Download - Society for the Study of Addiction

PALLIATIVE CARE
March 2016
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Take an adequate pain history exploring addiction issues to
offer appropriate interventions
Ensure that patients on opioid substitution receive adequate
analgesia
Recognition of addictive behaviours
Counselling patients who are reluctant to take medication
which they regard as addiction inducing
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Pain affects eight million people in the UK
Patients with drug or alcohol problems may have pain due to:
Trauma – head injury, falls, accident
Infection – pneumonia, cellulitis, abscess, septicaemia, injecting,
HIV, hepatitis Band C
Neuropathy – vascular, traumatic, viral, carcinoma, nutritional
Cancer – lung, head and neck, oropharynx, oesophagus, liver,
colorectum, breast
Musculoskeletal disorder – fractures, osteoporosis, myopathy
Cardiovascular disease – chest pain, cardiomyopathy, stroke
Gastrointestinal – hepatitis, pancreatitis, cirrhosis, peptic ulces
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Effective pain management is part of good medical practice
Palliative care is specialised medical care for people with serious
illnesses
The goal is to improve quality of life for patients and their families
Patients may suffer pain from a variety of chronic illnesses directly
or indirectly associated with addiction
This group are more likely to need palliative care
Patients who are addicts are just as prone as non-addicts to
acquire painful conditions
Patients with chronic pain only occasionally become addicted to
analgesia
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Drug dependent patients have a greater need for pain relief
due to increased tolerance and a lower threshold for pain
Drug dependent patients are likely to require higher doses of
analgesia than non-dependent patients
Drug users or dependent patients may seek over the counter
medications, other people’s medications, street drugs
Drug dependent patients may also use heroin to manage pain
Communication between oncology, addiction, palliative care,
occupational therapists is necessary
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Drug dependent patients feel stigmatised and uncomfortable
in the formal world of hospitals, appointments
Patients drop out of contact and do not attend appointments
because they feel they have been badly treated
Patients may feel guilt and shame, are reluctant to discuss
problems, fear withdrawal, pain recurrence, that medications
will not be prescribed, so may top up prescriptions
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Patients may lack the skills to follow complex dosing regimes
Patients who have a iatrogenic addiction may refuse to attend
addiction services
It is helpful for health professionals to be relaxed and form a
therapeutic relationship
Health professionals must refrain from prejudice
Health professionals may feel ill equipped to manage this
group
Lack of understanding of the pharmacology may lead to the
pain being poorly managed
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Undertake a full assessment with a complete pain history:
Location of pain, radiations, severity, timing, duration, quality,
aggravating and relieving factors
Associated sensory disturbances or power loss, type of pain,
Impact of psychological factors eg anxiety, depression
Full analgesic history including nature, dose, administration
Diagnostic investigations
Include physiotherapy, occupational therapy assessment
Frequent review of effectiveness and adverse effects of
medication
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Regular supervision and monitoring of medications
Patients may be receiving methadone or buprenorphine so any
opiate analgesia should be a different molecule
If patients cannot swallow all opiate needs will be with a syringe
driver
If a patient is on methadone, this should be continued but
additional medication needs to be prescribed for analgesia
If patients are on buprenorphine, it will have to be stopped if
patients are on illicit opioids or need to be prescribed opiates for
pain relief
Distinguish between withdrawal and poor analgesic response
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Consult with addiction specialists
Where possible, patients in the community may be treated
with slow release medications
Patients should be supported to have safe storage of all
medications
Patients with physical and psychological needs should be
supported by community palliative care teams
Patients need advice about driving
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Have a single point of prescribing
Coordinated approach
Regular monitoring is mandatory to avoid excess opiates and
respiratory depression leading to death
Prescribe medication weekly
Avoid likelihood of patients stockpiling drugs at home as
patient may risk being the target by other drug users
Be willing to prescribe addition medication if disease
progresses, pain worsens or tolerance develops
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Instability in the regime does not necessarily indicate deterioration
Family members or friends may bring the patient drugs or may buy
or steal prescribed drugs
Ensure out of hours service is aware of substance misuse issues
When making significant changes in the treatment, it may be
advisable to admit the patient under specialist care
Removal of drugs after the patient’s death should follow local
policies
If there is concern about the presence of illicit drugs in the
patient’s home, it may necessary to inform the police, with every
effort being made to maintain engagement with the patient
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Palliative care services should have access to advice and
training from the substance misuse team
Pain specialists require basic competence in the diagnosis of
drug dependence
Addiction services staff need knowledge of pain management
All services involved in the care of a patient need to work
together to meet the patient’s needs in a coordinated manner
Hospital protocols for the management of withdrawal,
initiation and maintenance of treatments
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Care can take place in the general hospital, out-patient
clinics, primary care, palliative care services
The patient and families need to be supported by:
Specialist pain services
Specialist addiction services
Specialist palliative care
Primary care
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Action on Addiction (2013)The management of pain in people with a past or current history of addiction.
British Pain Society (2007). Pain and Substance misuse; improving patient experience
https://www.britishpainsociety.org/static/uploads/resources/misuse_0307_v13_FINAL.pdf
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British Pain Society (2007). Pain and problem drug use -information for patients
http://www.britishpainsociety.org/pub_patient.htm#misuse_patient
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Royal College of Anaesthetists Opioids Aware http://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware
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Cooper D & Cooper J (2014) Palliative care and substance use: special considerations in Palliative Care within Mental Health - care
and practice. Radcliffe Health
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CMO Annual Report (2008) Pain: breaking through the barrier
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Ling GS, Paul D, Simantov R, et al. (1989) Differential development of acute tolerance to analgesia, respiratory depression,
gastrointestinal transit and hormone release in a morphine infusion model. Life Sci 45(18):1627-36,
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Neerkin, J; Cheung, Chi-Chi and Stirling C (2011) Guidelines for Cancer Pain Management in Substance Misusers.
http://www.palliativedrugs.com/download/100615_Substance_misuse_pain_guidlines_final.pdf
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NICE (2007) Methadone and Buprenorphine for the management of opioid dependence. NICE technology and appraisal guidance 114.
http://publications.nice.org.uk/methadone-and-buprenorphine-for-the-management-of-opioid-dependence-ta114
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NICE (2012) Opioids in palliative care: Clinical case scenarios for primary and secondary care. Support for education and learning. NICE clinical guideline
140. http://guidance.nice.org.uk/CG140/ClinicalScenarios
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Pease N, Taylor H, Major H (2004) Driving Advice for palliative care patients taking strong opioid medication Palliat Med. 2004 Oct;18(7):663-5
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Przekop,P (2015) Chronic Noncancer Pain: Is It Time for A New Treatment
http://www.painmedicinenews.com/ViewArticle.aspx?d=Commentary&d_id=485&i=March+2015&i_id=1153&a_id=29605&ses=ogst
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Scottish Intercollegiate Guidelines Network (2008). Control of pain in adults with cancer – a national clinical guideline.
http://sign.ac.uk/guidelines/fulltext/106/index.html
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Watson M.S. (2009) Oxford Handbook of Palliative Care.2nd ed. Oxford, Oxford University Press