OPIATES, CHRONIC PAIN AND COMPLEXITY. PLAN Study Day - Workshop 3 rd March 2017 Dr Adrian Flynn

Transcription

1 OPIATES, CHRONIC PAIN AND COMPLEXITY PLAN Study Day - Workshop 3 rd March 2017 Dr Adrian Flynn

2 Aims Context - North America - UK - Cornwall - openprescribing.net - Carnkie ward ASAM Addiction Winter Pressures / QI Project The contract etc.. How to do it differently

3 CONTEXT

4

5 North America Well Mr Smith, it seems that you have a severe case of addiction

6 Scale of the problem in US Value US Pain management Market $US15 billion Increase 4000 to 16,000 deaths Exceeding deaths from heroin and cocaine combined 165,000 total (Germany ~1.5M)

7 Scale of the problem 2010 US Prescription painkiller sales kg/10,000 Drug overdose deaths/100k Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for one month. 5% vs 80%

8 Who Influences Prescribing Purdue Pharma $600Mn fine vs $22Bn sales Pain Care Forum comments signature petition Academy of Integrative Pain Management 100 Million Americans in chronic pain 40% $740M in Washington $140M to local political campaigns $75M to federal candidates and parties FDA?

9 UK

10 National PCT prescribing data 2012 Cost of controlled drugs prescriptions 452 million Increased prescribing of opiates for non-cancer pain by UK doctors Deaths involving methadone and codeine doubled in England and Wales , while deaths involving heroin or morphine remained unchanged Trends: 6y continuous downward trend in temazepam prescribing Increases in prescribing of buprenorphine, morphine sulphate, oxycodone, fentanyl, methylphenidate, midazolam and diamorphine

11 Addiction to prescription drugs is so rife that more Britons die from taking painkillers and tranquillisers than heroin and cocaine. There were 807 fatal overdoses involving prescription drugs last year, a rise of 16 per cent in five years, official figures show. By comparison, there were 718 such deaths from taking heroin and cocaine, and numbers have been falling since Experts have warned that GPs give out repeat prescriptions too easily and there is not enough support for addicts.

12 Drug-related deaths by selected drugs reported in England, Wales and Scotland, Note that heroin and morphine are reported as one category in the data from England, Wales and Scotland; given that the focus of this analysis is on prescription opioids, that category was not included in this analysis. Methadone in England and Wales; SQUARE, Tramadol in England and Wales; TRIANGLE, Other opiate in England and Wales; CROSS, England and Wales total opioid-related deaths (excluding heroin/morphine); LINE, Methadone in Scotland; DIAMOND, Tramadol in Scotland CIRCLE

13 Cornwall

14 Items for Oxycodone Hydrochloride vs patients on list by NHS KERNOW CCG in Aug '16

15 Items for Tramadol Hydrochloride vs patients on list by NHS KERNOW CCG in Aug '16

16 Items for Pethidine Hydrochloride vs patients on list by NHS KERNOW CCG in Aug '16

17 Items for Morphine Sulfate vs patients on list by NHS KERNOW CCG in Aug '16

18 Items for Fentanyl vs patients on list by NHS KERNOW CCG in Aug '16

19 Items for Co-Codamol (Codeine Phos/Paracetamol) vs patients on list by NHS KERNOW CCG in Aug '16

20 Items for Non-Steroidal Anti-Inflammatory Drugs vs patients on list by NHS KERNOW CCG in Aug '16

21 Items for Amitriptyline Hydrochloride vs patients on list by NHS KERNOW CCG in Aug '16

22 Items for Pregabalin vs patients on list by NHS KERNOW CCG in Aug '16

23 Items for Paracetamol vs patients on list by NHS KERNOW CCG in Aug '16

24 Items for Opioid Analgesics vs patients on list by NHS KERNOW CCG in Aug '16

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27 Comparisons

28 Comparisons

29 Carnkie Ward

30 Morphine prescription by ward Oct 2012-Sep 2013 MAU = average of MAU1 + 2 Morphine injection = box (10mg amps X 10)

31 Injection Other Solution Injection Other Solution Injection Other Solution Injection Other Solution Injection Other Solution Injection Other Solution Bucking the trend: morphine use CARNKIE WARD - RCH GRENVILLE RENAL WARD - RCH WELLINGTON - RCH MEDICAL ADMISSIONS UNIT 1 MEDICAL ADMISSIONS UNIT 2 ROSKEAR WARD - RCH

32 Bucking the trend: morphine consumption (mg) CARNKIE WARD - RCH Injection Other Solution GRENVILLE RENAL WARD - RCH Injection Other Solution WELLINGTON - RCH Injection Other Solution MEDICAL ADMISSIONS UNIT Injection Other Solution MEDICAL ADMISSIONS UNIT Injection Other Solution ROSKEAR WARD - RCH Injection Other Solution Grand Total % reduction in morphine 75% reduction in IV morphine Rest increased except MAU

33 What makes managing these patients difficult? CURRENT CONTEXT Clinical authority Patient voice / awareness / expectations Public information media and shared Pharma new drugs, routes, preparations Guidelines Education / shared language GP continuity background factors Continuity in secondary care Prescriptions and deaths , 1999 vs 16000, 2010 in US

34 Stannard BMJ 2013 The contrary (pro-opioid) argument, usually framed in the language of pain advocacy, is unarguable in sentiment, given the distressing and disabling nature of persistent pain. Sadly, however, opioids are neither an easy nor necessarily effective solution to the problem. Opioids are prescribed more often and for longer periods than would be predicted by their known efficacy in the management of persistent pain. The data also suggest that opioids are often prescribed in doses above which we know that harms outweigh benefits

35 DEPENDENCE AND ADDICTION

36 Dependence Syndrome ICD10 Three or more during the previous year Strong desire or compulsion Difficulty controlling use onset, termination, levels Withdrawal state (or use of drugs to avoid) Tolerance higher amounts for same effect Neglect of alternative pleasures or interests Persistence despite use despite harm Also narrowing of repertoire / may only become aware of compulsion when withdrawn

37 ASAM American Society of Addiction Medicine In cortical, hippocampal circuits and brain reward structures previous exposures to rewards leads to biological and behavioural response to external cues Neurotransmission within reward structures nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala Motivational hierarchies are altered Addictive behaviour supplants healthy, self-care related behaviour

38 ASAM not only reward Altered connectivity in frontal cortex and between reward, motivation and memory circuits manifests in altered: - impulse control - judgment - dysfunctional pursuit of rewards Frontal lobes are important in inhibiting impulsivity and in assisting individuals to appropriately delay gratification

39 ASAM other factors Disturbed social support systems and inter-personal relationships has an impact on resilience Disruption in meaning, purpose and values Previous exposure to trauma Presence of psychiatric illness Cognitive and affective distortions

40 Cognitive Factors Preoccupation with substance use Altered evaluations of the relative benefits and detriments associated with drugs or rewarding behaviour e.g. I would never try that.. Inaccurate belief that problems experienced in one s life are attributable to other causes rather than being a predictable consequence of addiction

41 Emotional Factors Increased anxiety, dysphoria and emotional pain; Sensitivity to stressors associated with the recruitment of brain stress systems Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and ascribing feelings to other people (alexithymia) Tolerance to highs but not to lows

42 THE PROJECT AND RESOURCES

43 Winter Pressures vs QI Project

44 Opioids Aware

45 Opioids Aware RCoA / FPM SIDE-EFFECTS Immune suppression Endocrine depression, hypogonadism, amenorrhoea Fractures and falls increased Pain increased (central sensitisation, opiate induced hyperalgesia, narcotic bowel syndrome) OUTCOMES QOL reduced Healthcare increased Employment status worse Pain worse 20% experience a 30% reduction in pain

46 Opioid Policy No IV for >48hr without senior review Automatic notification to pain team Natural creep in practice

47 Parts 1,2,3,4 { Provenance

48 The plan delivers information on risks benefits goals and expectations Won t remove pain, might relieve somewhat. Use with other drugs / techniques Effectiveness of opioids in acute / chronic pain SE s including hyperalgesia, death. Euphoria / emotional numbing and come-down Driving

49 Beware alcohol especially when starting Tachyphylaxis Dependence Addiction Abuse Further info for clinicians and patients

50 Patient contract terms and conditions for continued prescribing GP & specialists in charge of dosing No funny business hoarding, diversion Security and safety at home No early scripts Will report SEs Declare any history of substance misuse Giving to other is illegal and dangerous If no clinical improvement then STOP

51 Clinician section Indication for opioids Summary of opioid treatments at time of writing

52 Today s script Duration of the trial period and when to review De-escalation / deprescribing plan Ceiling dose Patient and clinician signature

53 Expectations of treatment and mechanisms of pain { Opioids aware website golden rules

54 Other Resources Referral Management System Pain Toolkit 12 steps Team and Acceptance Sheffield Persistent Pain Video Radio Cornwall Phone-In

55 Film -

56 How do we do it differently? Opiate evidence Opioids Aware Opiate policy 48hrs IV opiate limit Team based approach Opiate contract Care planning MAXIMS care management plan and Oceano flag Communicate the plan RMS CCG Pharmacists DRD Meeting Think like CIWA

57 Thank you The Team Pain Team - Keith Mitchell/Sarah Meddlicott Paul Fortun - Gastroenterologist Jim Huddy - GP / Gastroenterologist Lorraine Moor - Pharmacist Georgina Praed - KCCG Mike Wilcox Lead Pharmacist Dan Thomas - KCCG Hannah Falvey/Lisa Hogbin - Clinical Health Psychology

58 Patients JP AS CH IW