Download Dr Jane Quinlan - APPG for Prescribed Drug Dependence

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
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
Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. BMJ Open June 20 2016
• There is little acknowledgement of patients with pain and
Impact of opioid prescribing
Rates of opioid pain reliever overdose death, treatment admissions and kilograms sold - United States,
1999-2010. Morbidity and mortality weekly report (MMWR). Centers for disease control and prevention.
Use of opioids in UK
Zin CS, Chen L-C, Knaggs RD. Eur J Pain 18 (2014) 1343–1351
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
World Health Organization. Traitement de la douleur cancéreuse. Geneva,
Switz: World Health Organization; 1987.
McQuay H. Lancet 1999; 353: 2229–32
Acute and cancer pain
Appropriate pain reflecting
ongoing tissue damage
Tissue
damage
after
trauma,
surgery,
cancer
Brain
Opioids are an effective and
important part of acute and cancer
pain management
Neuropathic (chronic) pain
Nerve
damage
with no
tissue
damage
Inappropriate pain signalling with
no tissue damage
Brain
No evidence that opioids are
safe or effective in the long
term management of chronic
pain
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
Eriksen et al. Critical issues on opioids in chronic non-cancer pain: An epidemiological study. Pain
•poor health orientated quality of life
2006;125:172-9
Spectrum of prescribed opioid use
Chronic pain
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
Addiction
pain
dependence
Pain services
No current service
Addiction services
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
•
•
•
https://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United
• States,
USA:
caution
over
50mg
MED
and a 90mg MED limit
2016. 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.
Global opioid availability
Current inequity of under-availability and overconsumption
Source: International narcotics control board
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