Pain in Secure Environments

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

4. 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

5. Pain in Secure Environments Introduction and background

6. www.britishpainsociety.org

8. Pain in Secure Environments Process of preparation

9. Pain in Secure Environments: cast list Chairs of project and co-editors • DrLinda Harris Medical Director RCGP Substance Misuse and Associated Health • Dr Cathy StannardConsultant in Pain MedicineBritish Pain Society, Faculty of Pain Medicine Royal College of Anaesthetists Members of Consensus Group • Danny Alba NHS Wakefield District • Prof Mike Bennett University of Leeds, Faculty of Pain Medicine Royal College of Anaesthetists • Dr Iain Brew GP at HMP Leeds and RCGP Secure Environments Group Member • Dr 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 Prisons • Dr Beverly CollettConsultant in Pain medicine:Chronic Pain Policy Coalition, Faculty of Pain Medicine Royal College of Anaesthetists • Mrs Cathy Cooke Chair: Secure Environment Pharmacists Group • Dr Annette Dale-PereraCentral and North West London NHS Foundation Trust • Mr Kieran Lynch National Treatment Agency • Mr David MarteauDepartment of Health • Ms Jan Palmer Department of Health • Dr Mary Piper Department of Health • Dr James RobinsonClinical Lead HMP Styal: RCGP Secure Environments Group • Mr Mark Warren Avon and Wilts Mental Health Partnership • Dr Amanda Williams Reader in Clinical health PsychologyUniversity 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. Pain in Secure Environments The guidance

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. 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

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. 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

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

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

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

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. 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)

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

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 • Patient’s 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 Yes No 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

42. Consider active physiotherapeutic strategies (paced increase in exercise) supported by education about meaning and consequences of pain 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 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. Opioid Prescribing Pathway 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

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

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