Download CannaTech 2017 - Green C Medical

UNderstanding Pain in Aged Care :
Exploring the nature and treatment of chronic
pain in the Australian aged care setting:
Leah Bisiani RN1, M HlthSc
Dementia Consultant
Managing Director, CEO - GreenC Medical
Innovative Cannabis Research
Chris Alderman
Clinical Director, Ward Medication Management
Natalia Soulsby
National Operations Manager, Ward Medication Management
Trevor Ward
Chief IT Officer and Data Analyst, Ward medication Management
Stuart Ward
Chief Executive Officer, Ward Medication Management
UNderstanding pain in the aged care sector:
Background:
Potent opioid analgesics are widely prescribed within the
aged care sector, yet these agents are associated with the
highest degree of drug-related harm.
Abstract:

Aim: This major research initiative examined current practices of pain management in the Australian
aged care sector, exploring scope for the potential positive and significant impact based on the
utilization of medicinal cannabinoids as an alternative to current pain management regimes. This
research, initiated by the partnership of GreenC Medical and Ward Medication Management is the first
large-scale, comprehensive examination of pain management investigating in detail the characteristics of
medication use amongst a large cohort of older Australians living in residential aged care.

Method: The study categorized the detailed features of unmanaged pain management in aged care, with
extensive examination of medication usage characteristics in context, identifying the extent to which
dose escalation occurs, and the extent to which this engenders potential prescribing cascades in response
to treatment-emergent adverse effects. All medications (prescription, non-prescription, and
complimentary/ alternative medicines) that are included in the active order documented on the
medication chart, were recorded, and the dosage, route and frequency of administration documented. In
addition, the profile records detailed all medical morbidities, demographic information such as age,
gender and facility location, and the subsequent results of other relevant investigations.

Results: Data from a total of 22,319 reviews was used for analysis. Prescribing of potent opiate analgesics
was relatively common, with extensive use of transdermal buprenorphine (9.6%), transdermal fentanyl
(3.4%), morphine (4.8%) and various products containing oxycodone (24.0%). Analgesic co-prescription
was also commonplace. In many cases a resident was prescribed two or more analgesic agents
concurrently. The prescribing of non-opioid adjuvant agents was also prevalent amongst the cohort. The
prescribing of medications commonly used in the management of adverse effects associated with opioids
was often observed. This study thus illustrates the need for an alternative approach, and discusses the
potential benefits of medicinal cannabis in treating poorly managed chronic pain. The study may
additionally identify dose escalation patterns and associated prescribing cascades occurring in response
to treatment-emergent adverse effects.

Conclusion: This research provides evidence of widespread use of analgesia and adjuvant medicines for
the management of chronic pain amongst older people living in aged care facilities. The findings
illustrate the scope for the use of medicinal cannabis as a beneficial alternative approach to enhancing
quality of life and maximizing comfort.
A critical and rapidly escalating
problem:

Pain has been recognised as a predominant and prevalent human encounter,
that no person is excluded from

It is considered one of the most poorly managed conditions due to ineffective
medication regimes

It should be recognised that access to effective pain relief is a basic human
right

If this integral right is disrespected then this could be considered
fundamentally neglectful towards those living with chronic, relentless pain

Thus an alternative must be sourced.
Chronic Pain in the Aged Care Setting:
The nature of the problem:

Australia has a current population of approximately 25
million people, with over 300,000 currently in RACFs

The nature of aged care has changed in recent years

Ageing in place - more people living at home for longer

Acuity in RACF has increased – people are sicker and have more
multimorbidity, disability and polypharmacy

Medication usage is extensive, creating substantial potential for
drug-related harm

Despite this, many have sub-optimal control of symptoms
Chronic Pain in Aged Care:
Pain in RACFs arises from various sources:

Acute pain – post-procedural, minor intermittent pain

Pain in the context of life-limiting illness – carcinoma, CRF, end-stage
illnesses - palliative care

Chronic somatic and visceral pain – e.g. OA, # with OP

Neuropathic pain - post-herpetic neuralgia, diabetic neuropathy,
phantom limb pain, trigeminal neuralgia
Chronic Pain – current options available:
Many traditional approaches used currently:

Non-pharmacological approaches

Simple analgesia – paracetamol/ibuprofen

Intermediate potency analgesics – codeine phosphate
tramadol

Potent opioids – morphine/oxycodone

Adjuvant agents – amitriptyline, duloxetine, pregabalin, carbamazepine
BOTTOM LINE – NO SOLUTION IS UNIVERSALLY EFFECTIVE
ALL HAVE LIMITATIONS AND PROBLEMS
MANY CREATE AS MANY PROBLEMS AS THEY FIX
Chronic Pain in Australian Aged Care:

Chronic pain is a massive burden:

Contributes to overall suffering/debilitating

Comes from different background etiologies

Especially difficult in context of dementia - BPSD

Opioids, NSAIDs are associated with substantial hardship and harm

Widespread use in aged care – we could do better………….
Chronic Pain in Australian Aged Care:

WHO stipulates a Defined Daily Dose (DDD) for all pharmaceutical
drugs, specified as the assumed average maintenance dose per day,
for a drug used for its main indication in adults

75 mg daily for oxycodone

100 mg daily for morphine

300 mg daily for tramadol

For 2014 & 2015, each drug prescribed below the DDD in > 99% of
cases, year to date (to May 2016) showed oxycodone doses above the
DDD have increased to 9.1%

Year on year prescribing rates for morphine and tramadol have
remained stable, prescribing of oxycodone increased rapidly (738
cases in 2014, 1512 in 2015 and 1106 cases for the first five months of
2016).
WHO Analgesic Ladder:
Downsides of Opioids in Aged Care:

Nausea, vomiting, constipation, potential for impaction

Sedation, respiratory depression

Tachyphylaxis, tolerance

Drug interactions

Administrative burden

Security risks
Chronic Pain in Australian Aged Care:
During the course of clinical pharmacy services for RACF’s by Wardmm:
Medication reviews include:

Basic data profile of 22,319 reviews

All prescribed/non prescribed/alternative medications

Dosage/route/frequency of administration

Medical morbidities

Demographic information – age, gender, location

Other relevant investigation results
*Stored in a sophisticated database that automatically indexes and analyses
information using industry standard descriptors and labels*.
Chronic Pain in Australian Aged Care:
Snapshot of the current state:

Most common frequent prescribed individual agent:

Paracetamol in over 19000 cases

29.5% of residents who received an RMMR, were treated with at least one of
three agents:

Oxycodone alone accounted for 24.1%

Transdermal buprenorphine for 9.6%

Morphine for 4.8%

Transdermal fentanyl for 3.4%
Non opioid adjuvant agents/adverse effects:

Most common co-prescription in combination with opioids occurred in high
proportion with adjuvant agents were:

Amitriptyline – 70.1%

Carbamazepine – 52.3%

Duloxetine – 77.4%

Pregabalin – 90.5%

Most common prescriptions for the management of adverse effects of opioids:

Metoclopromide – 24.7%(co-prescribed with morphine/oxy 2,584 cases)

Bisacodyl – 7.5%

Sennasides – 50.4% (11,252 cases)

Lactulose – 19.8% (4,412 cases)
Chronic Pain – new options to explore:

Widespread use of analgesics and adjuvant medicines for the
management of chronic pain amongst older people living in aged care
facilities is rampant.
The need for an effective alternative clearly exists.
If what we are doing now is not effective, and can actually cause harm,
why not do something differently?

Non-pharmacological approaches can be used better and more often

Consider referral for expert review for pain control

Analyse medications in context
Another solution is available – medicinal cannabis and
therapeutic cannabinoid products

Very optimistic/positive approach
Cannabinoid products for pain in RACF:
In Australia, barriers do exist but are systematically being overcome:

Regulatory issues

Conservative medical approaches

Perceptions of public

Dose standardization

Active ingredient standardization

Dose delivery

Individualisation of treatment approach
The findings positively illustrate the scope for the use
of medicinal cannabis as a beneficial alternative
approach to enhancing life and maximizing comfort.
Conclusion:
“Be the change you
want to see in the
world”
“Ghandi”