1. OPIOIDS IN NON MALIGNANT PAIN CONDITIONS DR JONATHAN TRING

2. THE PROBLEM  Ballantyne and Mao in NEJM 2003  Editorial in PAIN  Office for National Statistics shows steady increase in deaths from tramadol since 2003 and rise in codeine related deaths since 2003

3. ADVERSE EFFECTS OF LONGTERM OPIOIDS  Addiction  Endocrine dysfunction via an effect on the hypothalamic-pituitary-gonadal axis  Adrenal hormones, weight, blood pressure and bone density

4. ASSESSING PATIENT FOR OPIOIDS  BPS/RCA/RCGP/RCPSYCH published good prescribing guidelines  Optimise route (transdermal, oral, im/iv)  What are the goals of therapy?  Monitor response  Use minimum dose and be aware of amount of opioid you are prescribing

5. ADDICTION  Define: 4c’s ( Control, Compulsion, Consequences, Craving)  Recognition from staff, patient, doctor  Treatment and follow-up

6. SCREENING TOOLS FOR ADDICTION  CAGE ( Cut down, Annoyed, Guilty, Eye- opener)  Opioid Risk Tool  SOAPP-R (Screener and Opioid Assessment for Patients-Revised)

7. Clinical Scenarios  20 year old girl with abdominal pain. Laparoscopic evidence of adhesions. Unemployed, single mother. Tramadol 400mg per day, iv morphine 10 mg 4 hourly, cyclizine 50 mg iv ( ‘’allergic’’ to other antiemetics)

8. CLINICAL SCENARIO  40 year old heroin user has a compound tibial fracture and is scheduled for nailing.  Discuss analgesic plan

9. CLINICAL SCENARIO  80 year old patient with acute disc prolapse. Frail, uses regular cocodamol, using oromorph 10 mg prn in hospital.  Patient not mobilising well.  Discuss analgesia

10. CLINICAL SCENARIO  Methadone user requires a laparotomy for perforated duodenal ulcer. Currently using 120mg per day.  Lives in a hostel for homeless people and drinks very heavily.  Warfarinised for DVT. INR 1.6 when sent for theatre.  Discuss perioperative opioid plan