Non-malignant pain & its treatment in older people:

difficulties & dilemmas

Assoc Prof Martin C HenmanSchool of Pharmacy & Pharmaceutical Sciences

Trinity College Dublin

Irish Pain Association, Dublin, 2015

Analgesics• Pain & discomfort are the most common & frequently reported symptoms• Analgesics the most widely available & frequently purchased non-prescription medicines

• Ireland one of small group of countries with codeine-containing non-prescription products• Wide range of adjuvants (e.g. caffeine) & other drugs used in combination products

• Among the most extensively prescribed drugs• In 2011 almost 66% of medical card holders received a prescription

• 7% increase in prevalence of analgesic prescribing between 2003-2011• Analgesic users - 60% women, 40% men• Greater life expectancy – more elderly exposed to analgesics for longer• Most widely promoted drug class – best known brands• Everyone knows which drug is prescribed for severe pain & that it is potentially dangerous• Many countries are experiencing substantial increases in use of opioids & some leakage of

prescribed opioids into drug abusing population

Lecture Outline

Chronic (≥3 months), non-malignant pain in older people• Analgesics• TILDA• PCRS• Guidelines & utility• Prescriber’s views• Patient’s views

Analgesics• Non-opioids

• Paracetamol• Nefopam

• NSAIDs• Systemic (oral) or Topical• Selective – Coxcibs & Nimesulide• Non-selective – Ibuprofen,

Diclofenac, Mefenamic acid

• Weak opioids• Low dose codeine ≤15mg per unit• Combined with paracetamol or

ibuprofen

• Moderate opioids• Codeine ≥30mg per unit• Dihydrocodeine

• Combined with paracetamol• Tramadol

• Combined with paracetamol• Tapentadol

• Strong Opioids• Systemic or Transdermal• Morphine• Buprenorphine• Fentanyl• Oxycodone

• Adjuvants• Amitriptyline• Pregabalin• Gabapentin• Duloxetine

The Irish Longitudinal Study of Ageing: TILDA

• National randomised sample of 50y+ , living in community• “Are you often troubled with pain?”• Participants classified the severity of pain as mild, moderate or severe &

indicated the location of the pain• Self-rated physical health categories were collapsed into Excellent/Very

Good, Good/Fair and Poor• Interviewers asked participants, “to record all medications that you take on

a regular basis, like every day or every week. This will include prescription and non-prescription medications, over-the-counter medicines, vitamins and herbal and alternative medicines.”

• Medications were recorded using the WHO Anatomical Group Code (ATC), the international non-proprietary name (INN), brand name and drug code.

• ATC code for all paracetamol/codeine formulations is same regardless of the quantity of codeine

• To differentiate the higher strength paracetamol/codeine formulations from the non-prescription low dose formulations medications were by brand name & assigned to weak or moderate opioid groups

TILDA results• 36% of TILDA participants reported NM pain, approximately 40% of women and 31% of

men (p<0.001). • Of those reporting NM pain, 58% were women and 42% were men. • 38.3% (36.3-40.3%) of those with NM pain reported at least three chronic conditions,

compared to 17.2% (16.1-18.3%) • Similar proportion to PRIME

• Poor health 10.5% (9.3-11.8%) of NM pain participants vs 2.0% (1.6-2.5%) of the no NM pain population

• Higher prevalence of clinical depression (≥CESD-16) detected in the NM pain sample 17.2% (15.7-18.8%) in comparison to 5.8% (5.1-6.6%) of the no NM pain population.

• A slightly higher proportion of those with NM pain were widowed, 17.9% (16.3-19.6%) compared to 14.5% (13.4-15.7%) of those with no NM pain

• 36.2% (34.1-38.3%) of NM pain participants indicated they were currently unemployed/ sick or disabled/ looking after a family member.

Presence and Severity of NM Pain according to age-group (N=2,692) & by location of pain

• Highest prevalence • ≥75 years 19.1% (17.3-21.1%) • 50-54 year olds, 19.0% (17.4-20.7).

• Pain severity constant across all age-groups mean age of those reporting • mild NM pain 63.3(±9.7)• moderate NM pain 63.9(±9.8)• severe NM pain 64.7(±10.0).

Women were more likely to report back pain (56.3% (53.4-59.2), joint pain (61.9% (57.9-65.7%), all over pain (65.8% (58.3-72.6%), and other pain (54.9% (51.4-58.3%), than men (Chi-squared, p<0.01).

TILDA results 2• Depression was identified using The Centre for Epidemiological Studies Depression (CES-D)

which requires individuals to rate how often they have experienced symptoms of depression in a week.

• A score of 16 or greater identifies this with clinical depression with good sensitivity and internal consistency

• In the NM pain sample 17.2% (15.7-18.8%) were depressed according to this method vs 5.8% (5.1-6.6%) of the no NM pain population.

• Higher prevalence of polypharmacy (≥5 medications), amongst those with NM pain 31.7% (29.9-33.6%) vs 14.4% (13.4-15.5%).

• 54.7% (52.6-56.8%) reporting NM pain attended a GP on 4 or more occasions in the previous 12 months in comparison to 33.1% (31.6-34.5%) of participants reporting no NM pain.

• 28% participants reporting pain reported analgesic use• 5% participants who did not report pain reported analgesic use• 652 reported severe pain but only 36 of those reported a Strong Opioid

Prevalence of analgesics reported by class by male and female participants reporting NM painProportion of analgesic taking NM pain population by age-group reporting use of a specific analgesic medication

TILDA: Analgesics used in pain states & by age group

Moderate pain• Non-selective NSAID • Weak Opioid• Non-Opioid• Moderate Opioid

Severe pain• Strong Opioid• Selective NSAID• Moderate Opioid• Adjuvant

• Non-Opioid• Adjuvant• Selective NSAID• Weak Opioid

Mild pain

Concurrent use of analgesics• NSAIDs are used

mostly with Non-Opioids & Moderate Opioids• Opioids are not

often used together• Adjuvants are

mainly used with Moderate Opioids, Strong Opioids & Non-selective NSAIDs

Sedative & Laxative co-prescribing

Concurrent sedating agent use amongst those reporting opioids (by class) according to age-group for participants with NM pain (N=60)

• 65-74y strong opioid group receive most• Reduced treatment in 75y+

Concurrent laxative use amongst those reporting opioids (by class) according to age-group for participants with NM pain (N=11)

• 65-74y strong opioid group receive most• Reduced treatment in 75y+

Adaptation of the WHO Analgesic Ladder developed for the purposes of the multinomial regression models 1 & 2

• For both models, weak, moderate and strong opioids were separated so as to represent distinct stages of an analgesic management strategy

• Univariate analysis determine association between covariates.

• Those covariates significant at the p≤0.05 level were included in the multinomial model.

• Results reported as relative risk ratios (RRRs)

No Analgesic

Non-Opioid/NSAID/

Adjuvant

Weak Opioid

Moderate Opioid

Strong Opioid

Regression Model 2: Reference group

Regression Model 1: Reference group

No Analgesic

Non-Opioid/NSAID/

Adjuvant

Weak Opioid

Moderate Opioid

Strong Opioid

Step 1

Step 2

Step 3Step 4

Multinomial regression model 1

No Analgesic

Non-Opioid/NSAID/

Adjuvant

Weak Opioid

Moderate Opioid

Strong Opioid

Regression Model 1: Reference group

Step 1

Step 2

Step 3Step 4

• The first model evaluates the factors associated with use of an analgesic medication, comparing group (reference) is the population of NM participants reporting no analgesic usage with users

Significant factors• Polypharmacy across all 4 steps• Pain restricted daily activity @ steps 1, 3 & 4• Severe pain @ steps 1-3• Current smoker @ 2 & 3

Multinomial regression model 2

• The second model compares opioid use by NM participants according to the WHO Analgesic Ladder classification and compares them with non-opioid/NSAID/adjunct users (reference).

Significant factors• Polypharmacy @ steps 3 & 4• Current smoker @ 3 & 4; past smoker @ 4• No relationship between QoL & any analgesic group

Regression Model 2: Reference group

No Analgesic

Non-Opioid/NSAID/

Adjuvant

Weak Opioid

Moderate Opioid

Strong Opioid

CASP-19 QoL

• Measures of Control, Autonomy, Self-Realisation and Pleasure the extent of satisfaction of each of these domains via Likert Scales• Total possible score = 57• TILDA participants mean CASP-19 score was 42.7• Multinomial regression was used to identify the factors contributing

to the CASP-19

Quality of Life – Factors affecting CASP-19 score

Better

Worse

Primary Care Reimbursement System (PCRS)• Prescription items dispensed – drawn from pharmacy claims• Medications coded using WHO ATC code & a 5-Digit Drug Code,

• prescriber information, defined daily dose, strength, quantity, method of administration, net ingredients and pharmacy dispensing fee per item are also recorded. Gender and age-group

• Patients were categorised by gender and age group, 55-64, 65-69, 70-74 and ≥75 years• ≥1 dispensing indicates that the individual received at least one analgesic (or specific

class of analgesic e.g. nonopioids) in that year• Number of people per 1000 in receipt of >3 dispensings of an analgesic or adjunct

medications was also calculated as a method of indicating recurrent use• Concurrent dispensings of laxatives and sedating agents with weak, moderate and

strong opioids were also extracted. number of adults aged ≥55 years receiving at least one analgesic medication per 1000 GMS population

PCRS• In 2011 from 30 to 40% over 55y received

3 or more analgesic prescriptions• 75y+ were highest users 427.2/1000 vs

327.5/1000 for 55-64y• Non-opioids = paracetamol (99.9%)• NSAIDs shift from Selective to Non-

selective; also increase in topical especially in 75y+

• Increase in Moderate & Strong Opioids particularly after dextropropoxyphene removed

• In 2011 Pregabalin, Amitriptyline & duloxetine most frequently used adjuvants

Opioids according to strength• Moderate opioid dispensing for

men & women trend in opposite directions across age-groups• The prevalence rate per 1000

population increasing with the older female population

• And decreasing in the older male population.

• More repeat use - number receiving >3 dispensings of a moderate opioid has increased from 2009-2011.

55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥752009 2010 2011

0.0

50.0

100.0

150.0

200.0

250.0

300.0

79 78 7587 83 80 77

88 91 88 8795

232217

197209

232

215

199205

231

215200 204

34.8 40.0 38.2

69.4

34.7 40.7 38.8

72.9

37.3 40.6 42.3

79.3

Weak Moderate Strong

Year & Age-Group

Prev

alen

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ate

per 1

000

Popu

lati

on

Number of months dispensed a weak, moderate or strong opioid analgesic dispensed (per 1000 population receiving that class of opioid)

• Growth in Opioid use is in long term use – 8+ months/year

Year

Weak Opioid Moderate Opioid Strong Opioid

1-7 Months(95% CI)

8-12 Months(95% CI)

1-7 Months(95% CI)

8-12 Months(95% CI)

1-7 Months(95% CI)

8-12 Months(95% CI)

2004 842.8(838.1-847.5)

157.2(152.5-161.9)

825.6(823.5-827.8)

174.4(172.2-176.5)

846.5(840.5-852.4)

153.5(147.6-159.5)

2009 807.7(804.4-811.3)

192.3(188.7-196.0)

817.9(815.7-820.1)

182.1(179.9-184.3)

754.6(749.9-759.6)

245.4(240.3-250.4)

2010 815.8(812.4-819.3)

184.2(180.1-187.6)

814.1(812.0-816.3)

185.9(183.7-188.0)

735.9(730.9-740.9)

264.1(259.1-269.1)

2011 812.5(809.2-818.8)

187.5(184.2-190.8)

807.5(805.3-809.7)

192.5(190.3-194.7)

732.6(727.8-737.4)

267.4(262.6-272.2)

PCRS - transdermal patches

• Prevalence of strong opioid patches increases across both age-groups each year • Prevalence of dispensings

considerably higher in the oldest age group• And amongst women

55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥752009 2010 2011

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

9

1315

35

10

13

16

38

10

13

16

43

68 7

15

68 7

16

79 8

17

Female Male

Year & Age-Group

Prev

alen

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tate

Per

100

0 Po

pula

tion

Sedatives & Laxatives• Sedatives were concurrent in 20% of opioid

prescriptions• Women in the 55-64 year age-group consistently

have the highest rate of prevalence of concurrent dispensing

• Usage declines with age group in both sexes• Laxatives were concurrent in around 5% of

prescriptions• Those aged ≥75 years consistently received the

highest rate of concurrent dispensings of strong opioids and laxatives.

• However ~85% of those receiving >3 concurrent dispensings of a strong opioid did not receive a concurrent laxative

• Men also consistently had a higher rate of concurrent prescribing in comparison to their female counterparts across all age-groups and years

55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥752009 2010 2011

0.0

100.0

200.0

300.0

400.0

500.0

600.0

700.0

800.0

900.0

1000.0

247 264 274345

305 327 344416

316 328 347419

307375 365 392 374

423 443 469

377435 445 471

Women Male

Year & Age-Group

Prev

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of L

axat

ives

Per

100

0 ta

king

a

Stro

ng O

pioi

d

55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥75 55-64 65-69 70-74 ≥752009 2010 2011

0.0

100.0

200.0

300.0

400.0

500.0

600.0

700.0

800.0

900.0

1000.0

573 585 557524

573 582 556516

584 563 549508481 494 478

438508

461 461421

483 474 477424

Women MaleYear & Age-Group

Prev

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of S

eadt

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Age

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Per 1

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Clinical Guidelines & Opioids in CNMP

Clinical Guideline Quality

Clinical Guideline Content

Pain Assessment in Clinical Guidelines

Medicines Information

http://olh.ie/our-services/palliative-care/palliative-meds-info/pain-management/

Qualitative studiesGPs

• GPs were recruited using a snowball sampling approach.

• Interviews were audio-recorded using the Audacity® software and a portable recording device

• GPs were supplied with a copy of the interview transcript and invited to edit the document.

• Following application of these revisions, an electronic copy of the transcript was transferred to NVivo® Version 10.

• Twelve GPs were interviewed

Patients

• Members of Chronic Pain Ireland (CPI), aged 50 years and older were eligible

• Individuals could not take part in the study if they were not a current member of CPI, were unwilling participate in an audio-recorded telephone interview, had a terminal illness, or had been diagnosed with dementia or any other memory impairment.

• Twenty-eight interviews were conducted with members of CPI

• Ethics Committee approval was obtained for both studies

Prescribers’ views: assessment

• I don’t use standardised scales for pain, it is often volunteered by the patient who comes and says they are in pain and then over time it gets to where a pattern is established where certain medication is being prescribed regularly. (GP9)• No, I don’t use a scale, I probably should, but I don’t. Generally, it’s based on

patients symptomatology and how they can function… what they can’t do anymore I guess; in terms of their day to day living. (GP12)• Of course, the other point about pain is this, pain is not just pain, but it’s also

pain plus the anxiety and the whole preconception and all the social stuff, mood; a whole load of other things feed into pain. (GP10)• I would use the WHO pain ladder so starting off with a simple analgesic then

moving up to NSAIDs. (GP6)

Prescribers’ views: treatment

• Patients usually don’t like paracetamol regularly they don’t have any faith in it because you can buy it over the counter so you always have this conversation where they say that is no use and then you explain you have to try to take it regularly...it is interesting… definitely… in my experience patients perceptions of paracetamol… they do not equate it with good pain relief. (GP4)

• Usually I would start with an NSAID if it’s OA [osteoarthritis] type pain or I usually do try to get people onto regular paracetamol 1gr tds ongoing but I find that people don’t have much faith in it … and they have usually tried it and even if it’s in conjunction with something else, they will usually be not keen on starting it [pause] but ideally I would start them on paracetamol and move up to an NSAID and then onto something like tramadol (GP2)

• If I am needing to use something in the longer term then I would try to use a combination low dose, a paracetamol with a codeine. So I would probably step up to something like Solpadeine® [Paracetamol 500mg/Codeine 8mg/Caffeine 30mg] to see if that would help and try to get them to come back and review in two weeks to see where they are at. (GP4)

• ... and low and behold when you go to their house you find that they have got those little red boxes that you buy as well as those that you prescribe so they do buy them and they can get them… (GP5)

• It’s a very fine balancing act, I mean you have to take into consideration that there are serious side effects, but on the other hand sometimes if their pain isn’t well controlled then you have no choice but … to step up the ladder and put them on stronger painkillers. (GP12)

Prescribers’ views: Opioids• I would be quite cautious about starting patients on those, particularly for what appears to be a [pause]

what is likely to be a chronic problem. I do prescribe them but with a lot of reservations particularly Solpadol® [Paracetamol 500mg/Codeine 30mg] and Ixprim® [Tramadol 37.5mg/Paracetamol 325mg] things like that. Solpadeine® [Paracetamol 500mg/Codeine 8mg/Caffeine 30mg], I would prescribe a bit more easily. (GP6)

• I tend to be careful with codeine based medicines really. I don’t tend to use codeine a lot particularly in the elderly because it is nauseating and constipating and sedating and a lot of other things. (GP7)

• I did find the arrival of the opiate patches a huge relief to my stress over managing people who were going to have ongoing, continuous pain and we really have to put something significant in place on an ongoing basis (GP11)

• I’m certainly not a fan of using opiate patches… I know they are very commonly used, …certainly in people I have used them in…it would be for an agreed period of time …and with a view to getting them on to the lowest dose that you possibly can I am always trying to get them to wean down to the step below, I certainly try not to leave people on patches long term. (GP5)

• Battling to try and keep people on the lower end of the scale so you know encourage them to stay with regular paracetamol qds, or moving to Solpadeine® [Paracetamol 500mg/Codeine 8mg/Caffeine 30mg], so I would rarely move to something higher than that until you get into I guess what you are talking about, chronic pain patients. (GP9)

Prescribers' views: Opioids & adjuvants• I’m certainly not a fan of using opiate patches… I know they are very commonly used, I am not

a fan of them…certainly in people I have used them in…it would be for an agreed period of time with a view to reviewing them and with a view to getting them on to the lowest dose that you possibly can I am always trying to get them to wean down to the step below, I certainly try not to leave people on patches long term. (GP5)

• Yes for non-malignant chronic pain I would move up to tramadol and then I would add in probably at that point then Amitriptyline or Pregabalin...I generally….I wouldn’t go much beyond...in terms of me initiating the treatment I wouldn’t go much beyond tramadol...(GP6)

• I have reservations about pregabalin and Lyrica® because it seems in a way… it is just being pushed by pharmaceutical companies as super effective whereas, in reality, it isn’t any more effective (GP9)

• I identify with Amitriptyline being a potentially inappropriate drug in an older population. Amitriptyline would be bad, so yeah, probably go with for neuropathic pain pregabalin or gabapentin. (GP9)

Prescribers' views: Opioids & laxatives• Depending on a few factors I try to avoid NSAIDs in the elderly except

for very short periods of time obviously because of the risk of renal impairment and GI stuff but I will use them for short periods of time in people who don’t have contraindications. (GP4)• I would think I have been uniformly conservative about non-steroidal

in any age group really. For most of my career, I don’t know, I just always was. (GP11)• I tend to be careful with codeine based medicines really. I don’t tend

to use codeine a lot particularly in the elderly because it is nauseating and constipating and sedating and a lot of other things. (GP7)

Prescribers' views: the system • It’s kind of silo medicine, but that’s an awful lot of Irish medicine is silo medicine, and I

think a lot of the primary care teams are only teams in name. (GP10) • We don’t have Primary Care teams on the ground that are supposed to be there so,

you know, it is very much you having to refer to different… I wish there was a team we could refer them to that would look after them, but there isn’t. You can do a Physio referral or you can get the PHN [public health nurse] to call, it’s very disjointed. (GP12)

• I don’t think you are supported at all except by the drug companies who are mad keen to support you (GP8)

• [Access is] very bad unless you have a thing called money...and you could easily be waiting a long, long time if you have a medical card to see a pain specialist, it is a very under-staffed under resourced... unless you have money in which case you can head to the _________next week... a very bad system and a very unfair system unless you can afford it...(GP5)

Prescribers’ views: Clinics & collaboration• What happens is the people who staff those pain clinics have no real connection to

that person, they don’t really care about them, they have standardised scales for pains, they have a clinic waiting list they have to get though and they will see them again in six months’ time and they also have a book of medications that they use and they just throw them at them. (GP9)

• Things fall apart quite often with those patients and then they get into crisis and then you have to increase their painkillers and then....and there is a lack of structure in terms of how we deal with them and what they expect as well. That is where the pain clinics are very useful that they give a structure and they get a plan…(GP6)

• Recently I had a lady discharged from hospital and she was sent out on Lyrica® and Palexia® and Solpadeine® after one visit...it’s hard to figure out the rationale sometimes and then you think she is on that medication now for months because she could...and yet she has not got any nociceptive pain that I can figure. (GP5)

Patients’ views: Pain

• The pain was inhibiting me from doing other things. I do as much as I can while I am fit. That is the other thing, my stamina isn’t nearly what it was. I could do a full day’s work and do three meetings back to back whereas if I can do one expedition out of the house now in one day it is about as much as I can manage. (P28)• Getting dressed in the morning is okay, and I sort of manage a way

around doing things, but I would say now, in the evening now, at this time it would be, like if I was to go out say, to do something I just couldn’t go out, I wouldn't be able to sit, I wouldn’t be able to manage even if I go to a play or something like that, it would just be, the pain would be too intolerable. (P19)

Patients’s views: Medicines

• My perception of it is that it’s essential for the maintenance of my health and wellbeing. It also assists in maintaining my relationship with my wife, my children and my grandchildren. (P13)• If I happen to forget taking them or maybe went off by mistake, and I

wouldn’t have taken them, I’d know that evening that it would be much, much more painful anyway. (P8)• And you know it is a terrible vicious circle that you get into, you are taking the

medication, you know it is not going to cure it and at the same time you keep taking it in the hope of just bringing it down a few levels and that is [pause] I think if I was dealing with somebody else, I would be telling them for God’s sake [sic] come off that medication, and here I am. I am caught up in it. (P18)

Patients’ views: Family concerns

• Probably my family would be different because they’ve actually seen me and seen me in pain and they would be very much inclined to say look you know you’re going to end up taking it, why don’t you just take it now instead of in 4 hours time when you’re much worse. They would try to encourage me to take it much more. (P7)• My husband is the worst…He doesn’t understand like, why I don’t take

them all the time, you know…he wants me to be better…And he wants me to do things, you know, as a couple, as a family. (P4)

Patients’ views: Adverse effects

• I have osteoarthritis, a pain in my back, then eventually I got a stomach ulcer from taking Difene® [diclofenac] They say that it may have been stress but it may have been Difene® [diclofenac]. (P27)

Opioid side effects• That would have been the main reason I would have taken a break from them. I found

that I was too sedated [pause] not so much sedated more that I felt maybe a detached, like feeling like the world was going on around me. Even the children were saying that my favourite hobby was sleeping! (P26)

• I tried this other one that came out a few years ago, in 2010, Palexia® [Tapentadol], and I was very excited about it, but I couldn’t take it at all, I actually fainted after taking it, within an hour of taking one [pause] I was sick with them, and weak … well I was taking them for the two weeks and that’s it, it was only for two weeks, it sort of helped with the pain but I couldn’t [pause] you see I am trying to balance. (P11)

Patients’ views: Long term effects

• Addiction would be of a concern for me and with the family here and you’re concerned about things like this. And they are very much aware of what they do. And they’re concerned that I might be dependent too much on them. (P16)• In my opinion, and in my experience people with chronic pain people

don’t become addicted to opiates because it is just not something they would want to do. (P11)• I was speaking to a colleague at work about the very same thing, we

were sitting on night duty talking about it and she said, now you might die younger, but at least you won’t be in as much pain. [Laughter] (P 21)

Patients’ views: GPs, & the system

• The GPs there is a real need for more training and up-skilling in the area with me they just don’t know what to do anymore and they haven’t known what to do for a good while really. (P12)

• My doctor, I would give her, you know, top marks. She is excellent you know, and she kept going until she got a diagnosis, and she is proactive in looking up new medication and trying to get it right you know get it sorted, and as I said I always get her to check what the hospital say. (P2)

• I know there were doctors who were writing out things but no one was paying any attention to what the other fella was doing. (P23)

• It is so frightening and then you go from doctor to doctor, and surgeons to consultants, and all the different specialities and all trying to look at you from this angle and that angle. (P11)

• The way I have sort of gone because paying, not that I can afford it, but paying you will get in somewhere much quicker anyway and you sort of have to weigh up things. (P1)

Qualitative interpretation - GPs• Assessment• Pragmatic approach taken, but neither holistic nor systematic• WHO ladder useful at outset in Assessment but some GPs concerned to

slow/prevent progression/intensification of treatment

• Clinical Guidelines, except perhaps Palliative guidelines not routinely useful• Drug information – industry is main provider

• Silos, lack of access for referral - Collaborative care • Primary Care Centres?• Community Pharmacists?

Qualitative Interpretation - Patients

• Barriers to establishing relationships & working together at every level• Influence care pathway that patient pursues

• Hard to understand difficulty in Assessment & Treatment selection• Increases perception of need for ‘specialist’

• Practical modification & utilisation of treatments/adjuvants• Family’s needs influence behaviour

• Patient’s role as manager of their condition & in deciding about use of treatment/adjuvants is usually unrecognised

Unexplored

• Stigma & analgesics

• Vulnerable patients• Cognitively impaired• People with Intellectual Disability

Acknowledgements

• Anna Dahlgren• Maire O’Dwyer• Mary-Claire Kennedy• Eimear O’Dwyer

Thank you - Go Raibh Maith Agaibh

Martin Henman