Pain GuidelinesIpswich & East Suffolk CCG

16 January 2014

Mike BaileyIpswich Hospital Pain Clinic

Contents

• What is a guideline?

• Why different pains need different management

• What the BNF doesn’t tell you

What is a guideline?

“Guideline" is the NATO reporting name for the Soviet SA-2 surface-to-air missile

Courtesy : ‘Wikipedia’

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

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

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

Different Pains Need Different Management

Palliative Care• 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

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

E. Suffolk Primary Care Spend AnalgesicsApr-Aug 12 Apr-Aug 13

Total Items Total spend Total Items Total spend

Amitriptyline 40212 £67,562.98 43096 £75,025.31

Butrans 3393 £95,925.19 3698 £108,119.15

Transtec 443 £18,903.51 418 £18,842.96

Fentanyl patch 2952 £130,450.25 2916 £121,259.61

Gabapentin 9442 £76,145.08 12040 £63,617.31

Morphine MR 6766 £78,017.44 7275 £82,176.24

Oxycodone MR 1838 £109,420.81 1909 £111,730.44

Pregabalin 8024 £530,239.94 10217 £685,458.53

Targinact 396 £27,104.51 437 £28,585.53

Total 73466 £1,133,769.71 82006 £1,294,815.08

E. Suffolk Primary Care Spend Analgesics

E. Suffolk Primary Care Spend Anti-neuropathic Analgesics

Apr – Aug 2012 Apr – Aug 2013

Total items Total spend Total Items Total spend

Gabapentin 9442 £76,145 12040 £63,617

Pregabalin 8024 £530,239 10217 £685,458

Amitriptyline 40212 £67,562 43096 £75,025

Drug Strength tab/cap Cost per tab/cap Cost per 28 days

Amitriptyline

Once daily (bedtime)

10mg £0.03 £0.89

25mg £0.03 £0.90

50mg £0.04 £0.98

Gabapentin

Three times a day

300mg £0.04 £3.77

600mg £0.10 £8.71

800mg £0.36 £29.84

Pregabalin

Twice daily

75mg £1.15 £64.40

150mg £1.15 £64.40

300mg £1.15 £64.40

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

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

Pregabalin• Best NNT at least 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

Strong Opioids & Chronic Pain

Benefits

• Better functioning

• Synergy with anti-neuropathics

Risks• Constipation

• Tolerance

• Withdrawal

• Suppression HPA

• ? immune status

Beware the patch!

Drug Name Drug Dose Equivalent Morphine Dose

BuTrans 5 5 micrograms / hr 10mg / 24 hrs

BuTrans 10 10 micrograms / hr 20mg / 24 hrs

BuTrans 20 20 micrograms / hr 40 mg / 24 hrs

Transtec 52.5 (buprenorphine)

52.5 micrograms / hr 94 – 145 mg / 24 hrs

Transtec 70 (buprenorphine)

70 micrograms / hr 126 – 193 mg / 24 hrs

Fentanyl 25 patch 25 micrograms / hr 30 – 134 mg / 24 hrs

Fentanyl 50 patch 50 micrograms / hr 135 – 224 mg / 24 hrs

Fentanyl 75 patch 75 micrograms / hr 225 – 314 mg / 24 hrs

Fentanyl 100 patch 100micrograms / hr 315 – 404 mg / 24 hrs

NHS Wales website 2013

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

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

Danger Signs!

• High doses morphine (or equivalent: > 120mg / day)

• Multiple opioids

• Only injections work (when patient is eating & drinking) largely seen in secondary care

Non-pharmacological analgesia

• Pacing activity / exercise

• Positioning / posture / stretch

• Reassurance (not always easy!)

• Trans-cutaneous Electrical Nerve Stimulation (TENS)

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

Reasons for Referral

• Persistent / complex pain (moderate to severe)

• Previous appropriate use of analgesic guidelines

• Distress; disability; drug use; dependence

Questions