1. Dr Angus Robin Bradford VTS Feb 18 th 2014 (with some slides from Dr Tim Williams and Dr F Cole)

2. WHO pain ladder Was designed for cancer pain. Methadone was initially planned, morphine in the end.... Gives us ‘permission’ to escalate doses v quickly – or so it seems. Doesn’t remind us about topical things or neuropathic agents.

3. “But the drugs don’t work Dr...”

4. Expect analgesic failure; pursue analgesic success (BMJ 8 th June 2013, page 19-21) Most analgesics don’t work for most people, when you define ‘work’ as a 50% reduction (NNT...) Most studies in acute post-op pain...so useless in the vast majority of patients. Very few studies beyond 12 weeks.

5. DrugNNTNNH minorNNH major TCA2.65.716.9 Gabapentin4.44.112.3 Pregabalin4.94.3 Opioids2.73.66.3 Tramadol4.87.210.8 PHN Medications: NNT, NNH NNT number needed to treat, NNH number needed to harm Wu CL, Raja SN. J Pain 2008

6. In low back pain tapentadol has a 90% failure rate (to give 50% relief) and oxycodone has a 100% failure rate. This is consistent with observations of other opioids and what we see in the pain rehab ‘living with pain’ team.

7. When they do work they improve sleep, mood, fatigue, QoL, etc (unsurprisingly). If one drug in a class fails, others may not, so we don’t know the best order to try drugs which mainly fail. Due to low success rates, is polypharmacy the answer? (can of worms time....serotonin syndrome, etc). A 50% pain reduction in a small group of patients is worth seeking out....

8. Expect modest benefits and frame patient expectations of analgesia benefits more realistically Mention relaxation therapies as useful tools in setbacks / flare-ups All the meds can help, but nowhere near as much as pharma wants us to think

9. Before you start opioids Be aware safety and efficacy of long term opiates is uncertain. Be aware of BPS guidance. Do a comprehensive Pain assessment Including…….The meds they’ve tried (and how long for – actually go through the records) Co-morbid conditions GOALS and WIDER PLAN

10. There is no evidence from RCTs to support that benefits of long term opioid therapy outweigh the risks.

11. Starting Opioids Discuss well established side effects Appropriate preparation Long-acting Dose Never injectable (rarely short-act) Start low and go slow (<120mg/day) Co prescribe anti-emetic + laxative Agree follow up interval (1-2 weeks, then monthly) Same prescriber ideally Consider a contract

12. Opiate Adverse Effects 80% will experience side effects constipation nausea/vomiting itch dizziness sedation (driving?)...anecdote re: bus driver Long term immunological/endocrine effect Addiction, dependence. “Using for sleep Dr” Withdrawal (sweat/cramps/yawn/tremor) Opioid induced hyperalgesia is rare, but real.

13. Hormonal disturbance GnRH reduced and subsequent effects on FSH/LH levels. Leads to androgen/oestrogen level changes. Prolactin possibly increased. TFTs seem unaffected. Worsens diabetes, worsens obesity (multifactoral).

14. Mortality data In the US opioid related deaths rose from 4041 in 1999 to 14459 in 2007. This is more than road traffic accidents. In the UK deaths from prescribed opioids roughly doubled between 2005-09.

15. Approximate equivalent doses N.B. There is no universal agreement 24 hour doseMorphine equivalent per day Codeine240 mg40mg (26 – 60) Dihydrocodeine240 mg50mg Tramadol400 mgUp to 120mg Oxycodone20mg40mg

16. Oral Morphine (mg/24hrs)101530456090120180270 TransdermalBuprenorphine(µg/hr)510203552.570 TransdermalFentanyl(µg/hr)12255075 Dose Equivalents

17. Managing established patients Regular review (monthly/6monthly) to include…..effectiveness side effects plan compliance progression to goals clear documentation Alternatives for ‘flare-up’ management. Ideally this is where ‘compassion days’ come in....pacing skills.

18. Flare-Up Management Establish ‘flare-up’ and not new pain Re-assurance that will settle Consider short- term changes to other analgesics or use of alternatives E.g. TNS, relaxation techniques, pacing activities, self-compassion!(DWP not keen on this) Avoid dose escalation....A&E struggle with this.

19. Stopping Opiates – When and How When?Patient’s pain and function not improved, or is worse. Concerns over addictive behaviour. Unacceptable adverse effects. Patient preference. How?Slow/gradual dose reduction Consider other pain relieving strategies.

20. The future of opioid management (is it nearly now?)

21. Other tests to be considered in patients on long term opioid therapy.... Blood tests may include:  U&E’s  FBC  LFT  CRP  TFT’s  Testosterone and oestradiol levels  LH  FSH  SHBG  DHEA (an androgen)  Ca²⁺  Mg²⁺  ESR  VitD  Bone profile cost?

22. So what about GP now? Tramadol KPPI in Bradford and Airedale Tramadol is an opioid analgesic indicated for moderate to severe pain. Tramadol is a potent drug; at 200mg/day it is equivalent to 40mg of oral morphine in 24hrs. Tramadol is available as 12-hourly and 24-hourly modified release preparations. These preparations are significantly more expensive than the immediate release formulations and restrict the up or down titration of the analgesic according to the patient’s symptoms. All patients who are prescribed analgesics should have their pain symptoms and treatment reassessed on a regular basis.

23. Summary We need patients to know that the medicines will probably help less than we thought. We need to give them more information and review pain medicines better. We need to believe that other methods of dealing with chronic pain help and take the time to encourage a patients to engage with this.

24. BPS guidance Summary page: http://www.britishpainsociety.org/book_opioids_recommendations.pd f http://www.britishpainsociety.org/book_opioids_recommendations.pd f Patients version: http://www.britishpainsociety.org/book_opioid_patient.pdf http://www.britishpainsociety.org/book_opioid_patient.pdf