European Pain Federation (EFIC) Position Paper on: Appropriate Opioid Use in Chronic Pain Management

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1 European Pain Federation (EFIC) Position Paper on: Appropriate Opioid Use in Chronic Pain Management 2017 Structured Cooperation between Health Care Systems tackling the societal impact of pain! Prof Tony O Brien Marymount University Hospital & Hospice Cork University Hospital College of Medicine & Health, University College Cork, Ireland Malta June 2017

2 Disclosure Statement of conflict of interest in the context of the subject of this presentation Within the past 12 months, I have had following financial interest/arrangement(s) or affiliation(s) below. Support for travel Honoraria for lectures Honoraria for advisory board activities Participation in clinical trials Research funding Financial shares and options.. Mundipharma Mundipharma Nil Nil Nil Nil

3 Appropriate Opioid Use in Chronic Pain Management Poorly controlled pain is a global public health issue Pain management is inadequate across most of the world (Declaration of Montreal, IASP) Personal, familial, societal costs are immeasurable Opioids are highly effective and safe analgesics only when used appropriately by competent clinicians The misuse of opioids is very dangerous Achieving a Balance (UN Single Convention on Narcotics, 1961 & World Health Organisation, 2011) O Brien T, Christrup LL, Drewes AM et al. European Pain Federation Position Paper. Eur J Pain 21 (2017) 3-19

4 INCB data on opioid consumption ( ) 92% of the world's morphine is consumed by 17% of the world's population Consumption in defined daily doses for statistical purposes (S-DDD) per million inhabitants per day

5 Pain relief lottery

6 Opioid analgesics ensuring adequate access for medical and scientific purposes INCB, 2016 Lack of training & awareness amongst healthcare professionals Fear of addiction Fear of diversion Cultural attitudes Limited financial resources INCB / United Nations, New York

7 Negative Perceptions The negative perception about controlled drugs among medical professionals and patients in many countries has limited their rational use 1 Opioid phobia rooted in physician and patient attitudes driven by fear of addiction and misuse Lack of balanced debate and broad understanding of the benefit-risk ratio of opioids Impacts access and use of opioids (even if regulatory provisions are made); and in consequence contributes to undertreatment of pain The International Narcotics Control Board (INCB) Annual Report, Press Release No.6. Use of essential narcotic drugs to treat pain is inadequate, especially in developing countries. March Available at:

8 Silent epidemic of pain Uncomplaining patients & unquestioning doctors - a lethal conspiracy of silence -

9 Appropriate Opioid Use in Chronic Pain Management Opioids are indispensable for the management of pain Opioids are not a panacea for all painful conditions Opioids are not used in isolation, but as part of a multi- faceted strategy that includes: Adjuvant analgesics Non-drug interventions Psychological support Rehabilitation Opioids must be readily accessible under supervision for those who legitimately require such therapy O Brien T, Christrup LL, Drewes AM et al. European Pain Federation Position Paper. Eur J Pain 21 (2017) 3-19

10 Opioid misconceptions Dangerous Compromise function Shorten life / hasten death Tolerance Addiction Respiratory depression Confusion / disorientation End of life only Opioids kill pain by killing patient If a patient dies whilst on opioid medication, the opioid caused the death O Brien T, Christrup LL, Drewes AM et al. European Pain Federation Position Paper. Eur J Pain 21 (2017) 3-19

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12 Appropriate Opioid Use in Chronic Pain Management O Brien T, Christrup LL, Drewes AM et al. European Pain Federation Position Paper. Eur J Pain 21 (2017) 3-19

13 The Pendulum Swings for Opioid Prescribing Physicians and the public share a common belief that opioids, even if prescribed by a physician for a medical indication, cause addiction The belief that prescribed opioid drugs cause addiction is flawed We must understand how the data are generated Illustration 1: Divide the number of opioid addicts who first started on prescription drugs (numerator) by the total number of opioid addicts (denominator) = a large number!! But, this is the wrong methodology Illustration 2: Divide all of the people in pain who are treated with an opioid and who become addicted (numerator) by the total number of pain patients treated with an opioid (denominator) = % - a very small number Is it better to let patients suffer unnecessarily than to be falsely implicated in contributing to a rise in addiction and opioid related deaths? Charles F von Gunten. (ed) Journal of Palliative Medicine Vol 19, Number 4,

14 Opioid facts - for medical use in properly selected and supervised patients Indispensable in pain management No significant respiratory depression Safe & effective Bowel dysfunction is main concern Do not compromise function Inter-individual variation in response Introduce when less potent medicines are ineffective No single ideal opioid; therefore need a range of opioids Physical dependence is not addiction Opioid misuse causes harm; not opioid use O Brien T, Christrup LL, Drewes AM et al. European Pain Federation Position Paper. Eur J Pain 21 (2017) 3-19

15 Medical use of opioids Adequate patient assessment Close on-going patient supervision Clinicians familiar with best practice Treatment initiated on trial basis Non-specialists need access to expert advice Patient & family education on safe opioid use and storage Opioids prescribed by competent doctors Opioids dispensed by competent pharmacists Correct dose is lowest possible dose Honest doctor / patient relationship O Brien T, Christrup LL, Drewes AM et al. European Pain Federation Position Paper. Eur J Pain 21 (2017) 3-19

16 Appropriate Opioid Use in Chronic Pain Management Summary / Conclusions Pain is a global public health problem In Europe: Lack of understanding of the nature and impact of chronic pain Failure to routinely assess patients for pain Failure to apply basic fundamental principles of prescribing in respect of opioids Inappropriate and exaggerated fear concerning the legitimate scientific use of opioids in carefully selected and supervised patients In selected countries, overly stringent and ill-considered restrictions and regulations intended to prevent illicit, non-medical use of opioids, result in patients suffering unnecessarily Opioids should only be introduced when less potent analgesics and adjuvant therapies have failed to achieve and maintain adequate pain relief and rehabilitation A positive educational programme targeted at health care professionals / students and the general public is urgently required O Brien T, Christrup LL, Drewes AM et al. European Pain Federation Position Paper. Eur J Pain 21 (2017) 3-19

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18 The medical profession is compassionate enough and bright enough to learn how to prescribe opioids when they are indicated, in ways that maximise benefit and minimise risk...we owe it to our patients to ensure access to comprehensive pain management, including the medically appropriate use of opioids Alford DP. New Engl J Med, 2016

19 European Pain Federation position paper on appropriate opioid use in chronic pain management T O Brien (Chairperson) L L Christrup A M Drewes M T Fallon H G Kress H J McQuay G Mikus B J Morlion J Perez-Cajaraville E Pogatzki -Zahn G Varrassi J C D Wells Eur J Pain 21 (2017) 3-19