guideline - Ipswich and East Suffolk CCG

Pain Guidelines Ipswich & East Suffolk CCG 16 January 2014

Mike Bailey Ipswich Hospital Pain Clinic

Contents • What is a guideline? • Why different pains need different management • What the BNF doesn’t tell you

What is a guideline?

“Guideline" is the NATO reporting name for the Soviet SA-2 surface-to-air missile Courtesy : ‘Wikipedia’

What is a guideline? • A guideline is a statement by which to determine a course of action. A guideline aims to streamline particular processes according to a set routine or sound practice. By definition, following a guideline is never mandatory. Guidelines are not binding and are not enforced. U.S. Dept. of Veterans Affairs

Why use a guideline? • Guidelines are based on evidence of best practice • Guidelines should ensure consistent practice (if followed!) • Guidelines are designed to achieve value-formoney

What is a guideline (not)? • A guideline is not a substitute for common sense • A guideline is not a shortcut • A guideline is never foolproof

Different Pains Need Different Management Palliative Care • Shorter life expectancy

Chronic Non-Cancer Pain • Life expectancy ‘normal’

• Goal: pain control

• Goal: live with pain

• Sedation not always a disadvantage

• Sedation usually a disadvantage

• Gradual loss of ADL seen as norm for many

• Loss of ADL a big problem

Different Pains Need Different Management Nociceptive Pain • Somatic – Trauma – Arthritis / degenerative – Infection

Neuropathic Pain • Nerve dysfunction – Chronic Injury – Neuropathy – Secondary changes

Many chronic pains are due to a ‘mixed’ pain problem

E. Suffolk Primary Care Spend Analgesics Apr-Aug 12 Total Items Amitriptyline

Apr-Aug 13

Total spend

Total Items

Total spend

40212

£67,562.98

43096

£75,025.31

Butrans

3393

£95,925.19

3698

£108,119.15

Transtec

443

£18,903.51

418

£18,842.96

Fentanyl patch

2952

£130,450.25

2916

£121,259.61

Gabapentin

9442

£76,145.08

12040

£63,617.31

Morphine MR

6766

£78,017.44

7275

£82,176.24

Oxycodone MR

1838

£109,420.81

1909

£111,730.44

Pregabalin

8024

£530,239.94

10217

£685,458.53

Targinact

396

£27,104.51

437

£28,585.53

73466

£1,133,769.71

82006

£1,294,815.08

Total

E. Suffolk Primary Care Spend Analgesics

E. Suffolk Primary Care Spend Anti-neuropathic Analgesics Apr – Aug 2012

Apr – Aug 2013

Total items

Total spend

Total Items

Total spend

Gabapentin

9442

£76,145

12040

£63,617

Pregabalin

8024

£530,239

10217

£685,458

Amitriptyline

40212

£67,562

43096

£75,025

Drug

Strength tab/cap

Cost per tab/cap Cost per 28 days

Amitriptyline

10mg

£0.03

£0.89

Once daily (bedtime)

25mg

£0.03

£0.90

50mg

£0.04

£0.98

Gabapentin

300mg

£0.04

£3.77

Three times a day

600mg

£0.10

£8.71

800mg

£0.36

£29.84

Pregabalin

75mg

£1.15

£64.40

Twice daily

150mg

£1.15

£64.40

300mg

£1.15

£64.40

Tricyclic antidepressants • Amitriptyline 1st line – Nortriptyline

• NNT 2.9 (PHN & DN) • NNH 2.7 (minor) • NNH 17 (major)

Bandolier Little Book of Pain Moore A et al 2003

Gabapentin • Moderate benefit (equivalent to at least 30% pain relief) in almost one in two patients (43%) • Substantial benefit (equivalent to at least 50% pain relief) in almost one in three (31%). • Adverse events are experienced by about two-thirds of people • 1 in 10 (11%) have to stop the treatment because of .. unpleasant side effects Moore RA et al Cochrane Review 2011

Pregabalin • Best NNT at least 50% pain relief on 600mg/day – 3.9 postherpetic neuralgia, – 5.0 for painful diabetic neuropathy – 5.6 central neuropathic pain – 11 fibromyalgia

• Somnolence 15% to 25% • Dizziness 27% to 46%. • Treatment discontinued 18 to 28%. Moore RA et al Cochrane Review 2010

Strong Opioids & Chronic Pain Benefits • Better functioning

• Synergy with antineuropathics

Risks • Constipation • Tolerance

• Withdrawal • Suppression HPA

• ? immune status

Beware the patch! Drug Name

Drug Dose

Equivalent Morphine Dose

BuTrans 5

5 micrograms / hr

10mg / 24 hrs

BuTrans 10

10 micrograms / hr

20mg / 24 hrs

BuTrans 20

20 micrograms / hr

40 mg / 24 hrs

Transtec 52.5 (buprenorphine)

52.5 micrograms / hr

94 – 145 mg / 24 hrs

Transtec 70 (buprenorphine)

70 micrograms / hr

126 – 193 mg / 24 hrs

Fentanyl 25 patch

25 micrograms / hr

30 – 134 mg / 24 hrs

Fentanyl 50 patch

50 micrograms / hr

135 – 224 mg / 24 hrs

Fentanyl 75 patch

75 micrograms / hr

225 – 314 mg / 24 hrs

Fentanyl 100 patch

100micrograms / hr

315 – 404 mg / 24 hrs

NHS Wales website 2013

Strong Opioids & Chronic Pain

• Start low & go slow • Remember full dose codeine = 25 mg morphine daily • Slow release or regular dosing preferable • Don’t use ‘rescue’ doses • Stimulant laxative

Rescue Analgesia

• Not advisable for chronic pain • Encourages boosting dose to deal with increased activity – ignoring pacing advice • More likely to lead to dose escalation / dependence

Danger Signs! • High doses morphine (or equivalent: > 120mg / day) • Multiple opioids • Only injections work (when patient is eating & drinking) largely seen in secondary care

Non-pharmacological analgesia • Pacing activity / exercise • Positioning / posture / stretch • Reassurance (not always easy!) • Trans-cutaneous Electrical Nerve Stimulation (TENS)

When do people go to a Pain Clinic?

• GP or consultant referral • Diagnosis established • First line measures have been tried • Often after several other clinics

Reasons for Referral

• Persistent / complex pain (moderate to severe) • Previous appropriate use of analgesic guidelines • Distress; disability; drug use; dependence

Questions