Pain and Dependency / Pain Management in the Prison Population

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Pain and Dependency / Pain Management in the
Prison Population
Dr Rebecca Lawrence Consultant in Addictions
Psychiatry Ritson Unit Royal Edinburgh Hospital
Dr Lesley Colvin Consultant / Honorary Reader in
Anaesthesia and Pain Medicine University of
Edinburgh

• Dr Colin Baird
• Consultant in Anaesthesia Pain Medicine
• Western General Hospital
• Leith Community Treatment Centre

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Summary

• Pain and Dependency an overview
• Dr Rebecca Lawrence
• Management of Neuropathic Pain and how SIGN 136
  can be implemented in the PAD clinic
• Dr Colin Baird
• Opioids for chronic pain in the prison population
  good or bad?
• Dr Lesley Colvin

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Declaration of Interests / Funding

• Edinburgh Lothians Health Foundation Alcohol
  Problems Endowment Fund contribution to MSc in
  Pain Management
• Astellas Pharma Ltd funding to attend BPS
  annual scientific meeting (2014)
• Reckitt Benckiser funding to attend Opioid
  Painkiller Dependence Education Nexus (September
  2014)

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Overview

• Background / brief epidemiology
• Lothian Pain Dependency Clinic model

center-for-addiction-recovery.com
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Chronic Pain and Dependencythe emerging
co-morbidity?

• Chronic pain of moderate to severe intensity
  occurs in 19 of adult Europeans, seriously
  affecting the quality of their social and working
  lives (Breivik, H., et al, 2006. Eur J Pain) (BPS
  figure - one in seven of UK population)
• Estimated prevalence of problem drug use (opiates
  and/or benzodiazepines) Scotland 2012-13 of 1.68
  population aged 15-64 (Scottish Government)
• Up to 50 men and 30 women across Scotland
  exceeding weekly recommended guidelines (Changing
  Scotlands Relationship with Alcohol A Framework
  for Action, 2009)

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Access to pain relief an essential human right
IASP, the WHO and EFIC

• The UN Universal Declaration of Human Rights
  conceptualises human rights as based on inherent
  human dignity
• Perception and expression of pain is individual
• It is essential to listen to and believe the
  patient only they know what the pain feels like
• (A report for World Hospice and Palliative Care
  Day 2007 Published by Help the Hospices for the
  Worldwide Palliative Care Alliance )

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Substance misuse patients

• Increased prevalence of pain
• Poorer treatment outcomes. Yet treating pain
  improves outcomes
• More likely to use illicit opioids / more
  drug-seeking

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Chronic Pain Patients

• Increased prevalence of alcohol drug misuse
• Hoffman et al (1995) 23.4 of 414 hospitalized
  chronic pain patients in Sweden met criteria for
  active diagnosis of alcohol, analgesic or
  sedative misuse or dependence

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• No demographic / clinical factors that
  consistently differentiate CNCP (chronic
  non-cancer pain) patients with comorbid SUD
  (substance use disorder) from patients without
  SUD, though may be at greater risk for aberrant
  medication-related behaviors.

Morasco, B.J., Gritzner, S., Lewis, L., Oldham,
R., Turk, D.C., Dobscha, S.K., 2011. Systematic
review of prevalence, correlates, and treatment
outcomes for chronic non-cancer pain in patients
with comorbid substance use disorder. PAIN 152,
488497. doi10.1016/j.pain.2010.10.009
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Pain Opioid Dependency

• Aberrant drug-related behaviour (Red flags)
• Abuse (DSM IV Psychoactive Substance Abuse A
  maladaptive pattern of drug use that results in
  harm or places the individual at risk)

Pseudoaddiction Aberrant drug-related behaviour
in patients reacting to under treatment of pain
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Pain, Mental Health Alcohol

• Strong association between pain
  psychopathology, particularly depressive
  disorders, anxiety disorders, somatoform
  disorders, substance use disorders personality
  disorders
• Dersh J, Polatin GB Gatchel RJ (2002). Chronic
  pain and psychopathology research findings and
  theoretical considerations. Psychosom Med
  64(5)773-86.

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Licensed Treatments

• Amitriptyline depression neuropathic pain
• Duloxetine depression, generalized anxiety
  diabetic neuropathy
• Pregabalin peripheral / central neuropathic
  pain generalized anxiety
• Carbamazepine trigeminal neuralgia, prophylaxis
  of bipolar disorder
• PSYCHOLOGICAL INTERVENTIONS

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Other treatments for pain, mental disorders
substance misuse

• Valproate
• Gabapentin
• Topiramate
• Lamotrigine
• Other antidepressants
• Baclofen
• Opiates
• Benzodiazepines

• Ketamine infusion
• Deep brain stimulation

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Pain Dependency (PAD) the Edinburgh
experience

• Development of combined Pain Dependency (PAD)
  Clinic 2003 (by Dr Lesley Colvin Dr Michael
  Orgel)
• Patients with drug dependence should not be
  denied adequate pain relief
• Access to specialised services with experience in
  managing this patient group is essential

Scimeca, MC (2000)
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What is the PAD Clinic?

• Multidisciplinary
• Pain Specialist
• Addiction Psychiatrist
• Specialist Nurse
• Clinical Psychologist

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Location Referrals

• PAD clinic is located in, funded by, the
  Chronic Pain Service
• Majority of referrals from GPs, also from
  Substance Misuse Service, and some diverted from
  Pain Service

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Triage to PAD

• Current input from SMD (Substance Misuse
  Directorate)
• Current misuse of / dependence on illicit drugs
  (includes legal highs - increasing problem)
• Current misuse of / dependence on alcohol
• Any history of drug / alcohol misuse with
  associated ongoing mental health problems
• Not stable on prescribed methadone
• Prescribed gt 150mg methadone (guide)
• Iatrogenic opioid misuse / dependence
• Misuse of over the counter or other prescribed
  medication
• Concern regarding gabapentin or pregabalin use
  (prescribed or unprescribed)

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PAD Clinic

• Assessment of pain, mental health and substance
  misuse / addiction
• Does not matter which came first
• Verify past assessment
• Initiate further assessment/ investigations
• Does not provide key work or prescribing
• Liaison with appropriate services
• Mental health assessment (not ongoing monitoring
  and treatment)
• Liaison with appropriate services

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History Pain and Substance Misuse

• Pain
• Diagram, BPI associated symptoms
• Past treatment investigations
• Substance misuse history
• Stable/ chaotic prescription? Support?
• IVDA Hep C/ HIV (BBV) status and Rx
• Alcohol stimulants / or benzos cannabis
  NPS gabapentin
• Mental Health
• Social history
• Child protection issues

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Examination Pain and Substance Misuse

• Pain
• Sensory changes/ ? neuropathic
• motor impairment/ impact on function
• Sympathetic involvement
• Substance misuse
• Toxicology urine / oral swab
• Breathalyse
• Signs of chronic drug / alcohol use
• Track marks
• Intoxication

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Patients

• Established drug users with pain (often on
  substitute prescriptions). Pain often a result of
  chaotic lifestyle
• Pain resulting from alcohol dependence
• Concerning use of over the counter or prescribed
  medication (usually opioids, but may be other
  drugs, eg gabapentin)
• Past history of drug or alcohol use

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Review of 36 new patients seen in PAD in 2014

• 25 male, 11 female
• Average age 41(26-59)
• None in employment
• Addiction first 18
• Pain first 7
• Unstable use of opioids 19
• Mental health problem - 26

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Review of 36 new patients (2)

• On methadone 15
• On dihydrocodeine 4
• On buprenorphine 0
• On gabapentin or pregabalin 14
• Use of NPS 2
• Problem alcohol use 13
• Cannabis use 15
• Benzodiazepines frequently used / prescribed

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Management

• Assessment Explanation
• Non-pharmacological eg TENS (also acupuncture,
  craniosacral therapy, massage - availability)
• Pain Management Programme
• Individual psychological work
• Nerve blocks if appropriate
• Community support substance misuse services

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Management

• Antidepressants - ? amitriptyline
• ?Gabapentin / Pregabalin
• Non-opioids NSAIDs
• Optimise current opioid prescribing
• Strong opioids if needed monitor
• Strong opioids which?
• Topical treatments
• In patient assessment treatment

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The Future?

• Wider access to specialist care where and how
  best to deliver this?
• The changing patterns of drug misuse and
  management of pain abuse of prescribed drugs
  other than opioids, alcohol misuse and the spread
  of novel psychoactive substances
• Long term side effects of opioids and
  implications for practice

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Management of Neuropathic Pain and how SIGN 136
can be implemented in the PAD clinic
Dr Colin Baird
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Summary
Neuropathic pain the problem
Management of neuropathic pain
SIGN 136
How can this be applied to the prison / PAD
clinic population?
Gabapentin and pregabalin!
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Pain An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms thereof
Neuropathic pain Pain arising as a direct
consequence of a lesion or disease affecting the
somatosensory system
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Neuropathic pain the problem
Between 8 and 18 of adults in the UK, USA and
Europe will suffer from neuropathic pain
It has a negative impact on mood, ability to
function and general wellbeing
16 of sufferers rate it as worse than death on
the EQ5D
Current treatment is limited by side effects,
lack of efficacy and variable individual response
Doth et al. Pain (2010) Torrance et al. J Pain
(2006) Toth C et al. Pain Medicine (2009) B
Smith
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What causes neuropathic pain to develop?
Damage to the somatosensory nervous system
Surgery / Trauma
Disease diabetes, HIV
Infection (PHN)
Drugs chemotherapy, alcohol
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Features of neuropathic pain
Spontaneous
Hyperalgesia
Evoked
Allodynia
Impaired ability to function
Negative impact on mood
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SIGN 136 now available!
http//www.sign.ac.uk/guidelines/fulltext/136/inde
x.html)
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Key recommendations
Assessment and planning of care
Supported self-management
Pharmacological management
Psychologically based interventions
Physical therapies
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Three consensus pathways
Assessment, early management and care planning
Neuropathic pain
Use of strong opioids
Complementary to the British Pain Society Map of
Medicine Pathways (http//bps.mapofmedicine.com/
evidence/bps/index.html)
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LANSS DN4 DN4 NPQ Pain DETECT Id-Pain
Country UK France France USA Germany USA
Validated 100 160 160 382 392 308
Sensitivity 82 - 91 83 83 66 85 NA
Specificity 80 - 94 90 90 74 80 NA
Common symptoms Pricking, tingling,pins and needles Electric shocks/ shooting hot/ burning Pricking, tingling,pins and needles Electric shocks/ shooting hot/ burning Pricking, tingling,pins and needles Electric shocks/ shooting hot/ burning Pricking, tingling,pins and needles Electric shocks/ shooting hot/ burning Pricking, tingling,pins and needles Electric shocks/ shooting hot/ burning Pricking, tingling,pins and needles Electric shocks/ shooting hot/ burning
Common signs Brush allodynia raised pin prick threshold Brush allodynia raised pin prick threshold
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Case history - NF
45 year old male stab wound to the chest 10
years ago
Pain since incident. Had been managed with
gabapentin but this was stopped due to suspicion
of drug diversion
On amitriptyline 50mg at night
Referred to the PAD clinic
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Symptoms Burning, shooting pain like toothache
doctor!
Signs Hyperalgesia and allodynia around the
affected area.
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Pharmacological options 1st line therapy
Amitriptyline 25 125mg daily. Titrate up by
10mg per week
Gabapentin Titrate up by 300mg per week to 1200
18mg daily
Pregabalin 75mg BD, titrate up by 75mg per week
to 300 600mg daily.
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Gabapentinoids

• Gabapentin

• Pregabalin

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How should we incorporate these conclusions into
our clinical practice?
Advice for prescribers on the risk of the misuse
of pregabalin and gabapentin Ref PHE
publications gateway number 2014586 NHS England
publications gateway number 02387 PDF, 157KB, 9
pages
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Which if any, are options for NF?
Pregabalin
Gabapentin
Amitriptyline
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Pharmocological options 2nd line therapy
Alternative TCA Nortriptyline, Imipramine same
dosing regime as amitriptyline but may have more
favourable side-effect profile
SNRI Duloxetine, 30-60mg daily, can increase to
120mg daily. Nausea is main side-effect
Carbamazepine In trigeminal neuralgia
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Could try alternative TCA?
Duloxetine?
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Topical agents for neuropathic pain
Lidocaine patches Good side-effect profile.
Application may be problematic
8 Capsaicin patch For PHN, HIV neuropathy,
post-surgical scar pain.
TENS machine
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8 Capsaicin patch
1 application
Pain scores have fallen from 9 to 4 after 2 weeks
Plan to repeat the application after 12 weeks
Look for improvements in sleep and function
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Pharmacological options Opioids!!