OPIOIDS AWARE (and a few other musings) Nottinghamshire and - PowerPoint PPT Presentation

03/03/2019 Opioids Aware OPIOIDS AWARE (and a few other musings) Nottinghamshire and Derbyshire CD LIN meeting February 2019 http://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware Key messages • Opioids are very good painkillers for acute pain and pain at the end of life but there is little evidence that they are helpful for long term pain • There may be a small number of people who do well with opioids in the long term if the dose can be kept low and particularly if use is intermittent (it is difficult to identify these people at the point of opioid initiation) • The risks of harm increases substantially at doses above an oral morphine equivalent 120mg/day, but there is no increased benefit • If a patient has pain that remains severe despite opioid treatment it means they are not working and should be stopped, even if no other treatment is available • Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detailed assessment of the many emotional influences on their pain experience is essential 1

03/03/2019 History (the short version) • Mid 1980’s cancer patients dying in pain • Late 1990’s pain relief as a universal human right • role of Pharma and patient advocacy groups • Undertreatment of pain seen as malpractice • Pain as 5 th vital sign • Small trials showing efficacy of opioids in non- cancer pain A public health emergency Opioid prescribing in the UK — In 2017, 23.9 million prescriptions were dispensed in England costing £263.2 million Items Cost 6 80 70 Number of items (millions) 5 60 4 Cost (£ million) 50 Morphi ne Oxyc odone 3 40 Fentanyl 30 2 Buprenorphine 20 1 10 0 0 4 5 6 7 8 9 0 1 2 3 4 5 6 7 4 5 6 7 8 9 0 1 2 3 4 5 6 7 200 200 200 200 200 200 201 201 201 201 201 201 201 201 0 0 0 0 0 0 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 BNF classification 4.7.2 (opioid analgesics) Compiled from Prescription Cost Analysis. NHS Digital (formerly Health and Social Care Information Centre. 2

03/03/2019 How many patients are Duration of opioid prescribing prescribed opioids? • CPRD between 2000 and 2014 • Opioids • Length of continuous prescribing increased • 2000: 64 days • 2014: 102 days • Dependence forming medicines prescribed for longer in areas of deprivation Cartagena Farias J et al. Prescribing patterns in dependence forming medicines. 2017. London: NatCen. Cartagena Farias J et al. Prescribing patterns in dependence forming medicines. 2017. London: NatCen. Regional variation in opioid prescribing • Substantial regional — Efficacy or effectiveness • No evidence relating to: • No study of opioid therapy variation in opioid • different dosing strategies versus placebo, no opioid • short versus long acting prescribing therapy, or non-opioid therapy • continuous versus as evaluated long-term (>1 year) needed outcomes related to pain, function, or quality of life • opioid rotation • Lower SES, increased prevalence of patients aged more than 65 years, female gender, smoking, obesity and depression were significantly associated with increased opioid prescriptions Chen TC et al. Int J Drug Policy 2019; 64: 87 – 94. Chou R et al . Ann Intern Med 2015; 162 : 276. 3

03/03/2019 Authors' conclusions There is a critical lack of high-quality evidence regarding how well high-dose opioids work for the management of chronic non-cancer • 12-month pragmatic randomised clinical trial (n = 240 patients) pain in adults, and regarding the presence and severity of adverse • Compared the use of opioid vs nonopioid treatment for LBP and OA events. No evidence-based argument can be made on the use of high-dose opioids, i.e. 200 mg morphine equivalent or more daily, in • No improvement in pain-related function over 12 months (3.4 vs 3.3 points on an 11- clinical practice. Trials typically used doses below our cut-off; we need point scale at 12 months, respectively) to know the efficacy and harm of higher doses, which are often used in clinical practice. • Pain intensity was significantly better in the nonopioid group over 12 months (mean 12-month BPI severity was 4.0 for the opioid group and 3.5 for the nonopioid group (difference, 0.5 [95% CI, 0.0 to 1.0]) • medication-related adverse symptoms were significantly more common in the opioid group over 12 months (overall P = 0.03) Els C et al.. Cochrane Database of Systematic Reviews 2017, Issue 10. Art. No.: CD012299. Krebs EE, Gravely A, Nugent S, et al. JAMA. 2018;319(9):872–882. Psychiatric co-morbidities • Dysregulation of the endogenous opioid system in borderline personality disorder, depression, stress Absolute event rate for any adverse event with opioids in trials using a placebo as comparison was 78% • Patients with mood disorders more likely to be Withdrawal due to adverse events: moderate quality of evidence started on opioid treatment than those without Constipation: moderate quality of evidence Dizziness: moderate quality of evidence • Patients with depression almost twice as likely to Drowsiness or somnolence: moderate quality of evidence continue taking those opioids long term Increased sweating: moderate quality of evidence Nausea: moderate quality of evidence • Opioids being used to treat insomnia and stress – symptoms accompanying chronic pain – rather than Vomiting: low quality of evidence the pain itself Pruritus: very low quality of evidence Fatigue: very low quality of evidence Hot flushes: very low quality of evidence Halbert B et al. Pain 2016; 157: 2452. Sullivan MD. Pain 2016; 157: 2395. Prossin AR et al. Am J Psychiatry 2010; 167: Els C et al. Cochrane Database of Systematic Reviews 2017, Issue 10. Art. No.: CD012509. 925. 4

03/03/2019 Common misconception: Retraction July 2017 Addiction thought to be rare http://retractionwatch.com/2017/06/02/nejm-issues-unusual-warning-readers-1980-letter-opioid-addiction/ Porter J, Jick H. New Engl J Med 1980; 302:123. Crime Survey for England and Deaths related to drug poisoning Wales 2017 in England • In the last year 7.0% of adults aged 16 to 59 years had taken a 1400 prescription-only painkiller not prescribed to them for medical reasons Number of drug related deaths 1200 • Only 0.2% said it was just for the feeling or experience it gave them 1000 • Over twice as many people with a long-standing illness or disability 800 reported use of non-prescribed prescription-only painkillers for medical reasons (14.3%) compared with those with no long- standing illnesses 600 (5.8%) 400 200 • The use of non-prescribed prescription-only painkillers for medical reasons decreases as life satisfaction increases. Of those with low levels 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 of life satisfaction, 13.8 per cent reported use in the last year, compared with 5.3 per cent of those with very high levels of life satisfaction Morphi ne and heroi n Methadone Tram adol Oxyc odone Fentanyl Paracetamol Office of National Statistics Deaths Related to Drug Poisoning in England and Wales, 2009 – 2017. Drug Misuse: Findings from the 2017/18 Crime Survey for England and Wales. 5

03/03/2019 Tapering strategies 5 studies (n = 278 participants • Aims to develop a support programme that Two studies aimed to reduce opioid consumption via cognitive behavioural therapy (CBT) • aims to improve the everyday functioning • In-depth understanding of patients, or electroacupuncture for people living with chronic pain and clinical pharmacists and GPs’ Two studies aimed to reduce opioid misuse in people with chronic pain using CBT or • reduce their opioid use experiences and views about mindfulness RCT comparing two different treatments One study aimed to increase treatment compliance and adherence in people with chronic reducing opioids, and the role of • for people with long-term pain. pain receiving a pain-management treatment clinical pharmacists in helping GROUP 1 Usual GP care plus a opioid people with persistent pain information booklet and relaxation CD • Conclusions are limited regarding the benefit of psychological, pharmacological, or other • Feasibility trial with 80 patients GROUP 2 A support programme in types of interventions for people with chronic pain trying to reduce their opioid addition to the above. consumption • Full RCT and economic evalution There were reductions in opioid consumption after intervention, and often in control • Just finished recruiting with other > 1000 patients groups too. Eccleston C et al. Cochrane Database of Systematic Reviews 2017, Issue 11. Art. No.: CD010323 Assessing prescribing From: New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504 The rate of new persistent opioid use was 6% • By comparison, the incidence in the nonoperative control cohort was only 0.4% Risk factors independently associated with new persistent opioid use included: - • preoperative tobacco use (adjusted odds ratio [aOR], 1.35; 95% CI, 1.21-1.49) • alcohol and substance abuse disorders (aOR, 1.34; 95% CI, 1.05-1.72) • mood disorders (aOR, 1.15; 95% CI, 1.01-1.30) • anxiety (aOR, 1.25; 95% CI, 1.10-1.42) • preoperative pain disorders (back pain: aOR, 1.57; 95% CI, 1.42-1.75; neck pain: aOR, 1.22; 95% CI, 1.07-1.39; arthritis: aOR, 1.56; 95% CI, 1.40-1.73; and centralized pain: aOR, 1.39; 95% CI, 1.26-1.54) 6