Opioids for the management chronic non-cancer pain in Primary Care: Potential, perils and pitfalls All Party Parliamentary Group for Prescribed Drug Dependence 19.10.16 Dr George Ryan Former GP Clinical Advisor to Public Health England

16/05/2018 Opioid analgesic prescribing for chronic non-cancer pain in primary care What’s the problem? What patients need to know What doctors need to know Principles and practicalities of good practice

Number of patients prescribed opioid analgesics for chronic non-cancer pain in UK primary care Zin C et al. Eur J Pain 2014; 18: 1343 – 1351. Most opioid analgesics don’t work for most patients with CNCP British Medical Journal June 2013

Side effects of opioid analgesics Constipation Nausea Sedation Cognitive impairment Depression Hormonal changes Dependence Addiction Respiratory depression Hyperalgesia

Increased risk of: Sexual dysfunction [OR 1.45 (CI -1.87)] 16/05/2018 Increased risk of: Sexual dysfunction [OR 1.45 (CI -1.87)] Fractures [OR 1.27 (CI 1.21-1.33)] Myocardial infarction [OR 1.28 (CI 1.19-1.37)] Abuse [wide range – up to 37%] Overdose [HR 5.2 (CI 2.1-12.5)] Motor vehicle accident [OR 1.24-1.42] Death—especially above daily morphine equivalent of 120mg Chou R et al. Ann Intern Med 2015; 162: 276.

Pain and suffering Impairment Poor mobility Depression Irritability Isolation Rumination Impact on partner, family, carers Perceived as “heartsink” patients

What patients need to know Opioids.. ..rarely help chronic non-cancer pain ..cause numerous side effects ..can cause dependence ..can cause addiction ..can cause premature death ..if not working they should be reduced and stopped

What doctors need to know Opioids.. ..rarely help chronic non-cancer pain ..cause numerous side effects ..can cause dependence ..can cause addiction ..can cause premature death ..if not working they should be reduced and stopped

Principles of good practice 16/05/2018 Principles of good practice WHO analgesic ladder unhelpful for chronic non-cancer pain [CNCP] Use non-opioid analgesics for CNCP If opioids are used, prescribe the lowest possible dose If opioids are used exercise caution and arrange early and frequent review Do not initiate a medication if you are unable reduce or discontinue it Provide advice and support about reduction and cessation of opioid analgesics If necessary, prescribe medication for symptomatic treatment of withdrawal symptoms Commission primary care based services to manage dependence or use disorder Promote pharmacovigilance

DREAMS Dialogue Realistic expectations Equivalence of esteem Avoid over-medicalisation Menu of options from Acupuncture to Zen Support self-efficacy