opioids for persistent non-cancer pain british pain society recommendations karen h simpson...
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Opioids for persistent non-cancer painBritish Pain Society Recommendations
Karen H SimpsonConsultant in Pain ManagementLeeds
Need for recommendations for use ofopioids in persistent non-cancer pain
Persistent pain is being increasingly recognised as a medical and social problem
Large surveys from Europe suggest10% population have persistent severe pain
4600 patients in Scotland in primary care16% moderately/severely disabled by persistent pain
2000 patients in primary care79% still had pain after 4 years
Pain – a widespread problem
– One in five people in UK suffer from chronic pain
– Total of 7.5 million people
– One-third of UK households affected by chronic pain
3
9
20
26
17
4
21
0
5
10
15
20
25
30
6 Months to <1 Year
1 to <2 Years
2 to <5 Years
5 to <10 Years
10 to <15 Years
15 to <20 Years
20 Years or More
Patients Living in PainDuration of Pain (n=300)
Chronic pain present average 6 y
A fifth had pain for more than 20 y
%
6
5
4
3
3
40
18
15
8
0 5 10 15 20 25 30 35 40 45
Arthritis/osteoarthritis
Traumatic injury
Herniated/deteriorating discs
Rheumatoid arthritis
Nerve damage
Surgery
Fracture/deterioration of spine
Migraine headaches
Break/fracture that never healed correctly
Causes of chronic pain
Most frequently arthritis Most commonly low back pain
Need for recommendations for use ofopioids in persistent non-cancer pain
Persistent pain affects lots of people
UK 2-6 million people with persistentsevere non-cancer pain
England and Wales 1.3-1.75 million osteoarthritis
0.25-0.5 million rheumatoid arthritis
The problem is large and likely to grow as the population ages
Need for recommendations for use ofopioids in persistent non-cancer pain
Persistent pain is expensive
900,000 hospital bed days12 million GP consultations119 million days certified incapacityUK direct health care cost back pain £1632 millionInformal care/lost production cost £10668 million
The public and government are interested
Need for recommendations for use ofopioids in persistent non-cancer pain
There are an increasing number of strong opioids withmarketing authorisation for persistent non-cancer pain
There is increased use of strong opioids for this indication inprimary and secondary care
There is strong pressure from industry to use these drugs more freely
There is little training for health care professionals aboutopioid use for this indication
Need for recommendations for use ofopioids in persistent non-cancer pain
Patients and carers are becoming more aware of the use ofstrong opioids for non-cancer pain
In some European countries and USA there is intense pressure on doctors to provide opioids for non-cancer pain
This is balanced by concerns about medical use of opioids
Doctors accused on heroin advice Steven MorrisTuesday February 24, 2004The Guardian
Development of recommendations
2 years ago Pain Society consensus group developedProvisional recommendations for the appropriate use of opioids in patients with chronic non-cancer related painThere was an accompanying patient information leaflet
This was developed after literature review and consensus opinion from experts from a number of disciplines and patient’s representatives
During the 12 month consultation period over 300 responses from individuals and professional organisations have been received and considered
Consensus group
Joint chair and co-editorsDr Alf Collins UK Pain SocietyDr Karen Simpson UK Pain SocietyMembersDr Douglas Justins Royal College of AnaesthetistsProf Bruce Kidd Royal College of Physicians Dr Richard Potter Royal College of General PractitionersDr Marian de Ruiter Royal College of PsychiatristsDr Cathy Stannard Pain SocietyMr Phil Wiffen Royal Pharmaceutical SocietyDr Amanda Williams UK Pain Society Advice given by the following individuals:Mrs Jean Gaffin UK Pain Society Patient Group Chair Dr Mike Bennett Association for Palliative Medicine
Prof Antony Franks NHS Trust Risk Management Chair
Recommendations endorsed byAssociation of AnaesthetistsRoyal College of AnaesthetistsRoyal College of General PractitionersRoyal College of Psychiatrists/Faculty of Addiction Medicine
Recommendations reviewed byRoyal College of PhysiciansLiam Donaldson – Chief Medical OfficerBritish Pharmaceutical SocietyBritish Medical AssociationAssociation for Palliative MedicineMedical Defence Organisations and Hempsons SolicitorsBritish Medical AssociationComments invited from all Pain Society Members
What issues have been raised?Are opioids effective?
What type of pain?Appropriate patients?
Which drugsSide effects and toxicity?
Modified and transdermal vs. immediate release?Breakthrough pain?
Which routes?Monitoring?
Problem drug use?Drug diversion?
Withdrawal?Patient contracts?
Advantages of opioids
Strong opioids can provide analgesia
? improve quality of life
Problem drug use uncommon
Few long term randomised controlled trials
Unanswered questions about opioids
Adverse effects
Opioids not organ toxic
Patients must be carefully monitored
Side effect must be discussed and managed
Concerns about problem drug and diversion must be addressed
Long term studies?
Many unanswered questions about opioid use
Patients with persistent pain can be challenging often with poorly defined pathology and behavioural and social problems
Most studies are short-term and exclude patients with such problems
The use of opioids must be carefully considered and appropriate in this context
Indiscriminate prescribing must not be encouraged
Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003 Nov 13;349(20):1943-53.
Efficacy and adverse effects
Chou R, Clark E, Helfand M. Comparative efficacy and safety of long-acting oral opioids for chronic non-cancer pain: a systematic review.
J Pain Symptom Manage 2003 Nov;26(5):1026-48. (Oregon)
A total of 16 randomised trials until October 2002Efficacy and adverse effects n=1427 patientsNone rated as good quality evidence
Insufficient evidence that different long-acting opioids associated with different efficacy or safety
Insufficient evidence whether long-acting opioids as a class are more effective or safer than short-acting opioids
Recommendations – future plans
Pain Society will establish an implementation group
Dissemination of information to primary and secondarycare providers of pain management
Liaison with PCTs and Trusts
Data collection and surveillance – ongoing audit
Monitoring of emerging evidence base
Liaison with other European centres
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