrence
Management of Neuropathic Pain and how SIGN 136 can be implemented in the PAD clinic•Dr Colin Baird
Opioids for chronic pain in the prison population – good or bad?•Dr Lesley Colvin
Declaration of Interests / Funding
Edinburgh & Lothians Health Foundation Alcohol Problems Endowment Fund – contribution to MSc in Pain Management
Astellas Pharma Ltd – funding to attend BPS annual scientific meeting (2014)
Reckitt Benckiser – funding to attend Opioid Painkiller Dependence Education Nexus (September 2014)
Overview
Background / brief epidemiology
Lothian Pain & Dependency Clinic model
center-for-addiction-recovery.com
Chronic Pain and Dependencythe emerging co-morbidity?
Chronic pain of moderate to severe intensity occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives (Breivik, H., et al, 2006. Eur J Pain) (BPS figure - one in seven of UK population)
Estimated prevalence of problem drug use (opiates and/or benzodiazepines) Scotland 2012-13 of 1.68% population aged 15-64 (Scottish Government)
Up to 50% men and 30% women across Scotland exceeding weekly recommended guidelines (Changing Scotland’s Relationship with Alcohol: A Framework for Action, 2009)
Access to pain relief – an essential human right IASP, the WHO and EFIC
The UN Universal Declaration of Human Rights conceptualises human rights as based on inherent human dignity
Perception and expression of pain is individual: It is essential to listen to and believe the patient –
only they know what the pain feels like (A report for World Hospice and Palliative Care Day 2007 Published by
Help the Hospices for the Worldwide Palliative Care Alliance )
Substance misuse patients
Increased prevalence of pain
Poorer treatment outcomes. Yet treating pain improves outcomes
More likely to use illicit opioids / more drug-seeking
Chronic Pain Patients
• Increased prevalence of alcohol & drug misuse
• Hoffman et al (1995) – 23.4% of 414 hospitalized chronic pain patients in Sweden met criteria for active diagnosis of alcohol, analgesic or sedative misuse or dependence
• No demographic / clinical factors that consistently differentiate CNCP (chronic non-cancer pain) patients with comorbid SUD (substance use disorder) from patients without SUD, though may be at greater risk for aberrant medication-related behaviors.
Morasco, B.J., Gritzner, S., Lewis, L., Oldham, R., Turk, D.C., Dobscha, S.K., 2011. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. PAIN 152, 488–497. doi:10.1016/j.pain.2010.10.009
Pain & Opioid Dependency
Aberrant drug-related behaviour (Aberrant drug-related behaviour (““Red flagsRed flags””))
AbuseAbuse ( (DSM IV: Psychoactive Substance Abuse: A maladaptive pattern of drug use that results in harm or places the individual at risk)
PseudoaddictionPseudoaddiction: : Aberrant drug-related behaviour in patients reacting to under treatment of pain
Physical DependencePhysical Dependence Tolerance (side effects/ Tolerance (side effects/
analgesia)analgesia)
Pain, Mental Health & Alcohol
• Strong association between pain & psychopathology, particularly depressive disorders, anxiety disorders, somatoform disorders, substance use disorders & personality disorders
Dersh J, Polatin GB & Gatchel RJ (2002). Chronic pain and psychopathology: research findings and theoretical considerations. Psychosom Med 64(5):773-86.
Licensed Treatments Amitriptyline – depression & neuropathic
pain Duloxetine – depression, generalized
anxiety & diabetic neuropathy Pregabalin – peripheral / central
neuropathic pain & generalized anxiety Carbamazepine – trigeminal neuralgia,
prophylaxis of bipolar disorder
PSYCHOLOGICAL INTERVENTIONS
Other treatments for pain, mental disorders & substance misuse
Valproate Gabapentin Topiramate Lamotrigine Other antidepressants Baclofen Opiates Benzodiazepines
Ketamine infusion Deep brain
stimulation
Pain & Dependency (PAD)– the Edinburgh experience:
Development of combined Pain & Dependency (PAD) Clinic – 2003 (by Dr Lesley Colvin & Dr Michael Orgel)
Patients with drug dependence should not be denied adequate pain relief
Access to specialised services with experience in managing this patient group is essential
Scimeca, MC (2000)
Multidisciplinary
– Pain Specialist
– Addiction Psychiatrist
– Specialist Nurse
– Clinical Psychologist
What is the PAD Clinic?
Location & Referrals
PAD clinic is located in, & funded by, the Chronic Pain Service
Majority of referrals from GPs, also from Substance Misuse Service, and some diverted from Pain Service
Triage to PAD Current input from SMD (Substance Misuse Directorate) Current misuse of / dependence on illicit drugs (includes
legal highs - increasing problem) Current misuse of / dependence on alcohol Any history of drug / alcohol misuse with associated ongoing
mental health problems Not stable on prescribed methadone Prescribed > 150mg methadone (guide) Iatrogenic opioid misuse / dependence Misuse of over the counter or other prescribed medication Concern regarding gabapentin or pregabalin use (prescribed
or unprescribed)
PAD Clinic Assessment of pain, mental health and
substance misuse / addiction• Does not matter which “came first”• Verify past assessment• Initiate further assessment/ investigations
Does not provide key work or prescribing• Liaison with appropriate services
Mental health assessment (not ongoing monitoring and treatment)• Liaison with appropriate services
History: Pain and Substance Misuse
Pain• Diagram, BPI & associated symptoms• Past treatment & investigations
Substance misuse history• Stable/ chaotic – prescription? Support?• IVDA – Hep C/ HIV (BBV) status and Rx• Alcohol; stimulants & / or benzos; cannabis;
NPS; gabapentin…
Mental Health Social history Child protection issues
Examination: Pain and Substance Misuse
Pain: • Sensory changes/ ? neuropathic• motor impairment/ impact on function• Sympathetic involvement
Substance misuse: • Toxicology – urine / oral swab• Breathalyse• Signs of chronic drug / alcohol use• Track marks• Intoxication
Patients
“Established” drug users with pain (often on substitute prescriptions). Pain often a result of chaotic lifestyle
Pain resulting from alcohol dependence Concerning use of over the counter or
prescribed medication (usually opioids, but may be other drugs, eg gabapentin)
Past history of drug or alcohol use
Review of 36 new patients seen in PAD in 2014
25 male, 11 female Average age 41(26-59) None in employment Addiction first – 18 Pain first – 7 Unstable use of opioids – 19 Mental health problem - 26
Review of 36 new patients (2)
On methadone – 15 On dihydrocodeine – 4 On buprenorphine – 0 On gabapentin or pregabalin – 14 Use of NPS – 2 Problem alcohol use – 13 Cannabis use – 15 Benzodiazepines frequently used /
prescribed
Management
Assessment & Explanation Non-pharmacological – eg TENS (also
acupuncture, craniosacral therapy, massage - availability)
Pain Management Programme Individual psychological work Nerve blocks if appropriate Community support – substance misuse
services
Management Antidepressants - ? amitriptyline ?Gabapentin / Pregabalin Non-opioids – NSAIDs Optimise current opioid prescribing Strong opioids if needed – monitor Strong opioids – which? Topical treatments In patient assessment & treatment
The Future? Wider access to specialist care – where and
how best to deliver this? The changing patterns of drug misuse and
management of pain – abuse of prescribed drugs other than opioids, alcohol misuse and the spread of novel psychoactive substances
Long term side effects of opioids and implications for practice
Management of Neuropathic Pain and how SIGN 136 can be implemented in the PAD clinic
Dr Colin Baird
Summary
Neuropathic pain – the problem
SIGN 136
Management of neuropathic pain
How can this be applied to the prison / PAD clinic population?
Gabapentin and pregabalin…!
Neuropathic pain: ‘Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system’
Pain: ‘An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms thereof’
Neuropathic pain – the problem
Between 8 and 18% of adults in the UK, USA and Europe will suffer from neuropathic pain
It has a negative impact on mood, ability to function and general wellbeing
16% of sufferers rate it as ‘worse than death’ on the EQ5D
Current treatment is limited by side effects, lack of efficacy and variable individual response
Doth et al. Pain (2010); Torrance et al. J Pain (2006); Toth C et al. Pain Medicine (2009); B Smith
What causes neuropathic pain to develop?
Damage to the somatosensory nervous system
Surgery / Trauma
Infection (PHN)
Drugs – chemotherapy, alcohol
Disease – diabetes, HIV
Features of neuropathic pain
Spontaneous
EvokedHyperalgesia
Allodynia
Impaired ability to function
Negative impact on mood
SIGN 136 – now available!
http://www.sign.ac.uk/guidelines/fulltext/136/index.html)
Key recommendations:
Assessment and planning of care
Supported self-management
Pharmacological management
Psychologically based interventions
Physical therapies
Three consensus pathways:
Assessment, early management and care planning
Neuropathic pain
Use of strong opioids
Complementary to the British Pain Society Map of Medicine PathwaysComplementary to the British Pain Society Map of Medicine Pathways((http://bps.mapofmedicine.com/evidence/bps/index.html) )
LANSS
DN4 NPQ PainDETECT
Id-Pain
Country UK France USA Germany USA
Validated 100 160 382 392 308
Sensitivity
82 - 91 83 66 85 NA
Specificity
80 - 94 90 74 80 NA
Common symptoms
Pricking, tingling,pins and needles; Electric shocks/ shooting; hot/ burning
Common signs
Brush allodynia; raised pin prick threshold
Case history - NF
45 year old male – stab wound to the chest 10 years ago
Pain since incident. Had been managed with gabapentin but this was stopped due to suspicion of drug diversion
Referred to the PAD clinic
On amitriptyline 50mg at night
Symptoms: Burning, shooting pain ‘like toothache doctor!’
Signs: Hyperalgesia and allodynia around the affected area.
Pharmacological options – 1st line therapy
Amitriptyline: 25 – 125mg daily. Titrate up by 10mg per week
Gabapentin: Titrate up by 300mg per week to 1200 – 18—mg daily
Pregabalin: 75mg BD, titrate up by 75mg per week to 300 – 600mg daily.
GabapentinoidsGabapentinoids
GabapentinGabapentin PregabalinPregabalin
How should we incorporate these conclusions into our clinical practice?
Advice for prescribers on the risk of the misuse of pregabalin and gabapentin
Ref: PHE publications gateway number: 2014586; NHS England publications gateway number 02387 PDF, 157KB, 9 pages
Which if any, are options for NF?
GabapentinPregabalin
Amitriptyline
Pharmocological options – 2nd line therapy
Alternative TCA: Nortriptyline, Imipramine – same dosing regime as amitriptyline but may have more favourable side-effect profile
SNRI: Duloxetine, 30-60mg daily, can increase to 120mg daily. Nausea is main side-effect
Carbamazepine: In trigeminal neuralgia
Could try alternative TCA?
Duloxetine?
Topical agents for neuropathic pain
Lidocaine patches: Good side-effect profile. Application may be problematic
8% Capsaicin patch: For PHN, HIV neuropathy, post-surgical scar pain.
TENS machine
8% Capsaicin patch
1 application
Pain scores have fallen from 9 to 4 after 2 weeks
Look for improvements in sleep and function
Plan to repeat the application after 12 weeks
Pharmacological options – Opioids!!