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Pain management for people on opiate
substitute medication
Use and abuse of prescribed drugs
Over the counter medications of abuse
Dr Susanna Lawrence
Clinical Executive Director
St Martins Healthcare Services
May 2013
Is ‘primary problem’ helpful?
Patient with substance
misuse uses prescribed
and OTC medicines to
supplement illicit use
Patient with substance misuse
develops pain
Iatrogenic:
dependence develops on
prescribed medication
leading to change in behaviour
Patient with chronic pain
develops OTC analgesic
substance misuse
Co-morbidities exacerbate pain
and substance misuse
Scenario 1
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Patient prescribed and stable on methadone,
with no illicit drug use, using prescribed
fentanyl patches for ‘longstanding’ back pain
Scenario 1
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Patient prescribed and stable on methadone,
with no illicit drug use, using prescribed
fentanyl patches for ‘longstanding’ back pain
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Genuine pain?
Why short acting analgesic?
Assessing pain
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Mechanical pain usually associated with
decreased (though variable) physical
functioning – OBSERVE AND EXAMINE!
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Neuropathic pain – history of nerve damage,
abnormal findings on sensory examination
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Visceral pain – more difficult
Identifying possible
supplementation/diversion
In addition to usual ‘doctor hopping’, patient
 Is not interested in investigation of pain
 Is not interested in non-pharmacological
interventions
 Knows exactly what preparation they want
 Is resistant to discussing alternatives
Why do substance misusers get
pain?
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Part of general populaton
Hyperalgesia associated with long term opioid use
Culture of self-medication
Low tolerance of non-pharmacological interventions
Frequent episodes of intoxication and withdrawal,
increasing intensity of pain experience
Sleep disturbance and mood disorder – well established
exacerbating factors in chronic pain
Increased incidence of injury
May use medication as currency
What to do?
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Observe, Examine, Explore beliefs
Keep symptom and analgesic use diary 2wks
Convert to long acting opioid - morphine
No evidence that any opioid produces
superior pain relief to morphine
Keep OST and analgesic opioids separate
Scenario 2
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Patient on methadone 4 years, following
dihydrocodeine dependence developed post
LSCS, now successfully reducing by
5mls/fortnight, from 60mls. Pain free on
30mls, severe pelvic pain develops once
methadone reduced to 20mls.
Scenario 2

Patient on methadone 4 years, following
dihydrocodeine dependence developed post
LSCS, now successfully reducing by
5mls/fortnight, from 60mls. Pain free on
30mls, severe pelvic pain develops once
methadone reduced to 20mls.
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Is patient becoming anxious about abstinence?
Methadone is an effective analgesic, is this
genuine breakthrough pain as opioid reduced?
How is the patient taking the methadone?
What to do?
Establish appropriate need for analgesia
 Explore non-pharmacological adjunct
 Split dose of methadone to bd
 Titrate back to dose of methadone where
client is pain free
 Convert to long acting morphine
(conversion rates vary ++, be cautious)
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Scenario 3
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Patient (59y male) just registered with GP,
recently discharged from hospital following a
fall, requesting pregabalin for ‘sciatica’, says
tramadol (prescribed in hospital) not
effective, pregabalin only effective
medication. Has repeat slip from previous GP
citing pregabalin.
Scenario 3
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Patient (59y male) just registered with GP,
recently discharged from hospital following a
fall, requesting pregabalin for ‘sciatica’, says
tramadol (prescribed in hospital) not
effective, pregabalin only effective
medication. Has repeat slip from previous GP
citing pregabalin.
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Why did he fall?
Why not prescribed pregabalin in hospital?
GABA-ergics: The Evidence Base
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2004 – first reports of abuse
Increasing EB
What to do
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Review and/or obtain evidence for neuropathic pain
Offer alternatives:
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Explore possibility of abuse/overuse
If established dependence, reduce by max:
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Amitriptyline
Duloxetine
Carbamazepine
50mg/week pregabalin
300mg/week gabapentin
Offer physical therapy
Neuropathic pain
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Medication best treatment but <30% respond
NICE supports GABA-ergics
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Anxiety: if SSRIs or SNRIs not tolerated (2011)
Neuropathic pain: TCA or PG/GBP (2010)
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If any concern about/history of substance misuse
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Tricyclic antidepressants
– Carbamazepine
– Gabapentin and pregabalin are unsuitable as first-line
drugs
NOT caused by healed fractures or DVTs.
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Suggested starting and maximum
doses for neuropathic pain
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Amitriptyline 10-75mg once daily
Nortriptyline 10-75mg once daily
Duloxetine 60-120mg once daily
Carbamazepine 200-1200mg daily in two
divided doses
Scenario 4
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Patient has been requesting repeat
prescriptions for co-codamol 30/500mg more
frequently than prescribed, increasing over
6mth period.
Scenario 4
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Patient has been requesting repeat
prescriptions for co-codamol 30/500mg more
frequently than prescribed, increasing over
6mth period.
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Has she been into the surgery to discuss
escalating symptoms/need?
Is there anyone in the family who might be using?
Is she avoiding any particular prescriber?
What to do
Once overuse/misuse established
 Prescribe codeine separately from
paracetamol (codeine phosphate)
 Offer managed reduction of codeine,
reducing by 10% every 2 weeks
 Offer alternative pain management, use
analgesic ladder etc.
Scenario 5
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Patient on buprenorphine 16mg daily for
opioid dependence presents with acute low
back pain.
Scenario 5
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Patient on buprenorphine 16mg daily for
opioid dependence presents with acute low
back pain.
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Is it likely to have pain if on such a high dose of
opioid?
What options are open to me if on
buprenorphine?
What to do?
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Treat like anyone else
Treat the pain
Opioids contraindicated (buprenorphine)
Use combination of non-opioid analgesia and
benzodiazepine if muscle spasm
Acute pain management - patients on
current or previous OST
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Analgesic needs may be higher due to cross
tolerance and/or hyperalgesia)
Don’t assume methadone/buprenorphine will
cover analgesic needs
In a former user, treating acute pain unlikely to
precipitate relapse – but neglecting to treat pain
very likely to.
Opioid analgesia can & should be used if simple
analgesia ineffective or inappropriate
Scenario 6
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Patient attends on behalf of elderly mother
saying she is ‘always’ coughing and can she
have something to help her settle at night.
There is no history recorded in her mother’s
notes.
Scenario 6
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Patient attends on behalf of elderly mother
saying she is ‘always’ coughing and can she
have something to help her settle at night.
There is no history recorded in her mothers
notes.
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Genuine request?
What is she wanting?
Who for?
OTC medicines open to abuse
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Opioids
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codeine analgesics
cough preparations
kaolin and morphine
Antihistamines
Laxatives
Caffeine – Red Bull
Summary
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Keep alert for diverters, but treat pain
effectively
Use long acting opioids for chronic pain to
minimise diversion
Keep opioid dependence and analgesic
prescribing separate
Use amitriptyline or duloxetine, not pregabalin
Beware buprenorphine – partial agonist
CAUTION prescribing addictive analgesics
Drug Service
role mainly
advisory but we
can offer
practical help
including with
the
management of
certain
behaviours
GP
And/Or
Neurology
Pain
Clinic
Drug
Service
Pharmacotherapy for persistent pain
Addiction to Medicines Consensus Statement January 2013:
 Care needed initiating drugs which may lead to dependence
 Professionals should work towards preventing addiction
 Non pharmacological options should be explored, including
giving of advice on physical rehabilitation and the offering of
psychosocial interventions
 Anxiety and depression need to be addressed
 Support must be given to those who suffer from addiction
irrespective of route into addiction
 Consensus from: DOH, Royal Colleges, Professional
Groups, Specialist Services & Voluntary Organisations.
Resources
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RCGP/Royal Pharmaceutical Society November
2012: Safer Prescribing in Prisons.
RCGP/British Pain Society. July 2012: Pain in secure
environments – final draft
The British Pain Society’s: Opioids for persistent pain
– good practice. January 2010.
BPS/RCPsych/RCGP April 2007: Pain & substance
misuse: improving the patient experience.
PHE: Commissioning treatment for dependence on
prescribed and OTC Medicines (draft - 2013)
Assessment of pain
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Causation – corroboration of physical factors
Aggravating and relieving factors
Severity – visual analogue scores
Variability – may be pain free intervals
Affect on sleep
Social situation – beware co-dependancy
Affect on function: activities of daily living –
consistency?
What has been tried?
Expectations – are they reasonable?
Functional assessment
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Look for consistency – or inconsistency
Chronic disabling limb pain usually
associated with objective signs such as
muscle wasting/lack of callous
Ability to lower and rise from sitting requires
good spinal function.
Walking can be observed
Activities of daily living – are they affected?