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Pain in Secure Environments Addiction to Medicines: Commissioning services after health reforms Prospero House February 2013 Cathy Stannard: Bristol UK.

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Presentation on theme: "Pain in Secure Environments Addiction to Medicines: Commissioning services after health reforms Prospero House February 2013 Cathy Stannard: Bristol UK."— Presentation transcript:

1 Pain in Secure Environments Addiction to Medicines: Commissioning services after health reforms Prospero House February 2013 Cathy Stannard: Bristol UK

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4 Pain Management in Secure Environments Presentation overview Introduction and background to the project Process of preparation The guidance Context Clinical Issues Diagnosis and prescribing Non-pharmacological management Pathways

5 Introduction and background Pain in Secure Environments

6 www.britishpainsociety.org

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8 Process of preparation Pain in Secure Environments

9 Pain in Secure Environments: cast list Chairs of project and co-editors Dr Linda Harris Medical Director RCGP Substance Misuse and Associated Health Dr Cathy Stannard Consultant in Pain Medicine British Pain Society, Faculty of Pain Medicine Royal College of Anaesthetists Members of Consensus Group Danny AlbaNHS Wakefield District Prof Mike BennettUniversity of Leeds, Faculty of Pain Medicine Royal College of Anaesthetists Dr Iain BrewGP at HMP Leeds and RCGP Secure Environments Group Member Dr Michelle BriggsSenior Research Fellow, University of Leeds (on behalf of the Pain in Prisons NIHR programme development group) Ms Helen CarterHealthcare Inspector, Her Majesty's Inspectorate of Prisons Dr Beverly CollettConsultant in Pain medicine: Chronic Pain Policy Coalition, Faculty of Pain Medicine Royal College of Anaesthetists Mrs Cathy CookeChair: Secure Environment Pharmacists Group Dr Annette Dale-PereraCentral and North West London NHS Foundation Trust Mr Kieran LynchNational Treatment Agency Mr David MarteauDepartment of Health Ms Jan PalmerDepartment of Health Dr Mary Piper Department of Health Dr James RobinsonClinical Lead HMP Styal: RCGP Secure Environments Group Mr Mark WarrenAvon and Wilts Mental Health Partnership Dr Amanda WilliamsReader in Clinical health Psychology University College London; University College London Hospitals Policy Observers Mr Mark EdgintonDepartment of Health Dr Mark PruntySenior medical officer for substance misuse policy: Department of Health

10 The guidance Pain in Secure Environments

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12 It is the right of every person in custody to have access to evidence based pain management

13 It is the right of every person in custody to have access to evidence based pain management that can be safely delivered to them

14 Medications are properly a cause for concern Medications play a partial role only in pain management Document aims to empower clinicians working in secure environments

15 Pain Management in the Secure Environment: context Size of the problem Trends in prescribing Additional challenges in specific settings Female prison estate Male high security prisons

16 Key points: context The prevalence of long term pain in the secure environment population is unknown A number of risk factors for chronic pain exist in this population including mental health and substance misuse disorders, physical and emotional trauma There may be difficulty in distinguishing patients needing medication for pain and those requesting drugs to continue substance misuse or as a commodity for trade The secure environment offers an opportunity for regular assessment of the effect of analgesic medications on pain and function Professional isolation and fear of criticism and complaints erode confidence in prescribing decisions

17 Pain Management in the Secure Environment: clinical issues Diagnosis and prescribing Diagnosis of persistent pain Diagnosis of neuropathic pain Diagnosis of visceral pain and poorly defined disorders

18 Key points: diagnosis of pain Pain is a subjective experience and the diagnosis can only be made by interpretation of the patients report Good communication with the patients community healthcare providers helps identify pre-existing painful conditions Onset of pain can usually be related to an obvious inciting event including trauma or other tissue damage Pain is usually associated with an observable (but variable) decrement in physical functioning Diagnosis of neuropathic pain can be supported by the history (nerve injury or damage) and by abnormal findings on sensory examination Understanding the complexity of origin of visceral pain and of poorly defined disorders can help in planning realistic interventions.

19 Pain Management in the Secure Environment: clinical issues Diagnosis and prescribing Role of opioids in persistent pain Pharmacological management of neuropathic pain Pharmacological management of visceral pain and poorly defined disorders Non-pharmacological management of pain Psychological interventions Physical rehabilitation

20 Why are opioids prescribed?

21 Because… they are strong analgesics persistent pain is hard to treat so something strong is a tempting idea pain sufferers exhibit distress distress makes clinicians want to do something we know there are risks but think we can handle them

22 WHO 1986

23 Why are opioids prescribed? Because… they are strong analgesics persistent pain is hard to treat so something strong is a tempting idea pain sufferers exhibit distress distress makes clinicians want to do something we know there are risks but think we can handle them

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25 Figure 4: trends in the prescribing of opiates analgesics in general practice in England (Source: NHS National Treatment Agency May 2011). Population 56.1 million

26 Figure 5: variation between Strategic Health Authorities in prescribing of opioid analgesics (Quarter to March 2010) NHS prescribing services.

27 Total number of prescriptions and number of patients stratified by non-cancer and cancer CPRD 2000-2010

28 Defined daily doses per 1000 patients per day CPRD 2000-2010 Non-cancer pain Cancer pain

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31 Opioid use associated with: Report of moderate/severe pain Poor self-related health Unemployment Increased use of healthcare system Negative influence on QOL

32 Opioid adverse effects No pain relief Worsening of pain Cognitive impairment/somnolence precluding effective engagement with pain management strategies Endocrine and immune effects Addiction

33 www.britishpainsociety.org

34 Key points: opioids for persistent pain The WHO analgesic ladder has poor applicability in the treatment of persistent pain Evidence for effectiveness of opioids in management of long term pain is lacking, particularly in relation to important functional outcomes Opioid therapy should be used to support other strategies for pain management e.g. physiotherapy If useful relief of symptoms is not achieved at doses of 120mg morphine equivalent/day, the drugs should be tapered and stopped Both strong and weak opioids should be prescribed with caution There is no evidence that any opioid produces superior pain relief to morphine Symptoms should usually be treated with sustained release opioid preparations Fast acting preparations should not be used for the treatment of persistent pain Methadone has an established role in the treatment of long-term pain: patients with a diagnosis of pain receiving methadone opioid substitution therapy can be managed by maintaining an effective daily dose of methadone given in two divided increments Conversion ratios between opioids vary substantially especially when converting to or from methadone. Cautious conversion ratios should be used and the effect reviewed regularly

35 Key points: pharmacotherapy for neuropathic pain Medications are the best way to treat neuropathic pain but fewer than a third of patients will respond to a given drug Pain relief from neuropathic pain medications is modest Tricyclic antidepressants are the most effective treatment of neuropathic pain Carbamazepine may be effective in the management of neuropathic pain Gabapentin and pregabalin are unsuitable as first-line drugs for use in secure environments

36 Amitriptyline10-75mg once daily Nortriptyline10-75mg once daily Duloxetine60-120mg once daily Carbamazepine200-1200mg daily in two divided doses Gabapentin900-2700mg daily in three divided doses Pregabalin150-600mg daily in two divided doses Suggested dosing for commonly used drugs in the treatment of neuropathic pain (All drugs should be started at a low dose with at least one week between dose increments: the figures below represent the starting dose and a suggested upper dose limit)

37 Key points: visceral pain and poorly defined disorders Psychological interventions are the mainstay of management of visceral pain and poorly defined disorders Tricyclic antidepressant drugs may play a role in the management of pain associated with irritable bowel syndrome

38 Key points: non-pharmacological management of pain It is important to address fears and mistaken beliefs about the causes and consequences of pain Co-morbid depression and other psychological disorders should be treated as part of pain management There is good evidence for active physical techniques in the management of pain Physical rehabilitation is best combined with cognitive and behavioural interventions Interventions such as TENS and acupuncture are poorly supported by evidence for benefit but may support self- management of pain

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40 Patient presents with pain Assess pain including History of onset/inciting events Current symptom description Exacerbating and relieving influences Effect of pain on function including sleep Previous treatments for pain Current medication (confirm from previous HCP) Medical/surgical history Mental health history including substance misuse Social history Patients understanding of symptoms Previous healthcare provider confirms pre- existing persistent pain condition

41 History suggests obvious precipitating event (trauma/tissue damage) evidence of functional impairment History and examination confirm diagnosis of neuropathic pain Initiate paracetamol +/- NSAIDs Initiate amitriptyline 10mg nocte increasing every few days as tolerated to 75mg nocte. If sedation a problem change to equivalent dose of nortriptyline Yes No

42 If no response to tricyclic antidepressants use anti-epileptic drugs starting with carbamazepine. For refractory cases of neuropathic pain of confirmed origin consider opioid therapy Consider active physiotherapeutic strategies (paced increase in exercise) supported by education about meaning and consequences of pain Consider night-time amitriptyline if sleep disturbed by pain For refractory cases of well-defined pain consider opioid therapy Manage depression and other psychological disorder in accordance with local guidance

43 FOR ALL PATIENTS Manage depression and other psychological disorder in accordance with local guidance Consider active physiotherapeutic strategies (paced increase in exercise) supported by education about meaning and consequences of pain Opioid Prescribing Pathway

44 Consider opioid treatment for Severe osteoarthritis Pain following multiple spinal surgery Neuropathic pain unresponsive to tricyclic antidepressants/antiepileptic drugs Discuss harms of long term opioids including limited efficacy, endocrine and immune effects and hyperalgesia Initiate time constrained trial of opioid therapy. Define goals of therapy If symptoms not relieved and functional goals not met after three upwards dose adjustments, taper and stop opioids

45 Start once daily morphine 20mg and review regularly for upwards dose titration If no substantial pain relief or functional improvement at 120mg morphine equivalent/24 hours taper drug and stop

46 Patient established on methadone complains of pain on dose reduction Previous healthcare provider confirms pre- existing persistent pain condition History suggests obvious precipitating event (trauma/tissue damage) evidence of functional impairment Reassess pain as above with history and examination No Yes Patients on methadone

47 Suspend methadone taper and give daily dose of methadone in 2 x 12 hourly increments Convert to once daily morphine starting with conservative conversion (Methadone 1mg = morphine 2mg) and review regularly for upwards dose titration If dose of morphine exceeds 120mg/24 hours, consider gradual taper once conversion complete

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