Pain Guidelines Ipswich & East Suffolk CCG 16 January 2014

1. Pain GuidelinesIpswich & East Suffolk CCG16 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 missile 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 PalliativeCare • 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

10. E. Suffolk Primary Care Spend Analgesics

11. E. Suffolk Primary Care Spend Anti-neuropathic Analgesics

13. Tricyclic antidepressants • Amitriptyline 1st 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 atleast 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! 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. 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

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

24. Questions