Prescribing and Treatment Guideline

Document Title Awareness of Opioids Used For Pain Relief

Reference Number CG/Opioid awareness/07/16

Policy Type Clinical Guideline

Electronic File/Location N:\Pharmacy\Intranet

http://intranep/TeamCentre/pharm/PublishedDocuments/ Intranet Location Forms/Prescribing.aspx

Status FINAL

Version No/Date Version – 1 July 2016

Author(s) Responsible for Medicines Information and Research Pharmacist Writing and Monitoring

Approved By and Date MMG September 2016

Implementation Date September 2016

Review Date July 2019

© North Essex Partnership University NHS Foundation Trust (2016). All rights reserved. Not to Copyright be reproduced in whole or in part without the permission of the copyright owner. All matters or concerns regarding fraud or corruption should be reported to: Chris Rising, Senior Manager ([email protected] 07768 873701), Mark Kidd LCFS Lead ([email protected] ) Mark Trevallion, LCFS Lead ([email protected] 07800 718680) OR the National Fraud and Corruption Line 0800 028 40 60 https://www.reportnhsfraud.nhs.uk/

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AWARENESS OF OPIOIDS USED FOR PAIN RELIEF

The increase in opioid prescribing in recent years has led to concerns that England may be on the way to the “epidemic proportions seen in the USA” according to Opioids Aware – A new online resource developed in the UK through collaboration between a number of organisations including several medical Royal colleges, NICE, CQC, the British pain Society and the Royal Pharmaceutical Society to support the safe and rational use of opioids for pain.

This resource contains specific information relating to the clinical use of opioids for pain that aims to support prescribers and patients in making a fully informed decision to use, or to not use opioids.

It is available at:

www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware

The resource is aimed at both clinicians and the public. It is an exceptionally comprehensive resource fully referenced to the original evidence, there are a few documents available to download and print such as: - A checklist for prescribers. - Identification and treatment of prescription opioid dependent patients.

Headlines:

1. Opioids are very good analgesics for acute pain and for pain at the end of life, but there is little evidence that they are helpful for long term pain.

2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation).

3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit.

4. If a patient is using opioids but is still in pain, the opioids are not effective and should be discontinued, even if no other treatment is available.

5. 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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Facts and figures from the opioids aware website

 Rises in opioid prescribing have been accompanied by increases in harms such as unintentional overdose, addiction and death

 4% of our population are prescribed opioids

 Over 5% of our adult population have used opioid medicines not prescribed for them in the past year

Professional, Regulatory and Public Concerns

Guidelines for the use of opioids in pain management have been available in the UK and elsewhere for a number of years but have made no impact on the increasing use of opioids, particularly for persistent pain. There are as many different clinical situations as there are patients and treatment decisions should be individualised depending on the balance of benefits and harms and the needs and preferences of the patient. This resource does not suggest whether opioids are the most appropriate treatment for a patient but gives the prescriber and the patient the information needed to make an initial prescribing decision and next best steps at subsequent clinical review.

The increase in opioid prescribing is set in the context of a number of professional, regulatory and public health concerns:

 Lack of effectiveness of opioids for persistent pain

Opioids have demonstrable effectiveness in the treatment of acute pain and pain related to cancer (particularly at the end of life) but there is little evidence for the effectiveness of opioids for the treatment of persistent pain. In particular, there are no data that demonstrate improved quality of life for patients taking opioids for persistent pain and an association has been shown between opioid treatment and poorer health related outcomes.

 Complexity of chronic pain

It is important to recognise that pain, both acute and chronic, is a complex sensory and emotional experience shaped not only by biological but also emotional, social and cultural factors and it should be evaluated and managed in this context. Persistent pain is difficult to treat with the aim of therapy being to improve quality of life despite on-going symptoms. Medications should always be used as part of a broader pain management plan including discussion about the causes and consequences of pain, advice about activity and management of low mood.

 The prescription opioid ‘epidemic’ in the United States

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The upward trend in opioid prescribing is seen elsewhere in Europe, in Australia and in the US. The increase in prescribing in the US has been associated with a parallel increase in misuse of prescription opioids and opioid related harms including overdose and death. In 2011 there were 15 000 prescription opioid deaths in the US and a catastrophic burden of opioid related emergency admissions, addiction to and widespread non-medical use of prescription opioids. In the UK the prescribing trends are similar to those in the US and the potential for a burgeoning epidemic of prescription opioid misuse and death exists but there are a number of important cultural and healthcare differences between the US and the UK which should prompt caution in drawing direct comparisons between the two contexts.

 Addiction to medicines in England and elsewhere in Europe

Use of prescription opioids in combination with illicit drugs or, less often, as a sole drug of dependency, is noted by professionals working in drug misuse and recovery services. There are now some limited data that describe the scale of prescription drug misuse in those presenting to drug services. These data confirm that prescription opioid misuse exists in England and although rates of reported addiction to prescription opioids over the past five years have been stable in comparison to the upward trend in opioid prescribing, most recent data suggests a recent upward trend. The data however, underestimate the scale of prescription opioid misuse as not all patients with addiction to prescription opioids will present to drug services. The extent of prescription opioid misuse elsewhere in Europe is not well documented.

 Poisoning deaths in England and Wales

The Office for National Statistics produces data on drug related deaths in England and Wales. Notably there has been a consistent rise in deaths associated with Tramadol since the first reported death in 1996 (240 deaths in 2014). Deaths related to codeine and dihydrocodeine have been relatively stable with the most recent analysis (2014) showing 222 deaths.

 Misuse of prescription opioids: findings from the Crime Survey for England and Wales

The Crime Survey for England and Wales examines the extent and trends in illicit drug use among a nationally representative sample of 16 to 59 year olds resident in households in England and Wales, and is based on results from the 2014/15 Crime Survey for England and Wales (CSEW). For the first time this survey includes questions relating to misuse of prescription painkillers (use of prescription analgesics by those for whom they are not prescribed). Findings include:

 Overall, 5.4 % of adults aged 16 to 59 years had misused a prescription-only painkiller not prescribed to them  Painkiller misuse is more common in younger ages

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 7.2 % of 16 to 24 year olds had misused a prescription-only painkiller in the last year, while 4.9 % of 25 to 59 year olds had done so

Particular Challenges of Long Term Pain Management

The experience of pain is complex and influenced by the degree of tissue injury, current mood, previous experience of pain and understanding of the cause and significance of pain. Previous unpleasant thoughts, emotions and experiences can also contribute to the current perception of pain and, if unresolved, can act as a barrier to treatment. The assessment of chronic pain needs to be wide-ranging and comprehensive. The persistence of symptoms is particularly relevant in relation to prescribing where patients may be exposed to cumulative harms of drugs over prolonged periods. If a patient continues to have pain despite taking a number of medications, drugs should be sequentially tapered or stopped to establish continued utility. Similarly, if a patient reports reasonable pain relief from a medication regimen in the longer term, it is also necessary to taper medications intermittently to assess whether the symptoms have resolved spontaneously or whether the patient is relatively pain free because of continued efficacy of medication.

Dose Equivalent and Changing Opioids  Switching from one opioid to another should only be recommended or supervised by a healthcare practitioner with adequate competence and sufficient experience. If uncertain, ask for advice from a more experienced practitioner.  Opioid rotation or switching may be considered if a patient obtains pain relief with one opioid and is suffering severe adverse effects.  When converting from one opioid to another, the initial dose depends on the relative potency of the two drugs and route of administration.  An individualised approach is necessary.  Conversion factors are an approximate guide only because comprehensive data are lacking and there is significant inter-individual variation.  In most cases, when switching between different opioids, the calculated dose-equivalent must be reduced to ensure safety. The starting point for dose reduction from the calculated equi-analgesic dose is around 25-50%.  A dose reduction of at least 50% is recommended when switching at high doses (eg, oral morphine or equivalent doses of 500mg/24 hours or more), in elderly or frail patients, or because of intolerable undesirable effects.  The half-life and time to onset of action of the two drugs needs to be considered when converting so that the patient does not experience breakthrough pain or receive too much opioid during the conversion period.  Once the conversion has occurred, the dose of new opioid should be titrated carefully according to individual response and the patient monitored closely for side effects and efficacy, especially when switching at high doses.

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 Withdrawal symptoms (eg, sweating, yawning and abdominal cramps, restlessness, anxiety) occur if an opioid is stopped/dose reduced abruptly.

Approximate equi-analgesic potencies of opioids

There are a full set of basic conversion to morphine equivalence tables that starts at oral codeine and has conversion for transdermal burprenorphine and fentanyl.

Summary

Opioids Aware looks really good for supporting prescribers to work through the options available to patients to manage their pain. The fact that it is open access means that patients, (and their carers) who want to take an active role in decision making can see the information for themselves.

It has been co-produced by all the leading agencies.

Perhaps controversially for some, it states very clearly that long term repeat prescribing of opioids is not a solution for managing pain for most people. Until now most guidance has only advised on upward titration of dose to reach a stable point only briefly mentioning review and stepping down. Periodical reassessment to see if the underlying cause of the pain has resolved seems sensible particularly considering the potential for harm when used long term.

Even more controversially, how will prescribers feel about the advice to discontinue opioids when not effective, even when there is no other treatment, when faced with a patient using opioids who is still in pain.

SUMMARY OF CHANGES Page Date Summary of Changes Number(s)

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