Pain in Secure EnvironmentsAddiction to Medicines: Commissioning services after health reforms Prospero House February 2013

Cathy Stannard: Bristol UK

Pain Management in Secure EnvironmentsPresentation overview Introduction and background to the project Process of preparation The guidance

Context Clinical Issues Diagnosis and prescribing Non-pharmacological management

Pathways

Introduction and backgroundPain in Secure Environments

www.britishpainsociety.org

Process of preparationPain in Secure Environments

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 Alba NHS Wakefield DistrictProf Mike Bennett University of Leeds, Faculty of Pain Medicine Royal College of AnaesthetistsDr Iain Brew GP at HMP Leeds and RCGP Secure Environments Group MemberDr Michelle Briggs Senior Research Fellow, University of Leeds (on behalf of the Pain in Prisons NIHR programme development group)Ms Helen Carter Healthcare Inspector, Her Majesty's Inspectorate of PrisonsDr Beverly Collett Consultant in Pain medicine: Chronic Pain Policy Coalition, Faculty of Pain Medicine Royal College of AnaesthetistsMrs Cathy Cooke Chair: Secure Environment Pharmacists GroupDr Annette Dale-Perera Central and North West London NHS Foundation TrustMr Kieran Lynch National Treatment AgencyMr David Marteau Department of HealthMs Jan Palmer Department of HealthDr Mary Piper Department of HealthDr James Robinson Clinical Lead HMP Styal: RCGP Secure Environments Group Mr Mark Warren Avon and Wilts Mental Health PartnershipDr Amanda Williams Reader in Clinical health Psychology University College London; University College London Hospitals  Policy ObserversMr Mark Edginton Department of HealthDr Mark PruntySenior medical officer for substance misuse policy: Department of Health

The guidancePain in Secure Environments

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

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

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

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

Pain Management in the Secure Environment: context

Size of the problemTrends in prescribingAdditional challenges in specific settingsFemale prison estateMale high security prisons

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

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

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.

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

Why are opioids prescribed?

Why are opioids prescribed?Because…they are strong analgesicspersistent pain is hard to treat so something strong is a tempting ideapain sufferers exhibit distressdistress makes clinicians want to do somethingwe know there are risks but think we can handle them

WHO 1986

Why are opioids prescribed?Because…they are strong analgesicspersistent pain is hard to treat so something strong is a tempting ideapain sufferers exhibit distressdistress makes clinicians want to do somethingwe know there are risks but think we can handle them

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

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

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Opioid use associated with:

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

Opioid adverse effects No pain relief Worsening of pain Cognitive impairment/somnolence precluding effective

engagement with pain management strategies Endocrine and immune effects Addiction

www.britishpainsociety.org

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

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

Amitriptyline 10-75mg once daily

Nortriptyline 10-75mg once daily

Duloxetine 60-120mg once daily

Carbamazepine 200-1200mg daily in two divided doses

Gabapentin 900-2700mg daily in three divided doses

Pregabalin 150-600mg 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)

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

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

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•Patient’s understanding of symptoms

Previous healthcare provider confirms pre-existing persistent pain condition

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

YesNo

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

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

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

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

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

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