Date ratified: 30/09/16 Review due: March 2019

Chronic : Guidelines for Initial Management and Referral to Secondary Care

Document Author Authorised Signature Written by: Dr Isobel Rice Authorised by: Mr J. Makunde

Job title: Consultant Anaesthetist Job title: Chair - Clinical Standards Group

Date: 30/09/16 Signed:

Date: 30/09/16 Section Title Page 1 Background 1 2 Purpose 2 3 Scope 2 4 Course of Action 2 5 Implementation/training/awareness 2 6 Monitoring and key performance indicators 2 7 References 2-3 8 Links to other policies/documents 3 9 Disclaimer 3 Appendix A Neuropathic Pain Pathway 4 Appendix B Guideline 5 Appendix C Appropraite/Inappropraite 6 Appendix D Impact assessment forms 7-8 Appendix E Equality analysis and action plan 9-10

1 INTRODUCTION/BACKGROUND

 The Royal College of General Practitioners (RCGP) and The Pain Society recommend that primary care physicians and hospital specialists should work together to manage patients in the most appropriate environment.  Specialist Chronic Pain services are those, which serve the needs of people with complex pain disorders requiring diagnosis and treatment by multidisciplinary teams. (NHSIA)  It is important to refer early rather than late; these guidelines are designed as an aid to this, by describing a pathway for appropriate referral to the specialist services available on the Isle of Wight.  Waiting times for specialist pain services may be many months. The RCGP states that it is important to continue to see patients waiting for specialist referral and to modify treatment where appropriate. These guidelines are designed to provide a seamless treatment pathway between primary and secondary care.

2 PURPOSE

Chronic Pain: Guidelines for Initial Management and Referral to Secondary Care Version No. 3 Page 1 of 10

To facilitate the appropriate initial treatment, and referral to specialist services, for those suffering with chronic pain. This document is intended for all prescribers throughout the Trust.

3 SCOPE

 Pain is one of the most common reasons that patients present to primary care  Chronic pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. (International Association for the Study of Pain)  Statistics show that nearly 1 in 7 people (13%) suffer from chronic pain. It is hardly surprising that people suffering pain consult their doctor up to five times more frequently than others, and these results in nearly 5 million GP appointments each year.  Two thirds of chronic pain sufferers surveyed in the UK reported inadequate pain control with only 16% saying that they had seen a pain specialist.  Untreated pain can affect quality of life for sufferers and carers leading to helplessness, isolation, depression, and family breakdown.

4 PROCEDURAL DOCUMENT DETAIL / COURSE OF ACTION:

Who do these guidelines apply to?  All patients with chronic pain; i.e. pain following an episode of tissue damage that persists past the time when healing is expected to be complete, usually nominated as 3 months.  These guidelines are for use by all doctors, both within primary and secondary care, who are treating patients suffering from chronic pain.  These guidelines should be used for patients above the age of 16years. Below this age the same principles apply – dose adjustment is needed and early referral recommended.

5 IMPLEMENTATION/TRAINING/AWARENESS:

This document will be widely available on the Intranet. The Secondary care Pain Clinic will have responsibility for ensuring awareness and regular training of all staff groups within the Trust.

6 MONITORING & KEY PERFORMANCE INDICATORS

Referrals to the Secondary Care Pain clinic will be monitored to ensure this pathway is followed, by scrutinising pre-referral prescribing. Annual reports on prescribing practises throughout the Trust will be obtained by the secondary care pain service and training delivered accordingly.

7 REFERENCES

1. Pain in Europe. A 2003 report. Research project by NFO Worldgroup 2. Elliott AM, Smith BH Penny KL et al. The epidemiology of chronic pain in the community. Lancet 1999; 354: 1248-52

Chronic Pain: Guidelines for Initial Management and Referral to Secondary Care Version No. 3 Page 2 of 10 3. A practical guide to the provision of Chronic Pain Services for Adults in Primary Care. The British Pain Society and the Royal College of General Practitioners. 4. Services for Patients with Pain. London: Clinical Standards Advisory Group 2000 5. Cancer Pain Relief: With a guide to availability. Geneva: World Heath Organisation 1996 6. McQuay HJ, Tramer M, Nye BA et al. A systematic review of anti-depressants in neuropathic pain. Pain 1996; 68: 217-27 7. Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain. An update and effect related to mechanism of drug action. Pain 1999; 83: 389-400 8. McQuay HJ, Carroll D, Jadad AR, et al. Anticonvulsant drugs for the management of pain: a systematic review. BMJ 1995; 311: 1047-52 9. Recommendations for the appropriate use of for persistent non-cancer pain. The British Pain Society 2004 10. The use of drugs beyond licence in Palliative Care and Pain Management. The Association for Palliative medicine and the Pain Society 2002 11. McQuay HJ, Moore AM, Eccleston C, Morley S, Williams A C de C. Systematic review of outpatient services for chronic pain control. Health Technology Assessment 1997; Vol 1: No.6 12. Management of depression in Primary and Secondary Care. National Clinical Practise Guideline No.23

8 LINKS TO OTHER POLICIES/DOCUMENTS

These guidelines link with the Chronic Pain Opiate Prescription Framework for Non-Cancer pain in Primary and Secondary care on the Isle of Wight.

9 DISCLAIMER

It is the responsibility of staff to check the Trust intranet to ensure that the most recent version/issue of this document is being referenced.

DOCUMENT HISTORY

Date of Issue Version Next Date Director Nature of Change No. Review Approved Responsible for Date Change 07/2005 1.0 07/2007 Clinical Director for Planned Services 04/2012 1.1 Clinical Director for Planned Services 05/2013 2.0 03/05/16 03/05/16 Clinical Director for Approved at CSG Planned Services 300/9/16 3 March 30/09/16 2019

Chronic Pain: Guidelines for Initial Management and Referral to Secondary Care Version No. 3 Page 3 of 10 Appendix A Neuropathic Pain

• Many possible causes: Diabetes, Herpes Zoster, nerve injury, post-operative • Much longer term “mechanical” pain has neuropathic elements • Neuropathic pain can be a feature of an underlying disease e.g. cancer, that will require investigation. Symptoms and signs: • Description of pain essential: key words are: “burning”, “shooting”, “stabbing” and “electric shocks” • Skin in affected areas abnormally sensitive to: o pain (Hyperaesthesia), o touch (Allodynia) – even wearing clothes • Affected area may have other unpleasant sensations or even be numb • Skin in painful areas looks different from normal e.g. atrophic or cyanosed • Unresponsive to conventional

Medication Management: (in addition to / instead of conventional analgesics)

STEP 1: Trial single drug therapy – success rate 40% Reassess regularly until pain managed

Amitriptyline

Usually first choice Slowly titrate to reduce side effects Week1 Week2 Week3 Week4 Am 300mg 300mg 300mg Week1 Week2 Week3 Week4 Week5 Midday 300mg 300mg 10mg 20mg 30mg 40mg 50mg Nocte 300mg 300mg 300mg 600mg • Analgesic effect separate from anti- depressant effect Max dose: 900mg tds • Taken at night to reduce unwanted sedation Alternatives: • Small doses usually effective. Max Pregablin - if unwanted sedation dose 75mg Carbamezepine - if classical trigeminal • If already taking SSRI max does = neuralgia

25mg

Alternatives: Duloxetine –1st line diabetic neuropathy –if elderly &/or sedated

STEP 2: Alternate / combine Antidepressant & Anticonvulsant (When switching medication use tapered withdrawal: reverse titration tables) STEP 3: Add (caution with SSRI)

For Secondary care specialist recommendation: • Plaster (Versatis®): for focal neuralgia where other treatments have failed or cannot be used due to co-morbidities • Strong Opioids • Appendix B

Chronic Pain: Guidelines for Initial Management and Referral to Secondary Care Version No. 3 Page 4 of 10 Analgesic Ladder Assess each change to analgesic regimen after 4–6 weeks

Step 1 1g four times a day Continue as patient moves through Steps 2 - 4

ST Step 2 1 LINE - start 30mg four times a day (maximum 240mg daily dose) NNT = 2.2 but: up to 10% of Caucasians may be unable to metabolise codeine to  Dihydrocodiene does not rely on this process for action:use if unresponsive to codeine phosphate Co-drugs e.g. Co-dydramol, co-codamol may improve compliance but difficult to titrate 2nd LINE Tramadol – start 50mg up to four times a day (maximum 100mg four times a day) Possesses serotonergic and adrenergic properties (Caution with SSRI) Possibly not well tolerated in elderly patients and can cause psychiatric reactions in patients of all ages. Lowers seizure threshold - use with care in epileptic patients. 3rd LINE Patch (Butrans) – starting dose 5mcg/hour (maximum 20mcg/hour) Useful for elderly patients, epileptics and those with renal failure Not for use with acute pain Consider;  Use of modified release preparations:better tolerated, improved compliance  Regular laxatives for patients taking opioids– e.g Magnesium hydroxide and Senna. Encourage regular fluid intake.  Anti-emetics during first 2 weeks of therapy – Cyclizine normally first line  Starting at lowest dose and titrating slowly reduces adverse effects  Non-drug therapies – education, explanation and reassurance. Pacing activities, physical therapies, TNS machine, acupuncture and complementary therapies Important:  NSAIDS are not appropriate for Persistent Pain management in elderly  No improvement in function / dose escalation = likely opioid non-responsive pain – tail off & stop  Opioids should be reviewed six monthly and doses reduced to the lowest effective ASAP Opioid equivalence:

Codeine/DH Tramadol Buprenorphine patch (Butrans) Morphine SR patch SR tablets C 60mg qds 50mg qds 20 mcg/hour 20mg bd 12 mcg/hour 10mg bd

Step 3 Opioids for severe pain  Only if opioid responsive  Preferably prescribe with anti-neuropathic medication  Refer to the Chronic Pain Team 1st LINE  Morphine SR (Zomorph capsules) 20mg twice daily 2ND LINE (if opiate responsive and unable to tolerate morphine)  Oxycodone SR tablets / Fentanyl patch /Buprenorphine

Opioids that are NOT recommended for Chronic Pain:     , Diconal , Sublingual Buprenorphine, Actiq (fentanyl lozenge), Effentora and Abstral (sublingual fentanyl), Meptazinol, Short acting opioids are not recommended in the management of severe persistent pain

Chronic Pain: Guidelines for Initial Management and Referral to Secondary Care Version No. 3 Page 5 of 10 Appendix C: Chronic Pain Clinic Referral Decision Making Tool

Uncontrolled Cancer Pain

Recognised neuropathic pain syndromes

Follow

Algorithm for PAIN Pain Clinic Patients making excessive demands CLINIC referral for treatment of their pain, or requesting a “second opinion”

Referral to psychiatry to Patients with significant psychiatric ensure stabilised as possible co-morbidity prior to Pain Clinic referral

Back Pain Refer as appropriate to triage pathway Lower Limb Pain

Intractable Headache Refer for neurology assessment

• Polyarthropathy ( >3 swollen joints & 30min a.m. stiffness & ESR/CRP > 30) • History of fragility fracture, family history or risk factors for osteoporosis Refer for rheumatology • Features of other connective tissue, sero- assessment negative, vasculitic disorders

Pain problems where treatable pathology has been inadequately assessed and excluded (e.g. abdominal or pelvic pain)

When there is a clear statement by a Pain Consultant that there are no further therapeutic options, the patient should NOT be re-referred with the same pain problem

Chronic Pain: Guidelines for Initial Management and Referral to Secondary Care Version No. 3 Page 6 of 10

Appendix D

IMPACT ASSESSMENT ON DOCUMENT IMPLEMENTATION

Summary of Impact Assessment (see next page for details)

Document Chronic Pain: Guidelines for Initial Management and Referral to Secondary title Care

Totals WTE Recurring Non £ Recurring £ Manpower Costs 0 0 0

Training Staff 0 0 0

Equipment & Provision of resources 0 0 0

Summary of Impact:

Risk Management Issues:

Benefits / Savings to the organisation:

Equality Impact Assessment

. Has this been appropriately carried out? YES / NO . Are there any reported equality issues? YES / NO

If “YES” please specify:

Use additional sheets if necessary.

Chronic Pain: Guidelines for Initial Management and Referral to Secondary Care Version No. 3 Page 7 of 10

IMPACT ASSESSMENT ON POLICY IMPLEMENTATION

Please include all associated costs where an impact on implementing this document has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered.

Manpower WTE Recurring £ Non-Recurring £ Operational running costs 0 0 0

Additional staffing required - by affected 0 0 0 areas / departments:

Totals: 0 0 0

Staff Training Impact Recurring £ Non-Recurring £ Affected areas / departments 0 0 e.g. 10 staff for 2 days 0 0

Totals: 0 0

Equipment and Provision of Resources Recurring £ * Non-Recurring £ * Accommodation / facilities needed 0 0 Building alterations (extensions/new) 0 0 IT Hardware / software / licences 0 0 Medical equipment 0 0 Stationery / publicity 0 0 Travel costs 0 0 Utilities e.g. telephones 0 0 Process change 0 0 Rolling replacement of equipment 0 0 Equipment maintenance 0 0 Marketing – booklets/posters/handouts, etc 0 0

Totals: 0 0

 Capital implications £5,000 with life expectancy of more than one year.

Chronic Pain: Guidelines for Initial Management and Referral to Secondary Care Version No. 3 Page 8 of 10

Funding /costs checked & agreed by finance: 0 Signature & date of financial accountant: 0 Funding / costs have been agreed and are in place: 0 Signature of appropriate Executive or Associate Director: 0

Appendix E Impact on Equality Assessment Form

Title/Subject: Chronic Pain: Guidelines for the Initial Management and Referral to Secondary Care

Name: Isobel Rice Date: 30/09/16

What are the intended outcomes of the protocol?

Who will be affected? E.g. staff, patients, service users etc

Evidence List the main sources of data, research and other sources of evidence you have reviewed. What evidence have you considered? Disability X Sex Race Age X Gender reassignment Sexual orientation Religion and belief Pregnancy and maternity Carers Other groups e.g. socio- economic , are inequalities, income

Summary of Analysis Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive What evidence have you considered?

Chronic Pain: Guidelines for Initial Management and Referral to Secondary Care Version No. 3 Page 9 of 10 Eliminate discrimination, harassment and victimisation

Advance equal opportunity and promotes good relationships between groups

Please select one of each of the following categories that apply to your protocol:-

EQUALITY GROUPING TRUST OBJECTIVES Patient Safety Quality Patient Experience Innovation Quality & Clinical Effectiveness Productivity Governance & Compliance Prevention Reform

Please select as many of the following that apply to your protocol:-

Health & Safety Issue Infection Control Issue Quality Issue Attitude or Behavioural Issue

Signed:

Name in full: Isobel Rice

Title/Grade: Consultant Anaesthetist

Protocol Agreed at: Clinical Standards Group

Date: 30/09/2016

Chronic Pain: Guidelines for Initial Management and Referral to Secondary Care Version No. 3 Page 10 of 10