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