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Persistent Musculoskeletal Pain Management Guidelines
Introduction
The pharmacological management of persistent musculoskeletal pain requires a holistic
approach and regular appropriate review and this is best provided by the patient’s General
Practitioner. These guidelines have been developed by the GPwSIs and Consultant
colleagues with extensive experience of prescribing for persistent musculoskeletal pain to
support GPs providing care for these patients.
The principles below should be applied when managing persistent musculoskeletal pain:



Specific
musculoskeletal
conditions
should
be
managed
as
per
guidelines/referral protocols e.g. NICE for RA, back pain referral guide etc.
A management plan using the principles of shared decision making should be
agreed between the clinician and the patient. The discussions with the patient
need to consider the bio-psycho-social aspects of persistent pain and address
these appropriately.
Supporting the patient to maintain/increase physical activity and addressing
concerns/fears about aggravating pain are of paramount importance in the
management of persistent pain. It is critical that the clinician does not reinforce
those fears by, for example, avoiding inappropriate advice regarding prolonged
rest for back pain, avoiding the use of terms such as degenerative arthritis or
wear and tear arthritis. The Pain Toolkit booklet describes a number of helpful
approaches.
Assessment of Pain
When a patient presents with chronic musculoskeletal pain it is important to consider:1. Site, character, duration, aggravating and relieving factors.
2. It can be difficult to differentiate between referred and radicular pain:
a. Radicular/neuralgic component e.g. dermatomal, sharp, shooting
b. Referred pain e.g. non-dermatomal, aching, burning
3. What is the severity of the pain? Consider using a visual analogue scale.
4. What is the level of functional impairment?
5. Are there any other associated symptoms e.g. Joint swelling, stiffness,
fatigue, sleep disturbance?
6. Are there any red flags e.g. weight loss, fever, PMH Cancer etc?
Investigate/refer as appropriate.
7. Has a firm diagnosis of the pain been made? E.g. OA, RA, Ankylosing
Spondylitis, Seronegative Arthritis etc. should be managed appropriately.
Persistent widespread pain/fibromyalgia, regional pain syndromes and
chronic low back pain form the bulk of the remaining patients.
8. Investigations should be tailored to the underlying diagnosis. Vitamin D
screening is not worthwhile unless there are specific features of
Osteomalacia e.g. bone pain, proximal myopathy, raised alkaline
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phosphatase. Vitamin D replacement has not been shown to be beneficial in
persistent widespread pain.
9. What ideas, concerns, fears etc. are expressed?
10. Is there any associated anxiety and depression or other psychiatric or
psychological co-morbidity which requires assessment and treatment?
11. Are there any social/financial/employment
obstacles to recovery?
etc.
considerations
and
12. What treatment approaches including drug therapy have been tried and
what were the benefits or adverse effects of each?
13. Is there any ongoing alcohol or substance misuse? If so liaise with relevant
team. Are there risk factors for drug misuse?
14. Assessment and management of pain in the elderly requires special
considerations. Click on the link below for a useful resource.
http://www.rcplondon.ac.uk/sites/default/files/documents/pain_concise_
guidelines_web.pdf
Prescribing Guidelines for Persistent Musculoskeletal Pain
The Analgesic Ladder
Regular dosing of analgesia for patients with chronic musculoskeletal pain has been shown
to be superior to ‘as required’ dosing.
The purpose of the ladder is to provide a hierarchical approach to the initiation, titration
and cessation of analgesic medications. It is imperative that there is appropriate timing of
that review to balance the need to control pain with the need to minimise untoward
effects and to rationalise the patient’s repeat medication to minimise the potential for
drug interaction.
At each review an assessment of pain control, side effects, potential drug interactions etc
along with consideration of the psycho-social needs and approaches to pain management
should be undertaken. This will ensure a holistic approach to pain management as this will
help to reduce the impact of poly-pharmacy and reduce the need to use more potent
opioids. Use BNF dose conversion tables when switching opioids.
Consider using an atypical/neuropathic agent before using a strong opioid and do not
prescribe more than one opioid at a time. The use of a strong opioid without a full biopsycho-social assessment and an agreed self-management plan should be avoided. An
opioid should only be continued if there is clear evidence of a functional improvement
and/ or improvement in quality of life.
Use of a screening tool to assess for the risk of developing opioid dependence should be
considered before prescribing opioids eg the Opioid Risk Tool (BMJ 2013;346:f2937)
Please click on the link below for a useful resource from the British Pain Society.
http://www.britishpainsociety.org/book_opioid_main.pdf
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DRUG
1) Paracetamol
2) NSAIDs
DOSE
CONSIDERATIONS
1g four times a day
Safest analgesic.
Should be the first used and
maintained/added to.
Naproxen 250-500mg
twice a day
Ibuprofen 400mg
three times a day
3) Codeine
15-60mg four times a
day
4) Tramadol
M/R 100-200mg twice
a day
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First choice NSAIDs.
No evidence that alternative
NSAIDs including COX2s are more
effective/safer.
Co-prescribe GI protection in
>50s, PH dyspepsia etc.
Caution in hypertension, asthma,
heart failure and renal
impairment. Increased risk of GI
bleeding in combination with
SSRIs
Care needed/contraindicated in
patients taking diuretics, ACEI,
A2 blockers, and Lithium.
Special care needed in the
elderly.
The active metabolite is
Morphine and conversion is
variable.
Side effects: Drowsiness, nausea
and constipation. Low
Addiction/habituation potential.
Caution with higher doses in the
elderly.
Short acting opioids may not be
effective in chronic pain and
cause more adverse effects so
assess benefit carefully.
The active metabolite is O –
desmethyltramadol and
conversion is variable
Significant proportion of the
population are intolerant.
Side effects: Nausea, vomiting,
drowsiness, dizziness,
constipation and sweating.
Seizures and risk is increased
with other drugs that lower
seizure threshold. Serotonin
toxicity with SSRIs.
Caution with higher doses in the
elderly.
Modified release preparations
more appropriate for chronic
pain
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5) Oxycodone
M/R 10-40mg twice a
day
6) Fentanyl
12-100mcg/hour for
72 hours patch
7) Buprenorphine
5-20mcg/hour for 7
days patch
35-70mcg/hour for 96
hours patch
8) Morphine
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Potent opioid.
Use with caution in opiate naïve
patients.
Avoid short acting formulation
Side effects: Nausea, vomiting,
sedation, confusion in the elderly
and constipation.
Use very cautiously in the
elderly.
Evaluate benefits/side effects
carefully and regularly.
Preferable that initiation and
titration is undertaken under
Consultant supervision
Potent opioid.
Higher doses usually not
appropriate.
Use with caution in opiate naïve
patients.
Side effects: Nausea, vomiting,
sedation, confusion in the elderly
and constipation.
Use very cautiously in the
elderly.
Evaluate benefits/side effects
carefully and regularly.
Preferable that initiation and
titration is undertaken under
Consultant supervision
Potent opioid.
Use with caution in opiate naïve
patients. Opioid agonist and
antagonist properties may trigger
withdrawal in those with opioid
dependence
Side effects: Nausea, vomiting,
sedation, confusion in the elderly
and constipation.
Use very cautiously in the
elderly.
Evaluate benefits/side effects
carefully and regularly.
Preferable that initiation and
titration is undertaken under
Consultant supervision
Potent opioid.
Not usually appropriate for the
management of chronic pain and
should be initiated and titrated
only under Consultant
supervision
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Atypical/Neuropathic Analgesia
Regular review of the effectiveness and the development of side effects to guide dose
adjustment or treatment cessation is imperative.
It is usual to consider a trial of a tri-cyclic antidepressant (TCA) first, if appropriate, in the
hierarchy below. If the first choice of TCA is not tolerated then considering a switch to an
alternative TCA is appropriate.
A TCA should not be prescribed if there is a significant risk of overdose. Use with caution in
cardiac disease or in combination with other medications that increase QTc interval. Be
aware of the potential risk of serotonin syndrome when combining a TCA or duloxetine
with other antidepressant medication, or tramadol with an antidepressant, and discuss
with the patient. Do not stop an existing antidepressant without liaison with prescriber.
DRUG
DOSE
10-70mg in the
evening 2 hours
before bed
1) Amitriptyline
Can be titrated by
10mg increments
each week.
10-100 mg in the
evening 2 hours
before bed
2) Nortripyline
Can be titrated by
10mg increments
each week
20-150mg a day
3) Imipramine
Can be titrated by
20-25 mg increments
each week.
60- 120mg a day
4) Duloxetine
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Can be titrated by
30mg increments
each month
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CONSIDERATIONS
Tricyclic antidepressant.
Dose titrated by 10mg
increments weekly until pain
controlled or side effects limit
further dose increase.
Effective for improving sleep.
Common side effects;
drowsiness, blurred vision, dry
mouth and constipation.
Increases risk of falls in elderly
Tricyclic antidepressant
Dose titrated by 10mg
increments weekly until pain
controlled or side effects limit
further dose increase.
Common side effects; may be
less sedating than amitriptyline,
blurred vision, dry mouth and
constipation. Increases risk of
falls in elderly
Tricyclic antidepressant.
Usually given in a divided dose.
Alternative to Amitriptyline for
neuropathic pain.
Common side effects;
drowsiness, blurred vision, dry
mouth and constipation.
Increases risk of falls in elderly
Inhibitor of serotonin and
noradrenaline re-uptake.
Licensed for diabetic neuropathic
pain, anxiety, depression and
stress incontinence.
Common side effects; nausea,
vomiting, constipation, dry
mouth, nervousness, weight
changes. Caution in uncontrolled
hypertension
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100mg-1200mg three
times a day
5) Gabapentin
Total daily dose can
be titrated by 100300mg increments
every 3 days
75mg-300mg twice a
day
6) Pregabalin
Total daily dose can
be titrated by
between 25mg to
150mg each week
Slow and rapid titration regimes
available.
Effective for neuropathic pain.
Lower doses in renal impairment
Common side effects; nausea,
vomiting, weight gain, oedema,
dizziness, ataxia, confusion.
Do not stop abruptly.
Slow and rapid titration regimes
available
Licensed for for neuropathic pain
and generalised anxiety disorder
Lower doses in renal impairment
Common side effects; dry mouth,
constipation, oedema, weight
gain, confusion, irritability.
Do not stop abruptly.
Please refer to the BNF/ SPC for further information, including cautions,
contraindications and interactions
Links to useful resources:http://www.paintoolkit.org/
http://www.paintoolkit.org/assets/downloads/Pain-Toolkit-Booklet-Nov-2012.pdf
http://www.britishpainsociety.org/
http://www.britishpainsociety.org/pub_pain_scales.htm
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Review: 16/08/2014