March 2016 PALLIATIVE CARE

 Take an adequate pain history exploring addiction issues to offer appropriate interventions  Ensure that patients on opioid substitution receive adequate analgesia  Recognition of addictive behaviours  Counselling patients who are reluctant to take medication which they regard as addiction inducing

 Pain affects eight million people in the UK  Patients with drug or alcohol problems may have pain due to:  Trauma – head injury, falls, accident  Infection – pneumonia, cellulitis, abscess, septicaemia, injecting, HIV, hepatitis Band C  Neuropathy – vascular, traumatic, viral, carcinoma, nutritional  Cancer – lung, head and neck, oropharynx, oesophagus, liver, colorectum, breast  Musculoskeletal disorder – fractures, osteoporosis, myopathy  Cardiovascular disease – chest pain, cardiomyopathy, stroke  Gastrointestinal – hepatitis, pancreatitis, cirrhosis, peptic ulces

 Effective pain management is part of good medical practice  Palliative care is specialised medical care for people with serious illnesses  The goal is to improve quality of life for patients and their families  Patients may suffer pain from a variety of chronic illnesses directly or indirectly associated with addiction  This group are more likely to need palliative care  Patients who are addicts are just as prone as non-addicts to acquire painful conditions  Patients with chronic pain only occasionally become addicted to analgesia

 Drug dependent patients have a greater need for pain relief due to increased tolerance and a lower threshold for pain  Drug dependent patients are likely to require higher doses of analgesia than non-dependent patients  Drug users or dependent patients may seek over the counter medications, other people’s medications, street drugs  Drug dependent patients may also use heroin to manage pain  Communication between oncology, addiction, palliative care, occupational therapists is necessary

 Drug dependent patients feel stigmatised and uncomfortable in the formal world of hospitals, appointments  Patients drop out of contact and do not attend appointments because they feel they have been badly treated  Patients may feel guilt and shame, are reluctant to discuss problems, fear withdrawal, pain recurrence, that medications will not be prescribed, so may top up prescriptions

 Patients may lack the skills to follow complex dosing regimes  Patients who have a iatrogenic addiction may refuse to attend addiction services  It is helpful for health professionals to be relaxed and form a therapeutic relationship  Health professionals must refrain from prejudice  Health professionals may feel ill equipped to manage this group  Lack of understanding of the pharmacology may lead to the pain being poorly managed

 Undertake a full assessment with a complete pain history:  Location of pain, radiations, severity, timing, duration, quality, aggravating and relieving factors  Associated sensory disturbances or power loss, type of pain,  Impact of psychological factors eg anxiety, depression  Full analgesic history including nature, dose, administration  Diagnostic investigations  Include physiotherapy, occupational therapy assessment  Frequent review of effectiveness and adverse effects of medication

 Regular supervision and monitoring of medications  Patients may be receiving methadone or buprenorphine so any opiate analgesia should be a different molecule  If patients cannot swallow all opiate needs will be with a syringe driver  If a patient is on methadone, this should be continued but additional medication needs to be prescribed for analgesia  If patients are on buprenorphine, it will have to be stopped if patients are on illicit opioids or need to be prescribed opiates for pain relief  Distinguish between withdrawal and poor analgesic response

 Consult with addiction specialists  Where possible, patients in the community may be treated with slow release medications  Patients should be supported to have safe storage of all medications  Patients with physical and psychological needs should be supported by community palliative care teams  Patients need advice about driving

 Have a single point of prescribing  Coordinated approach  Regular monitoring is mandatory to avoid excess opiates and respiratory depression leading to death  Prescribe medication weekly  Avoid likelihood of patients stockpiling drugs at home as patient may risk being the target by other drug users  Be willing to prescribe addition medication if disease progresses, pain worsens or tolerance develops

 Instability in the regime does not necessarily indicate deterioration  Family members or friends may bring the patient drugs or may buy or steal prescribed drugs  Ensure out of hours service is aware of substance misuse issues  When making significant changes in the treatment, it may be advisable to admit the patient under specialist care  Removal of drugs after the patient’s death should follow local policies  If there is concern about the presence of illicit drugs in the patient’s home, it may necessary to inform the police, with every effort being made to maintain engagement with the patient

 Palliative care services should have access to advice and training from the substance misuse team  Pain specialists require basic competence in the diagnosis of drug dependence  Addiction services staff need knowledge of pain management  All services involved in the care of a patient need to work together to meet the patient’s needs in a coordinated manner  Hospital protocols for the management of withdrawal, initiation and maintenance of treatments

 Care can take place in the general hospital, out-patient clinics, primary care, palliative care services  The patient and families need to be supported by:  Specialist pain services  Specialist addiction services  Specialist palliative care  Primary care

 Action on Addiction (2013)The management of pain in people with a past or current history of addiction.  British Pain Society (2007). Pain and Substance misuse; improving patient experience  British Pain Society (2007). Pain and problem drug use -information for patients  Royal College of Anaesthetists Opioids Aware  Cooper D & Cooper J (2014) Palliative care and substance use: special considerations in Palliative Care within Mental Health - care and practice. Radcliffe Health  CMO Annual Report (2008) Pain: breaking through the barrier  Ling GS, Paul D, Simantov R, et al. (1989) Differential development of acute tolerance to analgesia, respiratory depression, gastrointestinal transit and hormone release in a morphine infusion model. Life Sci 45(18): ,

 Neerkin, J; Cheung, Chi-Chi and Stirling C (2011) Guidelines for Cancer Pain Management in Substance Misusers.  NICE (2007) Methadone and Buprenorphine for the management of opioid dependence. NICE technology and appraisal guidance  NICE (2012) Opioids in palliative care: Clinical case scenarios for primary and secondary care. Support for education and learning. NICE clinical guideline  Pease N, Taylor H, Major H (2004) Driving Advice for palliative care patients taking strong opioid medication Palliat Med Oct;18(7):663-5  Przekop,P (2015) Chronic Noncancer Pain: Is It Time for A New Treatment  Scottish Intercollegiate Guidelines Network (2008). Control of pain in adults with cancer – a national clinical guideline.  Watson M.S. (2009) Oxford Handbook of Palliative Care.2nd ed. Oxford, Oxford University Press