What Analgesics? Paracetamol – Aspirin Nefopam NSAIDS Opioids Topical – capsaicin, rubifacients, nsaids, Local anaesthetics

Add on’s Diazepam, methocarbamol. Amitriptylline TENS machine Stretching, massage, physio Osteopathy, Acupuncture Antidepressants

Pain overview - Approaches 28/03/2017 WHO's three step ladder to use of analgesic drugs www.who.int/cancer/palliative/painladder 3 2 1 National Prescribing Centre

Opioids Weak Equivalent dose of MORPHINE Codeine 30-60mg qds MAX 240mg/day 40mg / day Dihydrocodeine 50mg / day More s/e euphoria etc? Tramadol 50-100mg qds or s/r formulation 40 – 80mg / day Less predictable Buprenorphine 5mcg t/d 70mcg t/d 10mg / day 120mg / day 7 day patch

Opioids Strong Equivalent dose of MORPHINE OXYCODONE Oxycodone 20mg 40mg / day Less s/e resp depression etc. Fentanyl Patch 25mcg patch 100mcg patch 60-100mg / day 360mg / day 5 day patch Morphine

Equivalent strengths of transdermal opioids (i. e Equivalent strengths of transdermal opioids (i.e. Don’t mix up your fentanyl with your butrans!)

S/e of opiates constipation, nausea, somnolence, itching, dizziness, vomiting Tolerance to SE usually occurs within few days, Constipation & itching tend to persist Manage with antiemetics (cyclizine), aperients (movicol), antihistamines Respiratory depression only likely with major changes in dose, formulation or route. Accidental overdose is most likely cause Caution if >1 sedative drug or other disorders of respiratory control ( eg OSA)

Long-term adverse effects Endocrine impairment in both men and women Hypothalamic-pituitary pituitary-adrenal/ gonadal axis suppression leading to amenorrhoea, infertility, reduced libido, infertility, depression, erectile dysfunction. Immunological effects- in animals, effects on antimicrobial response and tumour surveillance. Opioid induced hyperalgesia - reduce dose, change preparation Pregnancy & neonatal effects

Stopping strong opioid medication Large differences between individuals in susceptibility to, and severity of, withdrawal syndrome Symptoms last up to 72hrs following reduction/withdrawal. Incremental dose reductions 10% -25% depending on patient response and bear in mind half life of preparation

Recommendations 1: Useful analgesia in the short and medium term. No data to support longer term use. Useful in neuropathic pain too. Complete relief of pain is rarely achieved. The goal should be to reduce pain sufficiently to facilitate engagement with rehabilitation and the restoration of useful function. Use as part of a wider management plan to reduce disability and improve QOL.

Recommendations 2 80% of patients taking opioids experience at least one adverse effect. Discuss before treatment! DO NOT USE in pregnancy / children and use with caution in Elderly. Resp. depression commoner if elderly/coprescription / comorbidity e.g. OSA. Withdrawl symptoms – yawning, sweating abdo cramps common with abrupt withdrawl even short courses of tramadol.

Recommendations 3 Educate re long term effects of opioids, particularly in relation to endocrine and immune function. Warn re Steroid induced Hyperalgesia. Do not use as first line Consider carefully the decision to start long term therapy and make arrangements for long-term monitoring and follow-up. Use modified release opioids for long term use

Recommendations 4 Avoid driving at the start of opioid therapy and following major dose changes. Patients responsibility to advise the DVLA that they are taking opioid medication. Addiction is characterised by impaired control over use, craving and continued use despite harm.