1. Persistent pain management An update
Dr Deepak Ravindran
Consultant Pain Medicine, RBH

2. OPIOIDS

3. Aims Opiate update Newer opiates tapentadol Opiate conversion ratios
Driving laws and advice from HCPs

4. Opioids update
BPS guidance on prescribing opioids oid_main.pdf
Opioid induced hyperalgesia
Opioid induced hypogonadism
No fentanyl for opioid naïve
Refer to specialist when needing more than 180mg/Day morphine equivalent

5. Opioid induced hypogonadism
Occurs in both sexes. More than 100mg/day equivalent
Features consistent with depressed pituitary function. Low testosterone, low FSH/LH, Low GH and thyroid function
Buprenorphine safest due to mixed action. All others can cause problems
If suspected, consider opioid switch to Buprenorphine, test for FSH/LH/Testosterone and refer to endocrine for advice and replacement

6. Conversion ratios Please follow BNF
New document from CCG being reviewed
Remember Fentanyl 12mcg patch is 45mg Morphine equivalent and 25mcg patch is 90mg morphine
Problems with addiction medicine and methadone dosing

7. Driving laws and changes
Guidance for healthcare professionals on drug driving – July 2014
Came into force March 2015
Roadside drug screening devices developed to detect drugs from saliva
All benzodiazepines/methadone/morphine and amphetamines
Establishes a statutory medical defence
Must keep a copy of their prescription in the vehicle, duty to inform DVLA and insurer

8. Driving laws
Patient needs to decide what evidence they will share with police
Does not prevent being charged if police have evidence of impairment
Ulitmately driver responsibility but HCP expected to warn patient
Not to drive if experiencing side effects
Not to drive when increasing doses
If another medicine is being added or an OTC is added which can impair
Developing another medical problem
Co-existing alcohol use/abuse

9. Tapentadol New analgesic. Similar to tramadol.
Better side effect profile compared to tramadol and most opioids
Has some Mu-opioid action but more noradrenergic action
Possibly useful as an opioid switch when all other drugs have failed
Presently low priority in Berkshire West
Possible role in future for patients on high opiates or neuropathics with side effects, no relief or poor QOL

10. ANTINEUROPATHICS

11. Topics Combinations of amitryptiline and tramadol
Gabapentin and Lyrica (pregabalin)
Conversion and switch between both
BPS guidance on patient information for drugs: Website has leaflets on Gabapentin, Pregabalin, Nortyptiline, Amitriptyline and Duloxetine

12. Antineuropathics
Risk of serotonergic syndrome with high doses of amitriptyline and tramadol
Low doses are ok and tolerated
Maximum high dose of amitryptiline and nortryptiline for chronic pain is 75mg/day
Imipramine and desipramine rarely used

13. Gabapentin and Lyrica Pfizer and Lyrica for pain
Patient on 900mg TDS gabapentin. No benefit. You want to switch to Pregabalin.
Do you
Taper down and then switch
Direct switch to high dose Pregabalin
start Pregabalin and then taper gabapentin while increasing Pregabalin

14. Gabapentin and Lyrica
Gabapentin has non linear pharmacokinetics. Dose increase is gradual and plasma levels are unpredictable.
Transfer from stomach is saturated quickly
Effects of increasing the dose are a hit and miss in terms of efficacy and blood levels
Lyrica is linear pharmacokinetics. Non saturable. Double the dose and double the concentration.

15. Lyrica Roughly 900mg Gabapentin is equal to 100mg Lyrica
No evidence regarding the safest method for switching
SO, upto 300mg TDS of Gabapentin, switch to 50mg BD of Lyrica
Any higher doses of Gabapentin, taper it first before switching
If any concern then taper further and switch to 25mg BD of Lyrica

16. Fibromyalgia More objective and better criteria for diagnosis
Symptom severity scale and Widespread Pain Index
No more 18 tender points
Evidence of fMRI changes, biochemical changes
Central nervous system dysfunction
Newer treatments – lignocaine and LDN

17. Fibromyalgia – local developments
GP and Patient information booklets
IPASS has dedicated FMS pain management programmes
Patient support group active – branches in Wokingham, Thatcham and Reading
Mayors charity, House of Commons debate

18. Further resources
RBH pain management website for medication information and patient information leaflets
IPASS website being developed
British Pain Society website
Or via CAB advice and guidance

19. Any questions?