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Opioids for persistent non-cancer pain
British Pain Society Recommendations
Karen H Simpson
Consultant in Pain
Management
Leeds
Need for recommendations for use of
opioids in persistent non-cancer pain
Persistent pain is being increasingly recognised as
a medical and social problem
Large surveys from Europe suggest
10% population have persistent severe pain
4600 patients in Scotland in primary care
16% moderately/severely disabled by persistent pain
2000 patients in primary care
79% still had pain after 4 years
Pain – a widespread problem
– One in five people in UK
suffer from chronic pain
– Total of 7.5 million people
– One-third of UK households
affected by chronic pain
Patients Living in Pain
Duration of Pain (n=300)
Chronic pain present average 6 y
A fifth had pain for more than 20 y
%
30
26
25
21
20
20
17
15
9
10
5
4
3
0
6 Months
to <1 Year
1 to <2
Years
2 to <5
Years
5 to <10
Years
10 to <15
Years
15 to <20
Years
20 Years
or More
Causes of chronic pain
Most frequently arthritis
Most commonly low back pain
40
Arthritis/osteoarthritis
18
Traumatic injury
15
Herniated/deteriorating discs
8
Rheumatoid arthritis
6
Nerve damage
5
Surgery
4
Fracture/deterioration of spine
Migraine headaches
3
Break/fracture that never healed correctly
3
0
5
10
15
20
25
30
35
40
45
Need for recommendations for use of
opioids in persistent non-cancer pain
Persistent pain affects lots of people
UK 2-6 million people with persistent
severe non-cancer pain
England and Wales 1.3-1.75 million osteoarthritis
0.25-0.5 million rheumatoid arthritis
The problem is large and likely to grow as the population ages
Need for recommendations for use of
opioids in persistent non-cancer pain
Persistent pain is expensive
900,000 hospital bed days
12 million GP consultations
119 million days certified incapacity
UK direct health care cost back pain £1632 million
Informal care/lost production cost £10668 million
The public and government are interested
Need for recommendations for use of
opioids in persistent non-cancer pain
There are an increasing number of strong opioids with
marketing authorisation for persistent non-cancer pain
There is increased use of strong opioids for this indication in
primary and secondary care
There is strong pressure from industry to use these drugs
more freely
There is little training for health care professionals about
opioid use for this indication
Need for recommendations for use of
opioids in persistent non-cancer pain
Patients and carers are becoming more aware of the use of
strong opioids for non-cancer pain
In some European countries and USA there is intense
pressure on doctors to provide opioids for non-cancer pain
This is balanced by concerns about
medical use of opioids
Doctors accused on heroin advice
Steven Morris
Tuesday February 24, 2004
The Guardian
Development of recommendations
2 years ago Pain Society consensus group developed
Provisional recommendations for the appropriate use of
opioids in patients with chronic non-cancer related pain
There was an accompanying patient information leaflet
This was developed after literature review and consensus
opinion from experts from a number of disciplines and
patient’s representatives
During the 12 month consultation period over 300 responses
from individuals and professional organisations have been
received and considered
Consensus group
Joint chair and co-editors
Dr Alf Collins
Dr Karen Simpson
Members
Dr Douglas Justins
Prof Bruce Kidd
Dr Richard Potter
Dr Marian de Ruiter
Dr Cathy Stannard
Mr Phil Wiffen
Dr Amanda Williams
UK Pain Society
UK Pain Society
Royal College of Anaesthetists
Royal College of Physicians
Royal College of General Practitioners
Royal College of Psychiatrists
Pain Society
Royal Pharmaceutical Society
UK Pain Society
Advice given by the following individuals:
Mrs Jean Gaffin
UK Pain Society Patient Group Chair
Dr Mike Bennett
Association for Palliative Medicine
Prof Antony Franks
NHS Trust Risk Management Chair
Recommendations endorsed by
Association of Anaesthetists
Royal College of Anaesthetists
Royal College of General Practitioners
Royal College of Psychiatrists/Faculty of Addiction Medicine
Recommendations reviewed by
Royal College of Physicians
Liam Donaldson – Chief Medical Officer
British Pharmaceutical Society
British Medical Association
Association for Palliative Medicine
Medical Defence Organisations and Hempsons Solicitors
British Medical Association
Comments invited from all Pain Society Members
What issues have been raised?
Are opioids effective?
What type of pain?
Appropriate patients?
Which drugs
Side effects and toxicity?
Modified and transdermal vs. immediate release?
Breakthrough pain?
Which routes?
Monitoring?
Problem drug use?
Drug diversion?
Withdrawal?
Patient contracts?
Advantages of opioids
Strong opioids can provide analgesia
? improve quality of life
Problem drug use uncommon
Few long term randomised controlled trials
Unanswered questions about opioids
Adverse effects
Opioids not organ toxic
Patients must be carefully monitored
Side effect must be discussed and managed
Concerns about problem drug and diversion must
be addressed
Long term studies?
Many unanswered questions about opioid use
Patients with persistent pain can be challenging often with
poorly defined pathology and behavioural and social problems
Most studies are short-term and exclude patients with such
problems
The use of opioids must be carefully considered and
appropriate in this context
Indiscriminate prescribing must not be encouraged
Ballantyne JC, Mao J. Opioid therapy for chronic pain.
N Engl J Med. 2003 Nov 13;349(20):1943-53.
Efficacy and adverse effects
Chou R, Clark E, Helfand M. Comparative efficacy and safety of longacting oral opioids for chronic non-cancer pain: a systematic review.
J Pain Symptom Manage 2003 Nov;26(5):1026-48. (Oregon)
A total of 16 randomised trials until October 2002
Efficacy and adverse effects n=1427 patients
None rated as good quality evidence
Insufficient evidence that different long-acting opioids
associated with different efficacy or safety
Insufficient evidence whether long-acting opioids as a class
are more effective or safer than short-acting opioids
Recommendations – future plans
Pain Society will establish an implementation group
Dissemination of information to primary and secondary
care providers of pain management
Liaison with PCTs and Trusts
Data collection and surveillance – ongoing audit
Monitoring of emerging evidence base
Liaison with other European centres