Schedule 8 medicines: Prescribing opioids for chronic non-malignant pain

1. Schedule 8 medicines:Prescribing opioids for chronic non-malignant pain Pharmaceutical Services Branch January 2014 Version: C20140101AG1

2. Aims of presentation This presentation will focus on the prescribing of opioid Schedule 8 (S8) medications for chronic non-malignant pain (CNMP) and includes: • patient management options • pharmacological or non-pharmacological treatment • difficult patients • documentation • practice monitoring.

3. Initiation of opioid therapy for CNMP • Before a short term therapeutic trial (< 60 days): • establish a definite pain diagnosis • do not use opioids to treat headaches (including migraine) and poorly or undefined general pain states such as fibromyalgia, chronic visceral pain or non-specific lower back pain • confirm that trials of non-opioid or non-drug treatment have failed.

4. Initiation of opioid therapy for CNMP • Evaluate mental health issues and current/previous substance misuse (including alcohol and benzodiazepines). • Consider referral to a clinical psychologist or other allied health professional (physiotherapist, occupational therapist). • Ensure patient is not a registered drug addict (if a notified addict, consultant support is required prior to prescribing).

5. Initiation of opioid therapy for CNMP • Have an exit strategy for each opioid trial. • Agree on this exit strategy with the patient and document this in the notes. • Introduce an opioid contract before you initiate a trial. • A valid outcome of an opioid trial maybe the decision not to proceed with opioids.

6. An opioid contract: • represents the gold standard • is recommended for all patients as a form of informed consent prior to initiating treatment • clearly outlines both the patient’s and the prescriber’s responsibilities • describes the rules of prescribing • states the need for adherence to the authorised dose • specifies the need for GP to discuss adverse effects • may contain additional conditions e.g. daily medication pick ups • is routinely used in specialist pain clinics • may be issued as a condition of authorisation

7. Initiation of opioid therapy for CNMP • Start cautiously with low doses of an appropriate long-acting or slow release opioid. • Be careful in particular with: • opioid naïve • frail elderly • significant co-morbidities. • Individualise dose during trial with incremental dose escalations. • Avoid use of immediate release or short-acting opioids in chronic pain states.

8. Initiation of opioid therapy for CNMP • Consider opioids only as one component of a multimodal treatment plan: • Opioids should facilitate mobilisation, participation in physiotherapy or other activation. • Consider early referral for specialist pain advice/management. • Opioids commenced as an inpatient: The pain team should consider: • changing to Schedule 4 opioids before discharge • the need to advise if S8s are to be continued on discharge (prior to discharge) • communication of plan back to the patient’s GP.

9. Prior to proceeding to long-term prescribing consider: • progress toward meeting therapeutic goals including pain relief, but in particular improved level of function • presence of adverse affects • changes in psychiatric or underlying medical co-morbidities • evidence of aberrant drug-related behaviours e.g. doctor shopping and escalating S8 dose • evidence of diversion.

10. Monitoring • regular monitoring required: • Is the treatment plan working? • Is there functional improvement? • need for additional non-opioid therapies • benefit outweighed by harm • is referral (specialist, allied health, other) required? • increasing the opioid dose is not always the correct response to missed goals of treatment • do not exceed recommended dose limits.

11. Monitoring • Regularly review the pain diagnosis and co-morbid conditions using the 4As • Analgesia • Activity • Adverse effects • Aberrant behaviour

12. Monitoring • Documentation of: • pain severity • functional ability • progress towards achieving therapeutic goals • adverse effects • signs for presence of • aberrant drug related behaviours • substance abuse • psychological issues.

13. Monitoring – patients at high risk of substance misuse • Minimise risk via • intense and frequent monitoring • limiting prescription quantities and dispensing intervals as a condition • consultation / co-management with persons who have expertise in mental health or addiction medicine • low threshold for referral to Next Step or other addiction service.

15. Pharmacological treatments for pain • Nociceptive pain • paracetamol • NSAIDs • Neuropathic pain • tricyclic antidepressants (e.g. amitriptyline) • serotonin-noradrenergic reuptake inhibitors (e.g. venlafaxine, duloxetine) • anticonvulsants (e.g. gabapentin, pregabalin) • Nociceptive and/or neuropathic pain • tramadol • opioids

16. Non-pharmacological pain management • Physiotherapy • paced exercise programs • hydrotherapy • aquarobics (in public pools) • any physical training e.g. gym membership • TENS treatment • Psychological options • CBT: focuses on patients developing coping strategies for their CNMP to improve function. Has shown consistently to be effective in the management of CNMP • mindfulness training • relaxation techniques

17. Non-pharmacological pain management • patient support groups • complementary therapies • massage • reflexology • aromatherapy • acupuncture • nutrition

18. Interventional therapies for pain • Nerve blocks/steroid injections • joint injections (including facet joints) • epidural steroid injections • Destructive procedures • facet joint denervation (rhizotomy) • Implanted devices • intrathecal drug therapies • dorsal Column Stimulators • Surgical options e.g. joint replacements

19. Summary of opioid management for CNMP • Evaluation of the patient • standard work up • pain diagnosis appropriate for treatment? • assess risk of misuse • Informed consent & contract • inform of side effects/risks/potential of ineffectiveness • outline expectations between provider and patient • Opioid trial • including exit strategy • Periodic review of long-term treatment • The 4 As: Analgesia, Activity, Adverse effects, Aberrant behaviour

20. Summary of opioid management for CNMP • Specialist consultation referral • registered drug addict (mandatory prior to prescribing) • if patient is not responding or diagnosis is unclear • high risk (e.g. dose refer to Schedule 8 Medicines Prescribing Code). • Review the four As (useful follow-up questions) • Analgesia • Activities of Daily Living (ADLs) • Adverse events • Aberrant behaviours • Compliance with WA state legislation

21. Resources • Pharmaceutical Services Branch: www.health.wa.gov.au/S8 • Royal Australasian College of Physicians: www.racp.edu.au/page/policy-and-advocacy/public-health-and-social-policy • Drug and Alcohol Office: www.dao.health.wa.gov.au/Informationandresources/publicationsandresources/healthprofessionals.aspx

22. Pharmaceutical Services Branch contacts • Telephone: (08) 9222 4424 • Fax: (08) 9222 2463 • Email: poisons@health.wa.gov.au • Post: The Pharmaceutical Services Branch PO Box 8172 Perth Business Centre WA 6849

23. Other contacts • Medicare Australia Medicines Information Line • 1800 631 181 • Next Step Specialist Drug and Alcohol Services • (08) 9219 1919 • Alcohol and Drug Information services (ADIS) • (08) 9442 5000 or 1800 198 024