1. 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

2. 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

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

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

5. 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

6. 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

7. 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

8. 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

9. 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
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 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.

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

11. 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