Opioids for persistent non-cancer pain British Pain Society Recommendations Karen H Simpson Consultant in Pain Management Leeds

Need for recommendations for use of opioids in persistent non-cancer pain Persistent pain is being increasingly recognised as a medical and social problem Large surveys from Europe suggest 10% population have persistent severe pain 4600 patients in Scotland in primary care 16% moderately/severely disabled by persistent pain   2000 patients in primary care 79% still had pain after 4 years

Pain – a widespread problem One in five people in UK suffer from chronic pain Total of 7.5 million people One-third of UK households affected by chronic pain

Patients Living in Pain Duration of Pain (n=300) Chronic pain present average 6 y A fifth had pain for more than 20 y %

Causes of chronic pain Most frequently arthritis Most commonly low back pain

Need for recommendations for use of opioids in persistent non-cancer pain Persistent pain affects lots of people UK 2-6 million people with persistent severe non-cancer pain   England and Wales 1.3-1.75 million osteoarthritis 0.25-0.5 million rheumatoid arthritis The problem is large and likely to grow as the population ages

Need for recommendations for use of opioids in persistent non-cancer pain Persistent pain is expensive 900,000 hospital bed days 12 million GP consultations 119 million days certified incapacity UK direct health care cost back pain £1632 million Informal care/lost production cost £10668 million The public and government are interested

Need for recommendations for use of opioids in persistent non-cancer pain There are an increasing number of strong opioids with marketing authorisation for persistent non-cancer pain There is increased use of strong opioids for this indication in primary and secondary care There is strong pressure from industry to use these drugs more freely There is little training for health care professionals about opioid use for this indication

Need for recommendations for use of opioids in persistent non-cancer pain Patients and carers are becoming more aware of the use of strong opioids for non-cancer pain In some European countries and USA there is intense pressure on doctors to provide opioids for non-cancer pain This is balanced by concerns about medical use of opioids Doctors accused on heroin advice Steven Morris Tuesday February 24, 2004 The Guardian

Development of recommendations 2 years ago Pain Society consensus group developed Provisional recommendations for the appropriate use of opioids in patients with chronic non-cancer related pain There was an accompanying patient information leaflet This was developed after literature review and consensus opinion from experts from a number of disciplines and patient’s representatives During the 12 month consultation period over 300 responses from individuals and professional organisations have been received and considered

Consensus group Joint chair and co-editors Dr Alf Collins UK Pain Society Dr Karen Simpson UK Pain Society Members Dr Douglas Justins Royal College of Anaesthetists Prof Bruce Kidd Royal College of Physicians Dr Richard Potter Royal College of General Practitioners Dr Marian de Ruiter Royal College of Psychiatrists Dr Cathy Stannard Pain Society Mr Phil Wiffen Royal Pharmaceutical Society Dr Amanda Williams UK Pain Society   Advice given by the following individuals: Mrs Jean Gaffin UK Pain Society Patient Group Chair Dr Mike Bennett Association for Palliative Medicine Prof Antony Franks NHS Trust Risk Management Chair

Recommendations endorsed by Association of Anaesthetists Royal College of Anaesthetists Royal College of General Practitioners Royal College of Psychiatrists/Faculty of Addiction Medicine Recommendations reviewed by Royal College of Physicians Liam Donaldson – Chief Medical Officer British Pharmaceutical Society British Medical Association Association for Palliative Medicine Medical Defence Organisations and Hempsons Solicitors Comments invited from all Pain Society Members

What issues have been raised? Are opioids effective? What type of pain? Appropriate patients? Which drugs Side effects and toxicity? Modified and transdermal vs. immediate release? Breakthrough pain? Which routes? Monitoring? Problem drug use? Drug diversion? Withdrawal? Patient contracts?

Advantages of opioids Strong opioids can provide analgesia ? improve quality of life Problem drug use uncommon Few long term randomised controlled trials Unanswered questions about opioids

Adverse effects Opioids not organ toxic Patients must be carefully monitored Side effect must be discussed and managed Concerns about problem drug and diversion must be addressed

Long term studies? Many unanswered questions about opioid use Patients with persistent pain can be challenging often with poorly defined pathology and behavioural and social problems Most studies are short-term and exclude patients with such problems The use of opioids must be carefully considered and appropriate in this context Indiscriminate prescribing must not be encouraged Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003 Nov 13;349(20):1943-53.

Efficacy and adverse effects Chou R, Clark E, Helfand M. Comparative efficacy and safety of long-acting oral opioids for chronic non-cancer pain: a systematic review. J Pain Symptom Manage 2003 Nov;26(5):1026-48. (Oregon) A total of 16 randomised trials until October 2002 Efficacy and adverse effects n=1427 patients None rated as good quality evidence Insufficient evidence that different long-acting opioids associated with different efficacy or safety Insufficient evidence whether long-acting opioids as a class are more effective or safer than short-acting opioids

Recommendations – future plans Pain Society will establish an implementation group Dissemination of information to primary and secondary care providers of pain management Liaison with PCTs and Trusts Data collection and surveillance – ongoing audit Monitoring of emerging evidence base Liaison with other European centres