APPG for prescribed drug dependence Dr Jane Quinlan MB BS FRCA FFPMRCA Consultant in anaesthesia and pain management Trust lead for pain Oxford University Hospitals Trust Honorary senior clinical lecturer University of Oxford Core member of Opioid Painkiller Dependence Alliance

Key messages Chronic pain is common (28 million people in UK) Inappropriate opioid prescribing for chronic pain is common There are large numbers of pain patients taking high dose opioids which are ineffective, harmful, addictive and difficult to stop There is little acknowledgement of patients with pain and iatrogenic opioid dependence There are currently very few facilities to support pain patients who have become dependent on their opioids, or for those needing to reduce or stop their opioids Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. BMJ Open June 20 2016

Impact of opioid prescribing Rates of opioid pain reliever overdose death, treatment admissions and kilograms sold - United States, 1999-2010. Morbidity and mortality weekly report (MMWR). Centers for disease control and prevention.

Use of opioids in UK Zin CS, Chen L-C, Knaggs RD. Eur J Pain 18 (2014) 1343–1351 4

Lessons from palliative care In 1985, WHO produced the pain ladder for treatment of cancer pain Simple, effective with drugs that were cheap and widely available Evidence from palliative care that opioids effective and non-addictive in pain Soon adopted for patients with non-cancer chronic pain: “the medical use of opioids does not create drug addicts, … restrictions on this medical use hurt patients.” IASP drive from 2007 to view pain relief as a human right further increased opioid prescribing World Health Organization. Traitement de la douleur cancéreuse. Geneva, Switz: World Health Organization; 1987. McQuay H. Lancet 1999; 353: 2229–32 5

Neuropathic (chronic) pain Acute and cancer pain Brain Tissue damage after trauma, surgery, cancer Appropriate pain reflecting ongoing tissue damage Opioids are an effective and important part of acute and cancer pain management Neuropathic (chronic) pain Inappropriate pain signalling with no tissue damage No evidence that opioids are safe or effective in the long term management of chronic pain Brain Nerve damage with no tissue damage

Long term opioid use and outcomes 228 opioid users compared with 1,678 non-opioid users Opioids usage significantly associated with: •reporting of severe pain •poor self-rated health •inactivity during leisure •unemployment •higher healthcare utilization •poor health orientated quality of life Eriksen et al. Critical issues on opioids in chronic non-cancer pain: An epidemiological study. Pain 2006;125:172-9

Spectrum of prescribed opioid use Chronic pain No pain but pain reported No pain Stable prescribed opioids Increasing dose of opioids Prescribed drug seeking Diverted opioids Risk of dependence Dependence and problem opioid use Addiction pain dependence Pain services No current service Addiction services

Current recommendations Short trial of low dose opioid to see if functional improvement Current recommendations in morphine equivalent dose (MED) per day: UK: Opioids Aware – FPM, BPS and PHE - max 120mg MED USA: caution over 50mg MED and a 90mg MED limit Germany: max 120mg MED Australia: max 60mg MED Large population of patients on 500mg MED and above https://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. Häuser W, Bock F, Engeser P, Tölle T, Willweber-Strumpf A, Petzke F: Clinical practice guideline: Long-term opioid use in non-cancer pain. Dtsch Arztebl Int 2014; 111: 732–40.

Global opioid availability Current inequity of under-availability and overconsumption Source: International narcotics control board 10

Current needs Programmes to screen and identify patients taking opioid painkillers who may be at risk of developing dependence Early access to effective treatment in a suitable environment Support and information services for patients and their families More informed communications to the public and healthcare services to reduce the stigma associated with opioid painkiller dependence