1. Pain Guidelines Ipswich & East Suffolk CCG 16 January 2014 Mike Bailey Ipswich Hospital Pain Clinic

2. Contents What is a guideline? Why different pains need different management What the BNF doesn’t tell you

3. What is a guideline? “Guideline" is the NATO reporting name for the Soviet SA-2 surface-to-air missileSA-2 Courtesy : ‘Wikipedia’

4. What is a guideline? A guideline is a statement by which to determine a course of action. A guideline aims to streamline particular processes according to a set routine or sound practice. By definition, following a guideline is never mandatory. Guidelines are not binding and are not enforced. U.S. Dept. of Veterans Affairs

5. Why use a guideline? Guidelines are based on evidence of best practice Guidelines should ensure consistent practice (if followed!) Guidelines are designed to achieve value-for- money

6. What is a guideline (not)? A guideline is not a substitute for common sense A guideline is not a shortcut A guideline is never foolproof

7. Different Pains Need Different Management Palliative Care Shorter life expectancy Goal: pain control Sedation not always a disadvantage Gradual loss of ADL seen as norm for many Chronic Non-Cancer Pain Life expectancy ‘normal’ Goal: live with pain Sedation usually a disadvantage Loss of ADL a big problem

8. Different Pains Need Different Management Nociceptive Pain Somatic –Trauma –Arthritis / degenerative –Infection Neuropathic Pain Nerve dysfunction –Chronic Injury –Neuropathy –Secondary changes Many chronic pains are due to a ‘mixed’ pain problem

9. E. Suffolk Primary Care Spend Analgesics Apr-Aug 12Apr-Aug 13 Total ItemsTotal spendTotal ItemsTotal spend Amitriptyline40212£67,562.9843096£75,025.31 Butrans3393£95,925.193698£108,119.15 Transtec443£18,903.51418£18,842.96 Fentanyl patch2952£130,450.252916£121,259.61 Gabapentin9442£76,145.0812040£63,617.31 Morphine MR6766£78,017.447275£82,176.24 Oxycodone MR1838£109,420.811909£111,730.44 Pregabalin8024£530,239.9410217£685,458.53 Targinact396£27,104.51437£28,585.53 Total73466£1,133,769.7182006£1,294,815.08

10. E. Suffolk Primary Care Spend Analgesics

11. E. Suffolk Primary Care Spend Anti-neuropathic Analgesics Apr – Aug 2012Apr – Aug 2013 Total itemsTotal spendTotal ItemsTotal spend Gabapentin9442£76,14512040£63,617 Pregabalin8024£530,23910217£685,458 Amitriptyline40212£67,56243096£75,025

12. DrugStrength tab/capCost per tab/capCost per 28 days Amitriptyline Once daily (bedtime) 10mg£0.03£0.89 25mg£0.03£0.90 50mg£0.04£0.98 Gabapentin Three times a day 300mg£0.04£3.77 600mg£0.10£8.71 800mg£0.36£29.84 Pregabalin Twice daily 75mg£1.15£64.40 150mg£1.15£64.40 300mg£1.15£64.40

13. Tricyclic antidepressants Amitriptyline 1 st line –Nortriptyline NNT 2.9 (PHN & DN) NNH 2.7 (minor) NNH 17 (major) Bandolier Little Book of Pain Moore A et al 2003

14. Gabapentin Moderate benefit (equivalent to at least 30% pain relief) in almost one in two patients (43%) Substantial benefit (equivalent to at least 50% pain relief) in almost one in three (31%). Adverse events are experienced by about two-thirds of people 1 in 10 (11%) have to stop the treatment because of.. unpleasant side effects Moore RA et al Cochrane Review 2011

15. Pregabalin Best NNT at least 50% pain relief on 600mg/day –3.9 postherpetic neuralgia, –5.0 for painful diabetic neuropathy –5.6 central neuropathic pain –11 fibromyalgia Somnolence 15% to 25% Dizziness 27% to 46%. Treatment discontinued 18 to 28%. Moore RA et al Cochrane Review 2010

16. Strong Opioids & Chronic Pain Benefits Better functioning Synergy with anti- neuropathics Risks Constipation Tolerance Withdrawal Suppression HPA ?  immune status

17. Beware the patch! Drug NameDrug DoseEquivalent Morphine Dose BuTrans 55 micrograms / hr10mg / 24 hrs BuTrans 1010 micrograms / hr20mg / 24 hrs BuTrans 2020 micrograms / hr40 mg / 24 hrs Transtec 52.5 (buprenorphine) 52.5 micrograms / hr94 – 145 mg / 24 hrs Transtec 70 (buprenorphine) 70 micrograms / hr126 – 193 mg / 24 hrs Fentanyl 25 patch25 micrograms / hr30 – 134 mg / 24 hrs Fentanyl 50 patch50 micrograms / hr135 – 224 mg / 24 hrs Fentanyl 75 patch75 micrograms / hr225 – 314 mg / 24 hrs Fentanyl 100 patch100micrograms / hr315 – 404 mg / 24 hrs NHS Wales website 2013

18. Strong Opioids & Chronic Pain Start low & go slow Remember full dose codeine = 25 mg morphine daily Slow release or regular dosing preferable Don’t use ‘rescue’ doses Stimulant laxative

19. Rescue Analgesia Not advisable for chronic pain Encourages boosting dose to deal with increased activity – ignoring pacing advice More likely to lead to dose escalation / dependence

20. Danger Signs! High doses morphine (or equivalent: > 120mg / day) Multiple opioids Only injections work (when patient is eating & drinking) largely seen in secondary care

21. Non-pharmacological analgesia Pacing activity / exercise Positioning / posture / stretch Reassurance (not always easy!) Trans-cutaneous Electrical Nerve Stimulation (TENS)

22. Referral to the Pain Clinic Helpful Content Current and previously tried medication / therapy Social history Diagnostics (inclusion & exclusion) –Pain clinic not a diagnostic clinic Other relevant medical problems

23. When do people go to a Pain Clinic? GP or consultant referral Diagnosis established First line measures have been tried Often after several other clinics

24. Reasons for Referral Persistent / complex pain (moderate to severe) Previous appropriate use of analgesic guidelines Distress; disability; drug use; dependence

25. Questions