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Long term opioid prescribing: a failed experiment? St Giles Hospice June 2016 Dr Cathy Stannard, Bristol

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Long term opioid prescribing: a failed experiment? St Giles Hospice June 2016 Dr Cathy Stannard, Bristol Session overview Current opioid conversations About persistent pain
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Long term opioid prescribing: a failed experiment? St Giles Hospice June 2016 Dr Cathy Stannard, Bristol Session overview Current opioid conversations About persistent pain (and pain and opioid treatment) Changing what we do Long term opioid prescribing: a failed experiment? CURRENT OPIOID CONVERSATIONS Current opioid conversations The prescription opioid epidemic in the US UK prescribing data Effectiveness of opioids for long-term pain Harms of opioid therapy Addiction to and misuse of opioid medicines Addiction to OTC medicines Managing pain in at risk populations Current opioid conversations The prescription opioid epidemic in the US UK prescribing data Effectiveness of opioids for long-term pain Harms of opioid therapy Addiction to and misuse of opioid medicines Addiction to OTC medicines Managing pain in at risk populations Opioids: how we got to where we are Mid 1980s cancer patients dying in pain Late 1990s pain relief as a universal human right Small trials showing efficacy of opioids in non-cancer pain Early 2000s escalation of opioid prescribing paralleled by misuse, diversion and deaths Recognition of limitations of trial data Systematic reviews of efficacy Recognition of dose related harms 2012: prescription opioid related deaths in US deaths April million prescriptions at cost of 314 million Number of items (millions) Cost ( million) Strong opioids: Prescription Cost Analysis 4 Items 80 Cost Morphine Oxycodone Fentanyl Buprenorphine Copyright NHSBSA 2014 Trends in Prescribing of Opioid Analgesics on NHS prescriptions in England Items per 1000 Patients Variation Between Strategic Health Authorities in Prescribing of Opioid Analgesics (Quarter to March 2013) Tramadol Codeine Morphine Dihydrocodeine Buprenorphine Fentanyl Oxycodone Others SHA median LONDON Copyright NHSBSA 2013 SOUTH CENTRAL WEST MIDLANDS SOUTH EAST COAST EAST OF ENGLAND EAST MIDLANDS SOUTH WEST YORKSHIRE AND THE HUMBER NORTH WEST NORTH EAST Variation between Strategic Health Authorities in prescribing of Benzodiazepines (Quarter to March 2010) NHS prescribing services. Chou R et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review Annals of Internal Medicine 2015;162:276 Chou et al 2015 Evidence is insufficient to determine the effectiveness of long-term opioid therapy for pain Dose dependent risk for serious harms Most trials shorter than 6 weeks Lack of non-opioid comparison Lack of external validity No evidence relating to different dosing strategies short versus long acting continuous versus as needed opioid rotation Chou et al 2015 No differences in effect of different long term opioids (methadone) Evidence for increased risk of overdose, abuse and dependence fractures, myocardial infarction use of medications to treat sexual dysfunction Hauser W, Bernardy K, Maier C Long-term opioid therapy in chronic noncancer pain. A systematic review and meta-analysis of efficacy, tolerability and safety in open-label extension trials with study duration of at least 26 weeks Schmerz Feb;29(1): Hauser et al 2015 A small proportion of patients selected for opioid therapy at randomisation complete the long term open label study Sustained effects can be demonstrated in this population Average pain scores are unrepresentative of patient experience Studies do not report percentage pain reduction The studies did not report increase in dose over time Positive effects may relate to placebo or spontaneous recovery Poor external validity because of patient selection Number of patients Number of patients prescribed opioids Cancer Non-cancer Zin C Chen L Knaggs R Eur J Pain 2014;18(9): Drug-related deaths 350 Prescription opioid related deaths: Any mention Other opiate Tramadol Dihydrocodeine not from compound formulation Codeine not from compound formulation Paracetamol & codeine compound formulation Deaths related to drug poisoning in England and Wales 2014 Office for National Statistics 2015 No. of presentations % of all presentations Px opioids + illicit use Px opioids, no illicit use Total px opioids as % of total presentations Px opioids + illicit use % Px opiods, no illicit use % Addiction to medicines. NDTMS personal communication https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/462885/drug-misuse-1415.pdf 5.4 % adults 16 to 59 misused a prescription-only painkiller not prescribed to them 7.2 % 16 to 24 misused a prescription-only painkiller in the last year: 4.9 % of 25 to 59 had done so Decline in misuse with age is less for prescription painkillers than other drugs Painkiller misuse less likely to be associated with misuse of other drugs (cf NPS) No association of painkiller misuse with alcohol misuse People with long-standing illness/disability more likely to have misused prescription-only painkillers and to have used illicit drug in the last year. Misuse of prescription painkillers distributed more evenly across the general population than use of illicit drugs Misuse of painkillers similar in both rural and urban areas Long term opioid prescribing: a failed experiment? ABOUT PAIN Thoughts about pain relief Yes we should try to treat pain but Pain can t always be treated Inability to reduce a patient s pain intensity is neither a reflection of lack of effort nor a sign of incompetence Trying hard to treat pain and making the patient worse is not a result WHO 1986 WHO 1986 Pain intensity Patients who report the highest pain intensity (10/10) respond less well to medications Pain intensity relates to anxiety and distress Reductions in pain intensity for any treatment (including CBT) are very modest c350 Cochrane reviews of chronic pain interventions Pharmacologic interventions to reduce chronic post-surgical pain TENS Capsaicin CBT (small benefit, no active controls/unclear)! Multidisciplinary rehab Self Management Programmes (short term benefit in self efficacy and self related health, no improvement in psychological health) Spinal Cord Stimulation (2004 not been updated) Sympathectomy Radiofrequency lesioning Acupuncture Injections Medication for neuropathic pain Exercise for fibromyalgia We believe that pain medicine has now reached a degree of maturity where it can confront its failings. BMJ 2013;346:f2690 Pain and opioid prescribing: where things might be going wrong Poor understanding of the complexity of pain particularly its refractory nature and emotional comorbidities and antecedents Lack of knowledge about efficacy of interventions Lack of awareness that Doing nothing is better than doing something harmful It s OK to stop trying Unrealistic expectations Overestimation of our ability to recognise risks and act accordingly Lack of recognition that patients move around a complex system Pain and opioid prescribing: where things might be going wrong Poor understanding of the complexity of pain particularly its refractory nature and emotional comorbidities and antecedents Lack of knowledge about efficacy of interventions Lack of awareness that Doing nothing is better than doing something harmful It s OK to stop trying Unrealistic expectations Overestimation of our ability to recognise risks and act accordingly Lack of recognition that patients move around a complex system Long term opioid prescribing: a failed experiment? ABOUT PAIN AND OPIOID THERAPY Risks of running into problems with high dose opioids Patient factors Depression/common mental health diagnoses Alcohol misuse/non-opioid drug misuse Opioid misuse Drug factors High doses Multiple opioids More potent drugs Concurrent benzodiazepines/sedative drugs Who gets long term opioid therapy? Increased risk includes: Patient factors Depression/common mental health diagnoses (x3-4) Alcohol misuse/non-opioid drug misuse (x4-5) Opioid misuse (x5-10) and At risk patients are more likely to receive High doses Multiple opioids More potent drugs Concurrent benzodiazepines/sedative drugs Summary of McCrorie et al Problems arise when Patients have consultations that don t meet their needs GPs feel unable to negotiate non-medication approaches Therapeutic short-termism resulting from inconsistent clinical encounters Inadequate emotionally-charged consultations Summary of McCrorie et al Problems arise when Opioids prescribed to establish false therapeutic relationships Absence of mutually agreed formulations and management planning (prescribing as default reaction) Importance of practice level planning Long term opioid prescribing: a failed experiment? CHANGING WHAT WE DO NEJM Feb 2016 NEJM Feb 2016 Influences on opioid prescribing Patients non-verbal communication Patient behaviour Gender of prescriber Experience of prescriber Cognitive load of prescriber Concerns about effectiveness and harms Availability of alternatives McCracken L, Velleman S, Eccleston C Primary Health Care Research & Development 2008; 9: Burgess D et al Pain Med 2014;6: Gupta A et al Pain Physician 2011;14(4):383-9 Influences on opioid prescribing Patients non-verbal communication Patient behaviour Gender of prescriber Experience of prescriber Cognitive load of prescriber Concerns about effectiveness and harms Availability of alternatives (NB doing nothing is a strategy) McCracken L, Velleman S, Eccleston C Primary Health Care Research & Development 2008; 9: Burgess D et al Pain Med 2014;6: Gupta A et al Pain Physician 2011;14(4):383-9 Who needs to engage in best practice development? Patients move around a complex system Healthcare professionals Managers Formulary committees Commissioners National strategy Political imperatives Family and friends The media Stakeholders important in effecting change A good prescription is effective for the condition prescribed does not harm the patient does not harm anyone else is acceptable to the patient and is accurate and legal Good practice in prescribing Adequate assessment Work within competence Prescribe in accordance with evidence and justify decisions Be sure that the drug meets the patient s needs Take account of co-morbidities Keep clear records including patient information Assess outcomes Prescribe within the law GMC 2013 (opioid) prescribing: a simple guideline Assess the patient Discuss the benefits and harms Agree what to prescribe Find out whether it works Stop the drug if it doesn t work Opioids are very good painkillers for acute pain and pain at the end of life but there is little evidence that they are helpful for long term pain There may be a small number of people who do well with opioids in the long term if the dose can be kept low and particularly if use is intermittent (it is difficult to identify these people at the point of opioid initiation) The risks of harm increases substantially at doses above an oral morphine equivalent 120mg/day, but there is no increased benefit If a patient has pain and they are on opioids it means they are not working and should be stopped, even if no other treatment is available Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detailed assessment of the many emotional influences on their pain experience is essential
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