chronic pain: supporting safer prescribing of analgesics · opioid analgesics, figure 1 provides a...

British Medical Associationbma.org.uk

Chronic pain: supporting safer

prescribing of analgesics

March 2017

http://www.bma.org.uk

http://www.bma.org.uk

1British Medical Association Chronic pain: supporting safer prescribing of analgesics

Contents

1 Background ............................................................................................................................................................2

2 Introduction ...........................................................................................................................................................32.1 Definingchronicpain ................................................................................................................................32.2 Prevalenceofchronicpain .....................................................................................................................32.3 Analgesic drugs ...........................................................................................................................................4

3 Analgesicuseforchronicpain .......................................................................................................................53.1 Analgesicprescribingforchronicpain:UKtrends...................................................................... 53.2 Analgesicuseinchronicpain–exploringtheevidence ...........................................................73.3 Potentialharmsassociatedwithlong-termanalgesicuseinchronicpain ...................11

4 Supportingthemanagementofpatientswithchronicpain ........................................................14

5 Roleoftrainingandeducationinimprovinganalgesicusefortreatingchronicpain .......205.1 A focus on undergraduate training .................................................................................................205.2 Promotingguidancetosupportimprovedanalgesicprescribingforchronicpain ...21

6 Conclusionandsummaryofrecommendations ................................................................................ 22

7 Furtherresources ............................................................................................................................................. 24

Appendix1–classificationofchronicpain .................................................................................................... 25

Appendix2–specialisttraininginpainmedicine ...................................................................................... 26

Acknowledgements ................................................................................................................................................. 27

References .................................................................................................................................................................... 28

Abbreviations

ACMD AdvisoryCouncilontheMisuseofDrugs BMA BritishMedicalAssociationBPS BritishPainSocietyCDC Centers for Disease Control and PreventionCQC CareQualityCommissionEPM EssentialPainManagement FPM FacultyofPainMedicineIASP InternationalAssociationfortheStudyofPain ICD InternationalClassificationofDiseasesNHS NationalHealthServiceNICE NationalInstituteforHealthandCareExcellenceNSAID Nonsteroidalanti-inflammatorydrugPHE PublicHealthEnglandRCGP RoyalCollegeofGeneralPractitioners RCOA RoyalCollegeofAnaesthetistsSIGN ScottishIntercollegiateGuidelinesNetworkSNRI Serotonin–norepinephrinereuptakeinhibitorSSRI SelectiveserotoninreuptakeinhibitorTCA TricyclicantidepressantWHO WorldHealthOrganization

ThispublicationwaspreparedundertheauspicesoftheBMAboardofscience.ApprovalforpublicationwasrecommendedbyBMAcouncilon24March2017.

WearegratefultotheFacultyofPainMedicineoftheRoyalCollegeofAnaesthetistsfortheirguidanceinproducingthisdocument.AfulllistofcontributorscanbefoundintheAcknowledgementssectionattheendofthisdocument.

2 British Medical Association Chronic pain: supporting safer prescribing of analgesics

1 Background

Themanagementofpatientswithchronicpaincanpresentsignificantchallenges,1 and thesubstantialpublichealthharmsinrelationtoprescriptionanalgesicsseenintheUnitedStatesandelsewherehaspromptedrenewedeffortstoassesstheroleofmedicinesinpainmanagement.TheBMA’s2016analysisreportonPrescribed drugs associated with dependence and withdrawal,notestheincreaseinanalgesicprescribingforthispatientgroup2andaddstothecurrentconversationaboutwhetherprescribinganalgesicsisalwaysinthepatient’sbestinterestsgiventhat,foropioidsinparticular,thereislimitedevidenceforefficacyintreatinglong-termpain.2,3Thisrepresentsapotentiallysignificantpublichealthissue,andourmembershavecalledfortheexplorationoffactorsthatcouldsupportthesaferprescribingofopioidanalgesics.Suchanapproachwouldensurethatpatientsareonlyprescribedmedicinesfromwhichtheyderivebenefitandwilllimitmedicationassociatedharms.Thisisimportantgiventhecostofopioidprescribing,whichinEnglandisestimatedtototalover£300million,andinScotlandtoover£32million,annually.4,5

Thisbriefingpaperhighlightssomeofthekeyissuessurroundingtheuseofanalgesicsinthemanagementofpatientswithchronicpain;settingoutarangeofrecommendationsforgovernments,policymakersandhealthcareprofessionals,withtheaimofsupportingthesaferprescribingofthesemedicines.Whilstitprovidesanintroductiontothecurrentstateoftheevidenceinthisarea,itisnotintendedtoprovideasystematicreviewoftheevidenceoractasaclinicalguide.Acomprehensiveresourcetosupporttheclinicaluseofopioids–Opioids Aware–hasrecentlybeendeveloped(seeSection 3).

IssuessurroundingtheappropriateuseofanalgesicsareofwiderelevancetoBMAmembersacrossdifferentbranchesofpractice.ThisbriefingfollowsaBMAboardofscienceseminarinSeptember2014,initiatedbyBaronessIloraFinlay(BMApresident2014-15),whichexploredproblemsfacingclinicianswhenprescribingopioidsinpalliativecareandforchronicpain.


2 Introduction

Paincanbedefinedasanunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage.6Thecomplexityandprevalenceofpainmakeitamajorclinicalandsocialchallenge.Accordingtothe2015globalburdenofdiseasestudy,chronicpainconditionsareamongstthemostsignificantcausesofsufferinganddisabilityworldwide.7 Pain canoftenco-occurwithemotionalandmentalhealthdifficulties.Paincanbeassociatedwithanxietyanddepressionandmentalhealthdiagnosesandemotionaldifficultiescaninfluencetheexperienceofpainandcomplicatemanagement.Anestimated49%ofpatientsintheUKsufferingfromchronicpainalsosufferfromdepression.8Datafromthe2011HealthSurveyforEnglandindicatethat,aswellasdepression,chronicpainisassociatedwithamultitudeofnegativehealthandsocialoutcomes,includingpoorermentalwellbeing,anxiety,job/incomeloss,impairedfunctionandlimiteddailyphysicalandsocialactivities.9

2.1 Definingchronicpain

TheIASP(InternationalAssociationfortheStudyofPain)defineschronicpainaspainthathaspersistedbeyondnormaltissuehealingtime.Itcanbecontinuousorinterruptedbypain-freeintervals.10Intheabsenceofothercriteria,chronicpainisusuallytakentobepainthathaspersistedforthreemonths.Althoughthistemporaldefinitionmaybemoreusefulforresearchratherthanclinicalpurposes,theBPS(BritishPainSociety)andtheSIGN(ScottishIntercollegiateGuidelinesNetwork)usethethree-monthdefinitionasthebasisfortheirrecommendationsonthetreatmentofchronicpain.11,12

Painhasbeenhistoricallysubdividedaccordingtothepresumednatureofthetissueinjury.Theremaybeanumberofunderlyingmechanismsincludingsomatictissueinjury,damagetonervesandpainfromviscera.Thesecategoriesoftenoverlap.Thereisoftennotanidentifiablecurrentinjury,butpainmayrelatetopreviousinjuryordiseaseorabnormalsensoryprocessing.Theperceivedintensityofpaindoesnotnecessarilyrelatetothedegreeoftissueinjuryandisinfluencedbymanyfactorsincludingthepatient’sunderstandingofandconcernsaboutthepain,anxiety,distress,expectationsandpreviousexperienceofpain. 13,14,15,16 Thereisalsonowincreasingunderstandingofthelongtermhealthimpactofearlyadverseexperiences,andtheassociationbetweenemotionaltrauma,post-traumaticstressdisorderandpainhasbeenwelldescribed.17,18

Therearemultipleclassificationsofchronicpain,andAppendix 1providesanoverviewofthosethathavebeendevelopedbytheIASPforinclusioninthe11threvisionoftheWHO(WorldHealthOrganization)InternationalClassificationofDiseases.

2.2 Prevalence of chronic pain

Ithasbeenestimatedthataround20%ofadultsinEurope,andthat13%ofadultsintheUKexperiencechronicpain,thoughthisvariesdependingonthecriteriaanddefinitionsused.19,20

Ameta-analysisofpopulationstudiesestimatedthatchronicpainaffectsbetweenonethirdandonehalfoftheUKpopulation,andthatbetween10.4%and14.3%ofthepopulationoftheUKreportseverelydisablingchronicpainthatiseither‘moderately’or‘severely’limiting.21 TheNationalPainAuditestimatedthat11%ofadultsand8%ofchildrenintheUKsufferfromseverepain.20Inthe2011HealthSurveyforEngland31%ofmenand37%ofwomenoverallreportedtohavepainordiscomfortthattroubledthemallofthetimeor‘onandoff’formorethanthreemonths;22thisincreasedwithage,from14%ofmenand18%ofwomenaged16-34comparedto53%ofmenand59%ofwomenaged75andover.22

Key message – ThereisasubstantialburdenofchronicpainintheUKpopulation,thoughspecificprevalencefiguresvarydependingonthecriteriaanddefinitionsused.


Theincreasingprevalenceofchronicpaininapopulationwithagrowingproportionofolderpeoplemaybedirectlycontributingtotheincreasedprescribingofanalgesics,includingopioids.Numerousstudieshavesuggestedthatchronicpainismorecommonamongstolderpopulations,althoughnotnecessarilytheveryoldestagegroups.23,24Thisisparticularlythecasewhenrelatedtopaincausedbyconditionssuchasosteoarthritis,25 withtheseverityofchronicpainalsoincreasingwithage.25AsthemedianageoftheUKpopulationhasincreasedsignificantly–from33.9in1974to40.0inmid-2014–and17.6%ofthepopulationisnowover65,26 itwillbeimportanttoconsidertheimpactthismayhaveondemandforpainmanagement.

2.3 Analgesic drugs

Anumberofdrugclasseshaveeffectsonpainprocessingsomeofwhichareusedforotherindicationse.g.depressionandepilepsy,astherearecommonunderlyingbiologicalprocesses.Whilsttheprimaryfocusofthisbriefingpaperisonthesaferprescribingofstrongopioidanalgesics,Figure 1providesasummaryofthevarioustypesofdrugsthatareusedforthetreatmentofpain.Box 1providesabriefoverviewofopioidpharmacology.

Figure1–Summaryofdifferentanalgesicdrugs

Analgesic type Examples

Simpleanalgesics paracetamol,aspirin

NSAIDs(nonsteroidalanti-inflammatorydrugs)

ibuprofen,naproxen,diclofenac,celecoxib,mefenamicacid,etoricoxib,indomethacin,aspirin

compoundanalgesics co-codamol(codeineandparacetamol), co-dydramol(dihydrocodeineandparacetamol),co-codaprin(codeineandaspirin)

weakopioid codeine,dihydrocodeine

strongopioid morphine,buprenorphine,fentanyl,methadone,oxycodone,tapentadol,tramadol

drugswithanti-epilepticaction carbamazepine,pregabalin,gabapentin

tricyclicantidepressants amitriptyline,nortriptyline

serotonin-noradrenalinereuptakeinhibitors

duloxetine

Source:BritishNationalFormulary(availableat:www.evidence.nhs.uk/formulary/bnf/current)

Box 1 – Basic opioid pharmacology

Opioiddrugsproducetheireffectsbyactivatingopioidreceptors,locatedinthecentralnervoussystem,peripheralnervoussystemandperipheraltissues.Activation,27 results in areductionofneuronalcellexcitabilitythatinturnreducestransmissionofnociceptiveimpulses.

Opioidscanbenatural,syntheticorsemi-synthetic.Naturalopioidsarethosederivedfromthealkaloidsfoundinopium,suchasmorphineandcodeine.Semi-syntheticopioidsarederivedfromnaturalopioids,andincludeoxycodone(derivedfromthebaine),hydrocodone(derivedfromcodeine)anddihydromorphine(derivedfrommorphine).Syntheticopioidsaresynthesisedfromchemicalsandmoleculesthatdonotcomefromthealkaloidsfoundinopiumbutsharetheabilitytobindtoandactivateopioidreceptors.Examplesofsyntheticopioidsincludemethadone,fentanylandtramadol.28Someopioids–includingcodeine–areprodrugsthatexerttheiranalgesiceffectaftermetabolism.


3 Analgesic use for chronic pain

Theprescribingofopioidshasincreasedmarkedlyoverrecentyears,althoughtheevidencefortheirefficacyinthetreatmentofchronicpainconditionsremainsweak,andourincreasingknowledgeoftheirshortandlong-termsideeffects,raisesquestionsovertheiruse.2,3Thefollowingsectionshighlightrecenttrendsintheprescribingofopioidandotheranalgesics,andexploretheevidencefortheefficacy,safetyandpotentialharmsassociatedwiththeiruseinpeoplesufferingfromchronicpain.

3.1 Analgesic prescribing for chronic pain: UK trendsInrecentyearstherehasbeenasubstantialincreaseinthenumberofopioidanalgesicsprescribedforthemanagementofchronicnon-cancerpain,withincreasesoccurringinallpartsoftheUK,significantlyinexcessofanypopulationincreases(seeBox 2).Whileitisnotpossibletodetermineifitemswereprescribedforchronicpain,orwhethertheywereusedinpalliativecare,researchindicatesthatthemajorityofprescriptionsforopioidanalgesicsareforpatientswithchronicnon-cancerpain.29

Box 2 – Opioid prescribing trends in the UK

England – Therewasayearonyearincreaseinopioidprescribinginthecommunityfrom228millionitemsin1992to1.6billionin2009.30

– ThenumberofopioidanalgesicsprescribedingeneralpracticeinEnglandincreasedby1.5millionbetween2008and2013.22

– ThemostcommonlydispensedopioidanalgesicinEnglandisco-codamol,acompoundanalgesicofcodeineandparacetamol,withnumbersofprescribeditems–bychemicalname–increasingby5%from14.89millionto15.58millionbetween2010and2014.31,32 Overthesametimeperiodtheuseofmorphineroseby66%from2.44millionprescribeditemsto4.05million; buprenorphineuseroseby53%(1.19millionto1.83million);oxycodoneby44%(0.89millionto1.28million);codeineby37%(3.03millionto4.16million)andfentanylprescribingroseby22%(0.99millionto1.21million).32

Scotland – Theprescribingofanumberofopioidsincreasedbetween2010and2015.Thefastestincreaseswereseenforcodeineandmorphine.

– Over50%moremorphinewasdispensedin2014/15thanfouryearsearlier,upfrom280,351to440,472items.Codeineuseroseevenmorerapidly,witha64%increasefrom89,159to146,561items.Tramadoluserose12%from972,922to1,091,237items.Therewasalsoa33%increaseinoxycodoneuseanda23%increaseforfentanyl.33

Wales – Between2010and2014theprescribingofmorphineincreasedby105%,from168,736to345,808items,andcodeinefrom63%from85,528to120,257items.Tramadoluseroseby5%overtheperiod(563,071to592,678),buprenorphineby22%(93,843to114,559)andoxycodoneby23%(72,139to88,997).

Northern Ireland – AvailabledatafromNorthernIrelandindicatethatanalgesicuseoverallincreased by9.7%between2010and2014andby36.4%between2004and2014.34

Key message – AllpartsoftheUKhaveseensubstantialincreasesintheprescribingofopioidsoverrecentyears.


3.1.1 Other analgesics

Gabapentin and pregabalin TherehasbeenasteepriseinthenumberofprescriptionsofgabapentinandpregabalinforthemanagementofchronicpainingeneralpracticeinEngland.22In2012,nearlythreemillionitemsofpregabalin,andthreeandahalfmillionitemsofgabapentinwereprescribed,representinga350%and150%increaseinprescribingofthesedrugsrespectively,since2007.35,36In2013,thetotalcostforthesemedicinesinEnglandwas£237.9m,mostofwhichwasaccountedforbypregabalin,whichisstillunderpatentforuseinpain,andcostatotalof£211.2min2013.37

Scotlandhasseenasimilarlyrapidincreaseintheprescribingofgabapentinandpregabalin.Between2010/11and2014/15,thenumberofitemsdispensedforeachdrugmorethandoubled,withgabapentinrisingfrom302,736itemsto629,741,andpregabalinrisingfrom133,985to364,111items.34InWales,pregabalinitemsdispensedmorethandoubledbetween2010and2014,increasingfrom121,495to282,183,andgabapentinuserosefrom192,767to395,109items.42InNorthernIreland,pregabalinappearstobeprescribedmuchmorereadilythanintherestoftheUK,38withthecombinednumberofitemsofgabapentinandpregabalinprescribedtotalling352,000for2013,a29%riseintwoyears.39Asthesefiguresdonotbreakdowndispenseditemsbyindicationitisnotpossibletodeterminepreciselytheproportionprescribedforthetreatmentofpaincomparedto,forexample,thoseprescribedtotreatepilepsy.However,manufacturersofpregabalinhaveestimatedthatapproximately80%oftotalUKpregabalinprescriptionsareforthetreatmentofneuropathicpain.40

AntidepressantsTherehasbeenanincreaseintheuseofantidepressantsthataremostcommonlyusedorrecommendedforthetreatmentofpain.Totalprescriptionsforamitriptylineincreasedby36.1%andforduloxetineby131.3%,to11.85millionand1.36millionitemsrespectivelyinEnglandbetween2010and2014.31,32Althoughnotbrokendownbyindication,amitriptylineisnowusedmorecommonlyfortreatingpainthanitisfordepression.41InScotland,between2010/11and2014/15,amitriptylineprescriptionsincreasedby25.6%from931,799to1,169,917itemsandduloxetineby150%from60,279to150,790items.33InWales,amitriptylineincreasedby50.6%from575,196itemsto866,025items,andduloxetine108.7%from88,883to185,425items.42InNorthernIreland,prescribedamitriptylineitemsincreasedby76.2%from222,358to391,720andduloxetinefrom58,284to106,980items,or83.5%.34

NSAIDsItisnotclearwhatproportionofNSAID(nonsteroidalanti-inflammatorydrug)prescribingisforindividualswithchronicpain.TheprescribingofdiclofenacinthecommunityinEnglandhasreducedsignificantlyinrecentyears,fromover8.6millionitemstolessthan3million,nowaccountingforapproximately10%ofNSAIDprescriptions.43 ThesedatareflecttrendsthroughouttherestoftheUKwheretheprescribingofdiclofenachasdecreasedoverrecentyears.33,34,42Thishasmostlikelyresultedfromupdatedguidanceonitscardiovascularrisk(seeSection 3.3),andmayhaveimportantimplicationsfortheprescribingofopioidanalgesics.Incontrast,theprescribingofNaproxeninEnglandincreasedfrom1.1millionitemsin2005to7.6millionin2015.43 OverthesametimeperiodtheprescribingofIbuprofenincreasedfromapproximately6millionitemsto7.3million.InScotlandtheprescribingofibuprofeninthecommunityincreasedby79%between2014/15and2015/16,withNaproxenprescribingincreasingby18%.33


3.2 Analgesic use in chronic pain – exploring the evidence

Thefollowingprovidesabriefintroductiontotheevidencesurroundingtheeffectivenessofopioidsandotheranalgesicsfortreatingchronicpain,aswellasthepotentialharmsassociatedwiththesedrugs.

3.2.1 EfficacyofopioidsforchronicpainAshighlightedbyOpioids Aware,thereisalargebodyofevidence–includingrandomisedcontrolled trialsaandsystematicreviews–thathasconcludedthatopioidsmayreducepainforsomepatientsintheshortandmediumterm(lessthan12weeks).44Theiruseinacutepainandforpainattheendoflifeiswellestablished.Thereis,however,alackofconsistentgood-qualityevidencetosupportastrongclinicalrecommendationforthelong-termuseofopioidsforpatientswithchronicpain.Meta-analysesassessingevidenceoftheeffectivenessofopioidsforpatientswithchronicpainofwhateveraetiology,havesuggestedthattheyareonlyeffectiveinaminorityofpatients.4,45,46,47,48,49,50,51,52,53

Alimitingfactoristhatmostclinicaltrialsofchronicpainmedicinesareconductedovera12-weekperiod,andthereareverylimiteddatathatprovideevidencefortheiruseforperiodsoflongerthansixmonths.Giventhelimiteddurationofmostclinicaltrialsforopioidanalgesics,andtheimpracticabilityofusingplacebocontrolsoverprolongedperiods,dataontheefficacyoflong-termusehasbeenlimitedtoassessmentincaseseriesandopen-labelextensionsofcontrolledtrials,bratherthanplacebo-controlledstudies.44Analysisofthesedatadoesnotallowfirmconclusionswithregardstofunctionalimprovementorimprovementinapatient’squalityoflife.A2015meta-analysis–assessingtheefficacy,tolerabilityandsafetyofopioidanalgesicsinopen-labelextensiontrialsoveradurationofsixmonthsormore–highlightedthatonlyaminorityofpatientsselectedforopioidtherapycompletedthestudies,yetsustainedeffectsofpainreductioncouldbeseeninthesepatients,includinginthosewithneuropathicpain.54Longtermcohortdatamayprovidefurtherinformationontheexperiencesofpatientsusingopioidslong-terminclinicalpractice.55Similarly,ithasbeensuggestedthat‘pragmatictrials’measuringawiderangeofpatientoutcomesshouldbeutilisedforassessingtheeffectivenessofpainmedications.56

Onedifficultyinassessingtheeffectivenessofopioidtreatmentarisesfromthenumberofpossibleadverseeffects,includingnausea,headache,somnolence,urinarycomplicationsandconstipation(seeSection 3.3).Manystudiessufferfromlow-compliancerates,57withpatientsdiscontinuingtreatmentduetoadverseeffectsorwithinsufficientpainrelief.

Ina2009evidencereviewbytheAmericanPainSociety,itwashighlightedthatwhilstrecommendationsfortheuseofopioidsinchronicpainhavebeenmadeonthebasisofasystematicreview,thesearerarelysupportedbyhighquality,orevenmoderatequalityevidence.Instead,theyrelyonexpertconsensustoovercomenumerousresearchgapsinareassuchasbalancingtherisksandbenefitsofopioidtherapy.58

Key messages – Thereisalackofgood-qualityevidencetosupportastrongclinicalrecommendationforthelong-termuseofopioidsforpatientswithchronicpain

– Thereareonlylimiteddatathatprovideevidencetosupporttheuseofopioidsforperiodsoflongerthansixmonths

– Manyclinicalstudiesofopioidsforchronicpainsufferfromlow-compliancerates,withpatientsdiscontinuingtreatmentduetoadverseeffectsorwithinsufficientpainrelief.

a Randomisedcontrolledtrialsarestudiesinwhichpeoplearerandomlyassignedto2(ormore)groupstotestanintervention.Onegrouphastheinterventionbeingtested,theother(controlgroup)hasanalternativeintervention,adummyintervention(placebo)ornointerventionatall.

b Open-labelextensionstudiestypicallyfollowonfromrandomisedcontrolledtrials,toallowassessmentoveralongerperiodoftime.Theyarenotplacebocontrolledandbothresearchersandparticipantsknowwhattreatmentisbeingadministered.


Current guidance on opioid prescribing for chronic pain Despitelimitationsintheevidence,guidanceisavailableforprescribersintheUKontheuseofopioidsfortreatingpain.ClinicalguidancefromNICE(NationalInstituteofHealthandCareExcellence)ondrugtreatmentforneuropathicpainrecommendstheuseofmorphineortramadoltotreatneuropathicpainonlywhenadvisedbyaspecialist.59Ithasgradedmostoftheavailableevidenceasloworverylowduetoinsufficientfollow-upperiods.59Separately,guidancefromtheIASPNeuropathicPainSpecialInterestGroup(NeuPSIG)–basedonsystematicreviewandmeta-analysis–madeonlyweakrecommendationsfortheuseoftramadolandotherstrongopioidsassecondandthird-linetreatments,respectively,forneuropathicpaininadults.46Originallydevelopedtoassistthetreatmentofcancer-relatedpain,theWHO’sanalgesicladderisoftenusedasaguidetothetreatmentofchronicpainbutithasneverbeenvalidatedinthissetting.Theanalgesicladdersuggeststhatwithincreasingreportedpainintensity,increasinglystronganalgesicsshouldbeprovidedanddosesofstrongopioidsincreaseduntilpainiscontrolled.Chronicpainisacomplexentityreflectingfactorsbeyondtheoriginal,orongoing,stimuli.Furthermore,theevidencethatescalationofopioiddosesinthissettingconfersanimprovementinpainorfunctionisweakandthereisstrongevidencethatharmfromopioidsisdoserelated. IthasbeensuggestedthatuseoftheWHOladderinpatientswithlongtermpainfailstorecognisethecomplexityofthechronicpainexperience,andmaycontributetoinappropriateprescribing.60

In2010,theBPSproducedgoodpracticeguidelinesonopioiduseinpersistentpain,statingthat,whileopioidscanbeeffective,otherevidence-basedinterventionsshouldbeusedifavailable.11 Opioids Awarereplacesandsupersedesthe2010guidanceandplacesemphasisongeneralprinciplesofgoodprescribingpracticeunderpinnedbyanunderstandingoftheconditionbeingtreated,appropriatepainassessmentandmonitoringofprescribingtoensurethatmedicinesthatareineffectivearestopped(seeBox 3).61

Box 3 – ‘Opioids Aware’ prescribing resource

Opioids AwareisaprescribingresourcefundedbyPHE(PublicHealthEngland)andproducedbytheFPM(FacultyofPainMedicine)inconjunctionwithNHSEngland,othermedicalRoyalColleges,NICE,theCQC(CareQualityCommission),NHSBSA (NHSBusinessServicesAuthority),theRoyalPharmaceuticalSocietyandtheBritishPainSociety.Theresourceaimstosupportallhealthcareprofessionals,patients,andcarersinunderstandingthepotentialbenefitsandharmsofopioidtreatment.

Recognisingthatexistingguidancehasbeenrelativelyunsuccessfulininfluencingtheuseofanalgesics,ithastakenadifferentapproach.Itinsteadbreaksdowntheavailableevidenceintosmallersections,makingitmoreaccessibleandplacingopioidsinthewidercontextofpainmanagement.Itprovidesguidanceinthefollowingareas:

– Bestprofessionalpractice; – Thecondition,thepatient,thecontext – Clinicaluseofopioids – Astructuredapproachtoopioidprescribing – Informationforpatients

Theresourcecoversissuessuchasopioidsandthelaw;writingprescriptions;reportingharms;theroleofpharmacistsinsafeprescribing;assessingandmanaginglong-termpain;theroleofmedicines;effectivenessofopioids;sideeffectsandharms;prescribingtrends;problemdruguseandspecialcircumstances.


Adetailedexplanationoftherisksandbenefitsmustbeundertakenwiththepatientbeforeopioidsarestarted.Asmallproportionofpeoplemayobtaingoodpainreliefwithopioidsinthelongtermifthedoseiskeptlowandespeciallyiftheiruseisintermittent.Thesepatientscanbemanagedwithregularmonitoring.Toomanypeoplewithchronicpainareprescribedopioidsathighdoses.Theriskofharmincreasessubstantiallyathighdose.Aboveanoralmorphineequivalentdailydoseof120mg,furtherbenefitisunlikely.Ifbenefitinpainreductionandimprovedfunctionisnotachievedatlowdose,opioidsshouldbediscontinued,evenifnoothertreatmentisreadilyavailable.

Chronicpainisverycomplexandifpatientshavedisablingsymptomsthatdonotrespondtotreatment,adetailedassessmentofthemanyemotionalinfluencesontheirpainexperienceisnecessary.ThismaybedonebyaGPorinapainmanagementservice.Patientswithchronicpaininhighdoseopioidsshouldbereferredtospecialistpainmanagementservices,andifpossiblejointpainandaddictionservices.Theidealpracticeisthentoreducetheopioiddose.FurtherguidanceisavailablefromOpioids Aware

Recommendation:Tobetterinformclinicalpracticemoreresearchisrequiredintotheeffectsoflong-termprescribingofopioidsforpainrelief,includingtheirefficacy &safetyforperiodslongerthansixmonths.

3.2.2 Efficacyofotheranalgesicsforchronicpain

Gabapentin and pregabalinGabapentinandpregabalinarelicensedintheUKforthetreatmentofneuropathicpainandrefractoryepilepsy.Pregabalinisalsolicensedforthetreatmentofgeneralisedanxietydisorder.Theevidencefortheuseofgabapentinandpregabalinforthetreatmentofneuropathicpainismorecomprehensivethanthatofopioids,asreflectedintheirindicationsandtheirrecommendeduseinguidelines.NICEclinicalguidanceforprimarycareprofessionalsondrugtreatmentforneuropathicpainrecommendstheuseofgabapentinorpregabalin(aswellastheanti-depressantsduloxetineoramitriptyline)asinitialtreatment,withdueconsiderationofapatient’sco-morbiditiesandcontext.59,62 Thisrecommendationisbasedonevidencefromrandomisedcontroltrialsshowingthatbothreducepainincomparisontoaplacebo.59Separately,asystematic-reviewandmeta-analysisfromtheNeuPSIGoftheIASPrecommendedgabapentinandpregabalinforfirst-lineuseinadultswithneuropathicpain.46Despitetheserecommendations,a2014systematicreviewconcludedthatoverhalfofpatientstreatedwithgabapentinforchronicneuropathicpainorfibromyalgiacwillnothavesubstantialpainrelief,determinedasareductioninpainintensityofatleast50%.63Sixineverytenpatientscanexpecttohavesomeadverseeffects,suchasdizziness,somnolence(drowsiness),peripheraloedema(swelling)orgaitdisturbance.63

Aseparate2009systematicreviewconsideringtheuseofpregabalinsimilarlyfoundnousefulbenefittoasignificantproportionofpatients.64However,inbothcases,asmallnumberofpatientswerefoundtobenefitsubstantially,includingwithmarkedimprovementsintheirqualityoflife,whilemorebenefittedmoderately. Thereisnogoodevidenceforeffectivenessofgabapentinandpregabalinforacutepainorforlong-termpainthatisnotofneuropathicorigin.Moreresearchisrequiredtoensuregabapentinandpregabalinareusedinthebestpossibleway,tomaximisethepotentialbenefittopatientswithchronicpain,whilstminimisingtheriskofharm.50

c Fibromyalgiaisalong-termconditionthatcancausewidespreadpainandsymptomsinmanyotherbodilysystems.


AntidepressantsThereisevidencethatsomeantidepressantsmaybehelpfulforsomepatientswithchronicpain.A2007systematicreviewsuggestedthatanumberofantidepressants–in-particulartricyclicantidepressants–canbeeffectiveinthetreatmentofchronicpain.65However,a2015systematicreviewassessingtheuseofthetricyclicantidepressantamitriptylineforthetreatmentofneuropathicpainconcludedthat,despiteitswidespreaduseandsuccessfultreatmentinmanypeoplewithneuropathicpain,thereisalackofsupportiveunbiasedevidenceforitsbeneficialeffect,withfewstudiesmeetingthemostrecentresearchstandards.66

Inareviewof19studiesconsideringtheanalgesiceffectofSNRIs(serotonin-noradrenalinereuptakeinhibitors),12foundthattheyprovideclinicallyimportantpainreliefandareassociatedwithfewerside-effectsthantricyclicantidepressants.67Thereismoderatelystrongevidence–basedontheGradeProsystemofassessingevidenced–thattheSNRIsduloxetinereducespainindiabeticneuropathyandfibromyalgia.Asystematicreview,consideringsixrandomisedcontrolledtrials,concludedthatduloxetineisusefulforrelievingpainfromfibromyalgiaanddiabeticneuropathy,andaboutaseffectiveasotheravailabledrugs.68Althoughonesystematicreviewsuggeststhatamitriptylinedemonstratessuperiorefficacytoduloxetine.69Asystematic-reviewandmeta-analysisfromtheNeuPSIGoftheIASPrecommendedSNRIsortricyclicantidepressantsasfirst-linetherapyforneuropathicpain.46

NICEguidanceforthetreatmentofneuropathicpainrecommendstheuseofamitriptylineandduloxetineasfirstlinetreatmentsforneuropathicpain,alongsidegabapentinandpregabalin.Switchingbetweenthesefourisrecommendedifthefirstisnotsuccessful.62 SIGNguidanceforthetreatmentofchronicpainrecommendstheuseofamitriptylineforneuropathicpainandfibromyalgia,andtotryalternativetricyclicantidepressantsifthere isaneedtoreducesideeffects.

NSAIDsA2015systematicreviewconcludedthatthereisnoevidencetosupportorrefutetheuseofNSAIDsinneuropathicpainconditions,70whichisreflectedintheguidanceavailableforthetreatmentofneuropathicpain.A2015reviewofNSAIDsforchroniclowbackpainconcludedthattherewaslowqualityevidencethattheyareslightlymoreeffectivethanplacebo.71 AseparatereviewoftopicalNSAIDsforchronicmusculoskeletalpainindicatedthattheyprovidedsignificantlymoretrialparticipantswhohadosteoarthritisofthekneeorhandwithgoodlevelsofpainreliefthanplacebo,butthattherewasnoevidencefortheeffectivenessoftopicalNSAIDsinotherchronicpainfulconditions.72

d GradeProistheofficialsoftwareoftheGradingofRecommendationsAssessment,DevelopmentandEvaluation(GRADE)WorkingGroup,withthegoalofcreatingacommonapproachtogradingqualityofevidence.IthasbeenupdatedforusebyCochranereviewauthorstocreatesummaryoffindingstables. http://tech.cochrane.org/revman/other-resources/gradepro/about-gradepro


3.3 Potential harms associated with long-term analgesic use in chronic pain

Therearesignificantpublichealthconcernsabouttheharmfuleffectsofanalgesics,particularlyregardingtheirlong-termuse.Thefollowingbrieflyexploresthepotentialharmsassociatedwiththeuseofopioids,andotheranalgesics,forthetreatmentofchronicpain.

Box 4 – Opioid prescribing in the USA

ConcernsabouttheharmscausedbyextensiveprescribingofopioidshavebecomeparticularlypertinentasaresultoftheirextensivemisuseintheUSA.

AccordingtotheCDC(CentersforDiseaseControl),theannualnumberofopioidprescriptionsintheUSAquadrupledbetween1999and2014.73Thisincreasehasbeenmatchedbyasteepincreaseinopioid-relatedmortality.74Mortalitytrendsindicatearapidincreaseinthenumberofdeathsfromunintentionaldrugpoisoningwithopioidanalgesics,withdeathsinvolvingopioidsrisingfrom4,041in1999to14,459in2007.44Seventy-fivepercentofallpharmaceuticaloverdosedeathsintheUSAin2010involvedopioids.75In2014,morethan14,000peoplediedfromoverdosesinvolvingprescriptionopioids.74AccordingtodatafromtheCDC,prescriptiondrugoverdosesintheUSAoccurdisproportionatelyamongstpatientswhoareseeingmultipledoctors,orseeingonedoctorandreceivingahighdosage.76

IntheUK,therehasbeenafocusonunderstandingthelessonsthatcanbelearnedfromthesignificantprescriptionopioidmisuseintheUSA.Thishasincludedexplorationoftheextenttowhichthesituationiscomparablebetweenthetwocountries,andidentifyingwhichcontributoryfactorsmaybeuniquetotheUSA.77,78 Ithas,forexample,beensuggestedthatpharmaceuticalcompanymarketingpracticesintheUSAhaveservedtoinflatethebenefitsandobscuretheharmsofprescriptionopioids.78IthasalsobeenhighlightedthatspecificdifferencesinthehealthcaresystemsofthetwocountriesmayinfluencetherelativeharmsassociatedwithopioidmisuseintheUSAandUK,77,78asmayeachcountry’swiderpolicyonillicitdrugs.77

3.3.1 Harms associated with opioids

Mortality AshighlightedinSection 3.1,prescribingdataindicatesthattheuseofopioidshasincreasedsubstantiallyintheUK.TodatethishasnotresultedinthesamesignificantincreaseinopioidrelateddeathsthathasbeenseenintheUSA(seeBox 4).77TheUKhas,however,seenanincreaseindeathsinvolvingopioidswithheroin,methadoneandmorphine(thislatternotedatpostmortemasametaboliteofheroin)beingthebiggestcontributors.AlthoughthetotalnumbersaresubstantiallylowerthanintheUSA,theoveralltrendsaresimilar.ThoughitshouldbenotedthatintheUSAprescriptionopioiddeathssignificantlypredominateoverheroin.79EnglandandWalesexperiencedadoublingofannualdeathsinvolvingcodeinebetween2005and2009,80andtherewereatotalof128deathsinvolvingcodeinein2015.81 Therehasalsobeenasignificantincreaseinthenumberofdeathsrelatedtotramadol,risingfromonerecordedinEnglandandWalesin1996,to208in2014althoughmostrecent(2015)datashowafallinthelast12months.81Thesemortalitydatapromptedschedulingofthedruge in 2014.82Mosttramadoldeathswereinconjunctionwithotherdrugsanditisnotknownwhetherthetramadolwasorwasnotprescribedforthosepatientsinwhomthedrugwasmentionedonthedeathcertificate.InScotland,tramadol-relateddeathsincreasedfromeightin2001to34in2011.55 StatisticsfromNorthernIrelandalsoshowanincreaseindeathsfromarangeofopioids.Between2003and2013,thenumberofdeathsinwhichtramadolwasmentionedonthedeathcertificaterosefrom0to20,althoughthisisdownfromahighof31in2012.Deathsinvolvingcodeinerosefrom2to22overthesameperiod.83

e FurtherinformationfromNICEaboutcontrolleddrugsisavailablehere.

https://www.evidence.nhs.uk/formulary/bnf/current/guidance-on-prescribing/controlled-drugs-and-drug-dependence


Respiratory depressionOpioidscanhaveaneffectonrespirationviaanumberofmechanisms,84andrespiratorydepressionhasbeenhighlightedasaparticularprobleminacutepainmanagement–wherepatientshavenotdevelopedtolerance.44 Inpatientswithchronicpain,therearespecificconcernsoverdisturbanceofnocturnalrespiratorycontrol.85Forexample,therehavebeenreportedfatalitiesinpatientswithsleepapnoeawhoareprescribedopioids,andparticularrisksarisewhenopioidsareprescribedwithothersedativedrugs,particularlybenzodiazepines.44

Endocrine and immune effects Thereisevidencethatopioidusecanadverselyimpactuponarangeofendocrinefunctions.86AshighlightedinOpioids Aware,opioiduseisassociatedwithhypogonadismandadrenalinsufficiencyinbothsexes.61 Ithasalsobeendemonstratedinanimalandhumanstudiesthatopioidscanhaveasuppressiveeffectonimmunefunction,butthatthismaydifferfordifferentopioidanalgesics.61,87

Hypersensitivity to pain (hyperalgesia)Anumberofstudieshaveindicatedthat,paradoxically,prolongeduseofopioidscanresultinhypersensitivitytopain(hyperalgesia).A2006systematicreviewofopioid-inducedhyperalgesiahighlightedthatopioidanalgesicscanrenderpatientsmoresensitivetopainandpotentiallymayaggravatepre-existingpain.88 Opioids Awarestatesthathyperalgesiahasbeendemonstratedinpreclinicalstudies,inpatientsreceivinghighdosepotentopioidsasacomponentofgeneralanaesthesiaandinexperimentalstudiesofpatientsmaintainedonmethadoneforthetreatmentofopioidaddiction.Theclinicalsignificanceofthesefindingsinroutineprescribingisnotknown.61

Dependence and withdrawal The2016BMAanalysisreportonPrescribed drugs associated with dependence and withdrawalhighlightedthepotentialthatopioids,prescribedtotreatchronicpain,willleadtotoleranceandphysicaldependence,especiallywithprolongedtreatmentandathigherdoses.2Thereportalsonotedthatwithdrawalsymptomscanbesevereanddisabling.2It shouldbenotedthattoleranceandtheexperienceofwithdrawalsymptomsonopioidcessationarenormalpharmacologicaleffectsofopioidtreatmentandshouldnotbeconfusedwithaddictionoropioidmisuseorabuse.Therearecertainriskfactors–includingco-morbidmentalhealthdisordersandsubstancemisusedisorders–thatlong-termepidemiologicaldataindicateareassociatedwithindividualsbeingmorelikelytoreceiveopioidprescriptionsforpain.Patientswiththeseriskfactorsaremorelikelytobeprescribedhigherdosesofopioidsandmorelikelytobeco-prescribedothercentrallyactingdrugsincludingbenzodiazepines–aphenomenondescribedas‘adverseselection’.44

3.3.2 Harms associated with other analgesics

Gabapentin and pregabalin Aswithopioids,gabapentinandpregabalinhavebeenassociatedwithincreasingmortalityintheUK.Instancesofgabapentinbeingmentionedondeathcertificatesincreasedsignificantly,from4in2010to49in2015.81Pregabalinhasshownanincreasingtrendintermsofprescriptionlevels,positivepost-mortemtoxicologyfindings,andinthemisuseofthedrugbeingimplicatedindeath.59Instancesofgabapentinbeingmentionedondeathcertificatesincreasedfrom4in2010to90in2015.81

ThedependencepotentialassociatedwithgabapentinandpregabalinhasalsoledtoconcernsthatthenumberofpeoplemisusingtheseprescriptionmedicinesmayberisingintheUK. PHEandNHSEnglandhaveproducedadviceforprescribersonthepotentialformisuseofgabapentinandpregabalin,warningofthedangersofdependenceandthediversionofprescribeddrugs –wherebydrugsareunlawfullytransferredfromtheirintendedrecipienttoanotheruserordistributor.37Highlevelsofmisuse,particularlyofpregabalin,havebeenreportedinprisonpopulations,and, inJanuary2016,theACMD(AdvisoryCouncilfortheMisuseofDrugs)recommendedthat–duetotheharmsassociatedwiththesedrugs–gabapentinandpregabalinshouldbecontrolledundertheMisuseofDrugsAct1971.89


AntidepressantsDatafromtheOfficeforNationalStatisticsindicatethat,in2013,therewere466deathsinEnglandandWalesassociatedwithantidepressants,withthenumberofdeathsassociatedwithamitriptylinerisingby12%since2012.90Thoughavailabledatadoesnotallowforadistinctionbetweenpatientswhoweretakingantidepressantsfordepressionandthosetakingthemforthereliefofpain.

TCAs(tricyclicantidepressants)areassociatedwithanumberofadverseeffects,includingdrymouth,constipation,tachycardia,cardiacarrhythmia,andblurredvision.Overdosewiththesedrugsisassociatedwithahighrateoffatality.91IncomparisontoTCAs,SSRIs(selectiveserotoninreuptakeinhibitors)havemoretolerablesideeffectsandgreaterrelativesafetyinoverdose,92,93butareassociatedwithgreaterwithdrawalsymptomsinpeoplediscontinuinguse.94A2009systematicreviewoftheuseoftheSNRIduloxetineindicatedthatmostpeopletakingitwillhaveatleastonesideeffect,butthesearemostlyminor.Neverthelessaboutoneinsixpeoplediscontinueduloxetineasaresultofsideeffects.68

NSAIDs TherearespecificissuesaroundtheuseofNSAIDs,includinglong-standingandwell-recognisedgastrointestinal,cardiovascularandrenalsafetyconcerns,whichhavebeensummarisedinNICEprescribingguidance.95ThishighlightsthatadecisiontoprescribeNSAIDsshouldbebasedonanassessmentofaperson’sindividualriskfactors,includinganyhistoryofcardiovascularandgastrointestinalillness.95ConcernsoverthecardiovascularandgastrointestinalsafetyofNSAIDsmayhavecontributedtoincreasedprescribingofotheranalgesic classes.


4 Supporting the management of patients with chronic pain

Overthelastfewdecades,opioidshavebeenincreasinglyusedintheUKtomanagechronicpain.Potentialreasonsforthisincludetheavailabilityofnewpreparationsandformulationsofopioids,changesinpatientexpectation,prescribingpractice,andsocietalattitudes.12Otherstudieshaveidentifiedalackofconsensusregardingappropriateuseofmedicines,alackofsuitablealternatives,thedifficultystoppingorreducingapatient’sopioidprescription,andpatientdemandforopioidtreatments(includingfromthosewhomaybeaddictedoraredivertingprescriptionmedicines).96Afurthercontributoryfactoristhehistoricunder-treatmentofpain,whichmayhavemotivatedwell-intentionedeffortstoenhancetheavailabilityofprescriptionanalgesics,includingopioids.96Giventheweakevidencebaseandpotentialharmsassociatedwithlongtermanalgesicusediscussedintheprecedingsection,thereisaneedtoexploretherangeofsupportrequiredforpatientssufferingfromchronicpain.

Thefollowingsectionsfocusonthestepsrequiredtoensurethatallpatientswithchronicpainhaveaccesstothemostappropriatetreatment,andtoensuredoctorsareadequatelysupportedinthemanagementofthesepatients.

4.1.1 Attitudes towards the use of opioidsfor chronic painAnalysisoftheattitudestoopioidprescribingintheUSAhassuggestedthat,historically,concernsaboutaddiction,thepotentialforincreaseddisabilityandlackofefficacyoverlongertime-periodslimitedtheiruseinthetreatmentofchronicpain.97Inthe1980s,reportsandarticlesbegantoemergethatsuggestedopioidscould,orshould,beusedtotreatchronicpain,basedonearlierexperiencestreatingcancerpatients. Twopapershavebeenidentifiedasbeingparticularlyinfluentialinthisregard.97In1986,PortenoyandFoleypublishedapaperdescribingtheirexperiencesoftreatingpatientswithnon-malignantpainthatstronglyadvocatedtheuseofopioidsoverlongerperiodsoftime.98In1990,Melzackwrote‘TheTragedyofNeedlessPain’,97,99whichcalledformoreresearchintotheuseofopioidsfornon-cancerchronicpain,arguingthatpeoplewereunnecessarilysufferingfrompainbecauseoffearsofaddiction.

Prescribingbehaviourinrelationtoopioidsmaybesubjecttoarangeofinfluences.A2007surveyofGPs’attitudesfoundthat53%ofthosewithoutspecialisttrainingfeltthatboththeirmedicalschoolandprimarycaretrainingwereinadequatewithregardtopainmanagement.100Evensoitsuggestedthatthepresenceofguidelinesandthelevelofspecialisttraininghadlittleimpactontheprescribingofopioids.InthestudyGPswhodidnotcommonlyprescribeopioidswerefoundtobeolder,andtohavebeenpracticingforlonger,thanthosewhodid.100 Aseparate2008surveyofGPsintheUKindicatedthatthelikelihoodofprescribingopioidsmaybeinfluencedbyapractitioner’sage,genderanddegreeofspecialisttraining.101AfurthersmallqualitativestudyoftheattitudesofGPstoprescribingsuggestedthattheyhadamorecautiousapproachtoprescribingopioidsforchronicnon-cancerpainthanforcancer-relatedpain.102

A2015qualitativestudyofopioidprescribinginprimarycarehighlightedarangeoffactorsidentifiedbypatientsanddoctorsthatinfluencedprescribinginthissetting.Theseincludedthedifficultiesofshort-term,oftenemotionallychargedconsultations;highlightingtheimportanceofcontinuityinthedoctor-patientrelationship.103


4.1.2 Challenges when stopping opioid treatment Doctorscanfacesignificantchallengesinstoppingopioidtreatmentforpatientsinwhomthesemedicationshavenotprovidedeffectivepainrelief.Thismayresultinpatientsbeingprescribedopioidsdespitethefactthattheyarereceivingnobenefitfromthem.Assetout in Opioids Aware (seeSection 3.2), ifitisthoughtopioidtherapymayplayaroleinapatient’spainmanagement,atrialshouldbeinitiatedtoestablishwhetherapatientachievesareductioninpainwiththeuseofopioids–ifnottheyshouldbestopped.44Thedifficultiesinceasingopioidtreatmentifnoteffectivehavebeenacknowledged.3Itcan,forexample,beverydifficulttotellapatientthattheirtreatmentisnotworkingwhentheyareclearlyinpain,andthereareoftenfewalternativestousingopioidsinattemptingtoreducechronicpain.3

Guidanceontheuseofopioidsforchronicpaindoesrecommendstrategiestomanagethis.Forexample,theSIGNpathwayforusingstrongopioidsinpatientswithchronicpainrecommendsatrialofopioidswithstoppingrulesagreedwiththepatient,suchasiftreatmentgoalsarenotmet,orifthereisnoclearevidenceofdoseresponse.104Ithasbeenhighlightedthatwhileopioids,aswellasotheranalgesicsincludinggabapentinandpregabalin,canworkeffectivelytorelievepain,thisisonlyachievedinasmallpercentageofpatients,andprescribersmustexpectanalgesicstofailforthemajorityofpatients.105Itisunusualforanyanalgesic,includingopioids,tocompletelyeliminatepain,andthatthefocusoftreatmentshouldbeonreducingapatient’spainwithaviewtoimprovingtheirqualityoflife.

Recommendation:Considerationshouldbegiventotherangeofsupportthatisrequiredfordoctorsandpatientsduringtheprocessofassessment,trialandreviewofopioidtreatmentforchronicpain.Thisshouldincludesupportforstoppingopioidtreatmentthatisnotworking.

4.1.3 SupportingtheeffectivemanagementofchronicpaininprimarycareMostpatientswithchronicpainfirstcontacthealthservicesthroughprimarycare,andaresubsequentlymanagedinthissetting.AccordingtotheRCGP(RoyalCollegeofGeneralPractitioners),peoplewithchronicpainconsulttheirGParoundfivetimesmorefrequentlythanthosewithout,andchronicpainisapresentingconditioninaround22%of consultations.106Itisgenerallyacceptedthatmorestraightforwardpainproblemscanbeassessedandmanagedbynon-specialistsinaprimarycaresetting,withspecialistcarerequiredforcomplexpain,andevenwhenpatientsarereferredtospecialisttreatment,theirongoingcareislikelytoreturntotheirGP.107Ina2015parliamentaryreport,theChronicPainPolicyCoalitioncalledforaminimumstandardofyearlyassessmentofpatientsbeingtreatedwithopioidsfortheirchronicpain.108

Supportingactioninthisareaisdependentuponadequateresourcingofgeneralpractice.AshighlightedintheBMA’s2015visionforgeneralpractice–Responsive, safe and sustainable: towards a new future for general practice–havingsufficienttimetospendwithpatientsisoneoftheleadingfactorsidentifiedbyGPsthatcouldhelpthemtobetterdelivertheessentialsofgeneralpractice.109Thevalueofadequateconsultationtimesisparticularlyimportantforpatientsthathavecomplexconditionswhichmayrequiregreaterexploration,asisoftenthecaseforpeoplesufferingfromchronicpain.Sufficientresourcesarealsonecessarytosupportregularreviewsofmedicationuse.Furtherconsiderationshouldbegiventotheroleofpharmacistsinpainmanagementinprimarycaresettings.110,111

Recommendation:Sufficientinvestmentandresourcesforprimarycare,includinglongerconsultationtimes,arerequiredtosupportimprovementsinanalgesicprescribingforpatientswithchronicpain.


4.1.4 Supporting the development of specialist chronic pain servicesSomepatientswithchronicpain,includingthosewithcomplexco-morbidities,willrequirethesupportofspecialistservices.115Specialistsinpainmedicineplayacentralroleinpainmanagementascompetentphysicianswiththetrainingandexpertisetounderstandandmanagepainfulmedicalconditions,diagnosetreatableunderlyingcausesofpainandhighlightunmetphysicalandmentalhealthneeds.Referraltospecialistpainservicesisindicatedwherepainisassociatedwitheitherorbothhighlevelsofdistressand disabilityorwhenseverepainremainsrefractorytotreatment.Improvingaccesstospecialistserviceswouldbettersupportpatientstocopewithpain,andmayreduceinappropriateprescribingofstronganalgesics.Amultidisciplinary/multiprofessionalapproachisrecognisedasthemainrequirementforthisandthereshouldbereadyaccesstopainmanagementprogrammesforpatientswhoarelikelytobenefit(seeBox 5).112Multidisciplinarychronicpainservicesaremoreeffectivethannotreatment,ortreatmentasusual,forarangeofpatientoutcomes,includingpainexperience,moodandactivitylevels.115Therearearangeoffactorsthatimpactuponaccesstospecialistservices,including:thegeographicaldistributionofclinics;whetherservicesmeettheminimumstandardsforamultidisciplinaryservice;andreferraltopainmanagementservicesandthewaitingtimestoaccessthem.113 Thedevelopmentofspecialistservicesnecessitatessufficientavailabilityofappropriatelytrainedhealthcareprofessionals.Ithas,forexample,beenhighlightedthatthereisalackofpainmedicinespecialistsinsomepartsofEnglandandWales,andasawholeEngland&Walescurrentlyhavefewerchronicpainconsultantsper100,000populationthanScotlandandNorthernIreland–equatingtoatotalshortfallof118chronicpainspecialists.114

Box 5 – Pain management programmes

TheBPShaveproducedguidelinesforpainmanagementprogrammesforadults.Thesehighlightthattheprincipleofpainmanagementprogrammesisto“enablepeoplewithchronicpaintoachieveasnormalalifeaspossiblebyreducingphysicaldisabilityandemotionaldistress,andimprovingtheindividual’sabilitytoself-managepain-associateddisabilityandreducerelianceonhealthcareresources”.115

Thoughtheyshouldnotnecessarilybeexpectedtoachieveareductioninapatient’spain,thereisgoodevidencefortheefficacyofpainmanagementprogrammesinimprovingpainexperienceandphysicalfunctioningandfortheirpotentialtoreducemedicationuse.115

Psychologicalinterventionsmayhaveanimportantroleinthetreatmentofsomepatientswithchronicpain.Thereismoderateevidencethatpsychologicaltherapiescanhelppeoplewithchronicpainreducenegativemood(depressionandanxiety),anddisability.116 Thoughforsometypesofpain–forexampleneuropathicpain–thereisalackofstudiesassessingtheeffectivenessofthesetherapies.117Researchalsosuggeststhatpatient’sattitudestowardstheirpaincanhaveaninfluenceontheirqualityoflife.Forexample,fearofmovementasaresultofthepain,andotherpain-relatedfearscanbemoredisablingthanthepainitself,sotacklingsuchissuesisavitalconsiderationofanytreatment.118

Itisveryimportantthatco-morbidmentalhealthdisordersareidentifiedandmanagedappropriately.Oneapopulation-basedcase-controlstudyfconductedinManchesterfoundthatpatientswithchronicpainwerethreetimesmorelikelytosufferfromamentaldisorder,withmostpatientssufferingfrommoodandanxietydisorders.119

f Case-controlstudiesareobservationalstudiesthatcomparegroupsofpeoplewithandwithoutaparticulardisease or condition.


Patientswithcomplexmultiplemedicalsymptoms,particularlyiftheyarefindingitdifficulttoreducehighharmfuldosesofopioids,needtobemanagedinteamswithmentalhealthexpertiseindiagnosingandmanagingcommonmentalhealthdisordersincludingsignificantdepression,personalityvulnerabilities,post-traumaticstressdisorder,somatisationdisorder,addiction,andinmanagingtheemotionaleffectsofprevioustraumaticexperiences.

Access to servicesThereishighvariationinaccesstomultidisciplinarycare,withmanypainclinicsnothavingadequateaccesstoapsychologist,physiotherapistandphysician.20The2012NationalPainAuditfoundthatonly40%ofpainclinicsinEngland,and60%inWales,mettheminimummultidisciplinarystandard–thepresenceofapsychologist,physiotherapistandphysician–comparedto64%and80%respectivelythatself-identifiedasmultidisciplinary.Thereportrecommendedbetteraccesstophysiotherapyandpsychologygiventhehighrateofanxietyanddepression,andthelinkwithpoorphysicalfunctioning.20Italsohighlightedthatpainclinicsshouldbeabletotreatawidevarietyofconditions;theaudit,forexample,indicatedthatsomeclinicsappeartofocusmainlyonspinalpainorothermusculoskeletalcomplaints,despitetheneedfortreatmentforconditionssuchaspelvicpainornon-musculoskeletalneuropathicpain.20FreedomofinformationrequestsfromtheChronicPainPolicyCoalitioninJune2013indicatedthat,ofall211CCGsinEngland,28%hadnonamedclinicalleadforpainservices,27%couldnotprovideanamedmanageriallead,and29%ofdidnotcommissionmultidisciplinarypainservices.120

Closerworkingbetweendifferentpartsofthehealthcaresystemisessential.Integratedworkingbetweenprimarycareandthespecialisttreatmentprovidedbysecondarycare,orspecialistcommunity-basedservices,isincreasinglyseenasthemoreappropriatemodelofcareforachievingthebestpatientoutcomes.112,121Patientsshouldbeabletomoveseamlesslybetweendifferentpartsofthesystemandbetweendifferentproviders,toensurethattheyreceivetimelyaccesstotheservicesrequired.112

WaitingtimesforspecialistservicesarenotconsistentacrosstheUK,withsomepatientshavingtowaitconsiderablylongerforspecialisttreatment.A2014reportbyHealthcareImprovementScotlandhighlightedsignificantvariationinwaitingtimesforspecialistservices,in-particularinaccesstopainpsychologyservices.122TheNationalPainAudit’sfinalreport–whichfocusedonEnglandandWales–suggestedthattheRCoA(RoyalCollegeofAnaesthetists)shouldadopttheIASPswaitingtimeguidanceforitsgoodpracticeguideforpainservices.Thisrecommendsthatpatientsshouldbeseenwithineightweeksforroutineorregulartreatment,onemonthforurgentorsemi-urgentcases,andoneweekforthemosturgent cases.20

Service provisionThereisavarietyofguidanceavailableontheprovisionofservices.SpecificguidanceonthecommissioningofchronicpainserviceshasbeenpublishedbytheRCGP,andendorsedbytheBPS,ChronicPainPolicyCoalitionandFPM.112Itexploreshowthecommissioningprocesscanbettersupportchronicpainpatientsandhowdoctorscanengagewithcommissionersmoreeffectively.Itskeypointsincludethat:

– painmanagementisbestdeliveredbymultidisciplinaryandmultiprofessionalteams; – thereshouldbeequityofprovisionacrosssocioeconomicscales,withservicesmeetingtheneedsoflocalpopulations;

– clinicalprofessionaladvicetocommissionersiskeytodeliveringthebestvalueservices – peopleshouldbeatthecentreofamulti-morbiditiesapproach,andinvolvedinservicedesignanddelivery.


TheFPMhavepublishedcorestandardsforpainmanagementservicesintheUK,whichareintendedtoprovideaclinicalguidelineandaframeworkforthoseplanningservices.113

Thesesetoutcorestandardsforpainmanagementservicesincommunity,secondarycare,andspecialistsettings.Theyhighlightthatspecialistpainmanagementservicesinthecommunityorsecondarycareshouldalwaysinvolveamultidisciplinaryteam,andthatamultidisciplinaryteammustinclude:

– medicalconsultants – nurses – physiotherapists – psychologists – pharmacists

Oftenthiswillalsoincludeoccupationaltherapists,andwhereavailable,suitablytrainedGPsaswellasSAS(specialtyandassociatespecialist)doctors.113 Thereneedtobecloseworkingrelationshipsinrelatedmedicaldisciplinesincludingorthopaedicsurgery,neurosurgery,neurologyandpsychiatry.

Somepainmanagementservicesholdcombinedpainandsubstancemisuseclinicswherepatientswhohavepainandwhoareusinghighdosesofprescribedopioidsorrecreationaldrugsandalcoholcanbeassessedandmanaged.

TheBPSguidelinesonpainmanagementprogrammesoutlinetheevidenceformultidisciplinaryservices,howpatientsshouldbereferredandtheresourcesthataserviceshouldhaveaccessto.Theyhighlighttheimportanceofpainmanagementprogrammesbeingproperlyresourcedwithadequatetime,personnelandfacilities,andrecognisetheneedtoimproveaccesstotheseprogrammestosupportearlyinterventionaswellascomprehensiverehabilitation.115TheBPShasalsodevelopeda‘commissioninghub’,whichisintendedtoprovideasourceofinformationondifferentservicemodels,commissioningissuesandoutcomesfromacrossthecountry.

Key messages – Painmanagementisbestdeliveredbymultidisciplinaryandmultiprofessionalteams. – ThereishighvariationinaccesstomultidisciplinarycareandwaitingtimesforspecialistpainservicesarenotconsistentacrosstheUK

4.1.5 Non-pharmacological interventions for chronic pain Non-pharmacologicaltreatmentmaybeeffectiveinreducinglong-termpainanddisabilityinsomepatientswithchronicpain.123Thesetreatmentoptionscanalsoaugmentandcomplementanalgesicuse.123Itisthereforeimportantthatpatientshaveaccessto,andopportunitytobenefitfrom,arangeofeffectivenon-pharmacologicaltreatmentoptionswhereappropriate.Non-pharmacologicalinterventionsforchronicpainincludepsychologicallybasedinterventions,suchasbehaviouraltherapies,aswellasphysicaltherapies.12 Thecorestandardsforpainmanagementservices,publishedbytheFPM,recommendthatpainmanagementprogrammesshouldutilisepharmacologicalandnon-pharmacologicaltreatmentoptions,andthatpatientswithchronicpainshouldhaveaccesstoclinicalpsychologyandspecialistphysiotherapyearlyintheirtreatmentpathway.115 As highlightedintheBPSguidelinesforpainmanagementprogrammes,thereisevidencefortheefficacyofcognitivebehaviouraltherapypainmanagementprogrammesinimprovingpainexperience,mood,coping,negativeoutlookonpain,andactivitylevels.115 Thoughthereremainsalackofstudiesassessingtheefficacyofpsychologicalapproachesforsometypesofpain.117 Furtherworkisalsorequiredtodeveloptheevidencebaseforinvasiveinterventionsinthetreatmentofchronicpain.124


Recommendations: – Allrelevantcommissioningandproviderorganisations–includingCCGsinEngland,healthboardsinScotlandandWales,andtheHealthandSocialCareBoardinNorthernIreland–shouldensurethatmultidisciplinarypainmanagementservicesareavailableforpatientsintheirareaandthatthesearecommissionedaccordingtoavailableguidance.Theseorganisationsshouldalsoworktoensuretimelyaccesstopainmanagementprogrammes,tosupportearlyinterventionandcomprehensiverehabilitationforpatientswithchronicpain.

– Allhealthcareprovidersthatareresponsibleforthemanagementofpatientswithchronicpainshouldbefamiliarwiththerangeofnon-pharmacologicalinterventionsthatmaybeeffectiveforthemanagementofchronicpain–includingphysicalandpsychologicaltherapies.Healthcareprofessionalsshouldalsobeawareofthelocalavailabilityoftheseservices.


5 Role of training and education in improving analgesic use for treating chronic pain

Thefollowingsectionexplorestheroleoftrainingandeducationinsupportingimprovementsinanalgesicprescribing.Itparticularlyfocusesonthestepsrequiredtoensureallnon-specialistshavethebasicknowledgeandskillstosupporttheappropriatemanagementofpatientswithchronicpain.ForinformationAppendix 2 providesanoverviewofthetrainingpathwayforpainmedicinespecialistsintheUK.Thereisaneedtoensurethattraininginmedicalschools,aswellaspostgraduatetraining–bothingeneralpracticeandforsecondarycaredoctorswhoarenotspecialistsinpainmedicine–equipsclinicianswiththeknowledgeandskillstosupporttheappropriatemanagementofpatientswithchronicpain.Trainingontheprinciplesofpainmanagementshouldensureallclinicianswhoarenon-specialistsinpainmedicineare:

– awarethatitisoftenunlikelythatanalgesics,includingopioids,willcompletelyeliminatepainandthattheyarelikelytobeeffectiveinonlyaminorityofpatients;

– awarethataswellasbeingacomponentofotherconditions,chronicpainisalong termconditioninitsownright,andlikemanyotherlongtermconditionsitusually cannotbecured;

– abletoeffectivelymanagetheexpectationsthatpatientsmayhaveabouttheirtreatment,forinstance,withregardtothelikelihoodthattreatmentwillsuccessfullyreducetheirchronicpainandthedegreeofpainreductionitcanberealisticallyexpectedtoachieve;

– comfortablehighlightingthatthefocusoftreatmentislikelytobeonreducingratherthaneliminatingpain,andmaintainingfunction,withaviewtoimprovingqualityoflife;

– abletoaccessspecialistinputandadvicetosupporttheseconversationswithpatients.

Aswellasthesebasicprinciples,theroleofdoctorsinassistingthosewithchronicpaintomanagetheimpactoftheirconditionandliveindependentlyhasbeenspecificallyhighlightedasanareathatwouldbenefitfromimprovedtraining.TheChronicPainPolicyCoalitionhavesuggestedthathealthcareprofessionalsshouldbe‘trainedtoencouragepeoplelivingwithchronicpaintoparticipateineducationandpeersupportprogrammestoaidindependentliving’.108Healthcareprofessionalsshouldalsobecomfortableinprovidinginformationregardingsupportedself-managementofchronicpain.113

5.1 A focus on undergraduate training

In2008,theChiefMedicalOfficer’s150thannualreportrecommendedthattraininginchronicpainbeincludedinthecurriculaofallhealthcareprofessionals.8Itnotedatthetimethatteachingatundergraduatelevelwaspatchyandinconsistent.ResearchintotheprovisionofpaineducationinmedicalschoolsacrossEurope–basedoninformationonthecontentofcurriculain2013–foundthattherewerecompulsorydedicatedmodulesinpaininonly4%ofUKmedicalschools,andonly11%offeredcompulsoryorelectivemodules.125 FiftypercentofmedicalschoolsintheUKdocumentedpain-specifictopicswithintheircurricula,eitheraspartofcompulsorydedicatedpainmodules,orpainwithinothercompulsorymodules–thelowestlevelof15Europeancountries,althoughtheresearchersdidindicatethatthelevelofdetailavailablewastoovariabletoallowcomprehensiveanalysis.125AdvancingtheProvisionofPainEducationandLearning(APPEAL)–aEuropewidereviewofundergraduatepaineducation–calledonmedicalschools,painspecialists,medicalstudentsandpolicymakerstoensurethatundergraduatestudentsreceivepaineducationtoallowthemtoadequatelytreatpain,inlightoftherelativelylittlecoverageitreceivesatpresent.126

TheGMC’s(GeneralMedicalCouncil)Outcomes for graduatesincludestherequirementtobeabletoprescribedrugssafelyandeffectively,andtoplandrugtherapyforcommonindications,includingpain.127Itisimportantthatthereisclearguidanceontheknowledgeandskillsinpainmanagementthatstudentsshouldbeexpectedtoacquireoverthecourseoftheirundergraduatequalifications.Medicalschoolsshouldconsiderhowtoincorporate


existingresourcesintotheirindividualcurricula.DespitetheproductionofpaincurriculabyIASP,128evidenceoftranslationintomoreeffectiveundergraduateeducationinpainislimited.

Arecentinternationalconsensushassetoutthecorecompetenciesinpainassessmentandmanagementthatshouldbeincludedinthecurriculaofallmedicalschoolsworldwide.129Thesecompetenciesareintendedtodriveimprovementsindeliveryofpaineducationandhelpshiftemphasistowardspainasadisease.Itisrecommendedthatthesecompetenciesareassessedwithintheexaminationprocessforgraduation.Inanotherinitiative,theFPMiscurrentlysupportingtheintroductionofapainmanagementcourse‘EssentialPainManagement-lite’tomedicalschools(seeBox 6)withemphasisondeliveryofpre-determinedpaincontent.TheFPMhasalsoproducedguidanceonthecompetenciesrequiredforarangeofpaininterventions,aswellasguidancespecifictothemanagementofpaediatricpain.130

Box 6 – Essential Pain Management (EPM-lite)

EPM-liteisascaleddownessentialpainmanagementcoursedesignedtobedeliveredtomedicalundergraduatesinhalfaday,withtheaimofexpandingthelevelofpainmanagementknowledgetaughtatundergraduatelevel.In2014,theFPMbeganaprojectofintroducingEPM-lite,andithasnowbeendeliveredinseveralUKmedicalschools.131

Recommendations: – Paincompetenciesshouldbeincludedinthecurriculaofallmedicalschoolsandbeassessedingraduationexaminations

– Medicalschoolsshouldensurethatexistingresources–suchastheIASP’scurriculumoutlineonpainandtheFPM’sEPM-liteprogramme–areusedeffectivelytoensuresufficienthighqualityundergraduateteachingonthebasicsofpainmanagement.

5.2 Promoting guidance to support improved analgesic prescribing for chronic pain

Topromotetheappropriatemanagementofchronicpain,renewedemphasisisrequiredontheutilisationofexistingguidance,andthedevelopmentoftoolstoassisthealthcareprofessionalswhenprescribinganalgesics.Aconsiderableamountofguidancehasalreadybeenproducedsettingouttherecommendedwaysofmanagingpainforpatientssufferingfromchronicpain(seeSection 3.2).Althoughawiderangeguidanceisavailabletosupportprescribing,thecontinuedincreaseinthelong-termuseofopioidstotreatchronicpain–despitethelackofevidenceoftheirlong-termeffectivenessinmostpatients–indicatesanongoingneedtopromotebestpractice,andtomonitorcloselycurrentprescribingtrends.

Recommendation: Existingguidanceonthemanagementofchronicpainandtheappropriateprescribingofanalgesicsneedstobepromoted,andconsiderationgivenhowitcanbemaximisedtosupportmoreappropriateuseofanalgesics,includingamongstclinicianswhoarenotspecialistsinpainmedicine.

http://www.rcoa.ac.uk/faculty-of-pain-medicine/essential-pain-management/epm-lite


6 Conclusion and summary of recommendations

Overrecentyearstherehasbeenasubstantialincreaseintheprescribingofopioids,leadingtosignificantpublichealthconcernsthattheharmsassociatedwiththesemedicationsareincreasing.Muchofthisincreasedprescribingislikelyassociatedwiththeiruseforthetreatmentofchronicpainbut,thereislimitedevidencetosupporttheirlong-termuseformostpatients.

Chronicpainisacomplexcondition,whichhasasubstantialimpactonthelivesofthoseaffected.Thereliefofpainshouldbeseenasaclinicalpriority,yettheprescribingofopioidsisoftennotthemostappropriateoreffectivetreatmentoptionformanypatientswithchronicpain,andcanriskexposingpatientstounnecessaryharm.Ifitisthoughtopioidtherapymayplayaroleinapatient’spainmanagement,atrialshouldbeinitiatedtoestablishwhetherapatientachievesareductioninpainwiththeuseofopioids–ifnottheyshouldbestopped.Patientsshouldbefullyinformedofpotentialbenefitsandharmsfromthistrial.Doseescalationshouldbelimitedasriskofharmrisesasdoseincreases,especiallyifthereisinadequatereliefofpain.Analgesicusebypatientswithchronicpainshouldbereviewedregularly.Bettersupportisrequiredforbothdoctorsandpatientsinstoppingopioidtreatmentwherethishasnotprovidedeffectivepainrelief.Adequateresourcesarerequiredtomoveawayfromprescribingasa‘default’option,towardsacomprehensive,multidisciplinaryapproachtothemanagementofchronicpain,whichisnowrecognisedasalong-termconditioninitsownright.Theneedtoavoidtreatmentsorproceduresthatareunlikelytobeofbenefithasbeenrecognisedacrossdifferentbranchesofmedicine,includingthroughthe‘choosingwisely’initiativefromtheAcademyofMedicalRoyalColleges.132

Supportingimprovementsinthetreatmentofchronicpain,andtheuseofanalgesics,necessitatesactionacrossarangeofareas,includingtheprovisionofservices;research;training;continuededucationandprofessionaldevelopment,andthedevelopmentandpromotionofguidance.Thisreportsetsoutarangeofrecommendationsforactionintheseareasthatneedtobetakenforwardbygovernments,policymakersandprofessionalsacrosstheUK.


Summary of recommendations

Developing the evidence base – Tobetterinformclinicalpracticemoreresearchisrequiredintotheeffectsoflong-termprescribingofopioidsforpainrelief,includingtheirefficacy&safetyforperiodslongerthansixmonths.

Pain management – Considerationshouldbegiventotherangeofsupportthatisrequiredfordoctorsandpatientsduringtheprocessofassessment,trialandreviewofopioidtreatmentforchronicpain.Thisshouldincludesupportforstoppingopioidtreatmentthatisnotworking.

– Sufficientinvestmentandresourcesforprimarycare,includinglongerconsultationtimes,arerequiredtosupportimprovementsinanalgesicprescribingforpatientswithchronicpain.

– Allrelevantcommissioningandproviderorganisations–includingCCGsinEngland,healthboardsinScotlandandWales,andtheHealthandSocialCareBoardinNorthernIreland–shouldensurethatmultidisciplinarypainmanagementservicesareavailableforpatientsintheirareaandthatthesearecommissionedaccordingtoavailableguidance.Theseorganisationsshouldalsoworktoensuretimelyaccesstopainmanagementprogrammes,tosupportearlyinterventionandcomprehensiverehabilitationforpatientswithchronicpain.

– Allhealthcareprovidersthatareresponsibleforthemanagementofpatientswithchronicpainshouldbefamiliarwiththerangeofnon-pharmacologicalinterventionsthatmaybeeffectiveforthemanagementofchronicpain-includingphysicalandpsychologicaltherapies.Healthcareprofessionalsshouldalsobeawareofthelocalavailabilityoftheseservices.

Training and education – Paincompetenciesshouldbeincludedinthecurriculaofallmedicalschoolsandbeassessedingraduationexaminations.

– Medicalschoolsshouldensurethatexistingresources–suchastheIASP’scurriculumoutlineonpainandtheFPM’sEPM-liteprogramme–areusedeffectivelytoensuresufficienthighqualityundergraduateteachingonthebasicsofpainmanagement.

– Existingguidanceonthemanagementofchronicpainandtheappropriateprescribingofanalgesicsneedstobepromoted,andconsiderationgivenhowitcanbemaximisedtosupportmoreappropriateuseofanalgesics,includingamongstclinicianswhoarenotspecialistsinpainmedicine.


7 Further resources

Please note: this listing of publications is intended for further information only. The BMA is not responsible for the content or accuracy of external websites, nor does it endorse or otherwise guarantee the veracity of statements made in non-BMA publications.

Supporting individuals affected by prescribed drugs associated with dependence and withdrawal – BritishMedicalAssociationAvailableat: https://www.bma.org.uk/collective-voice/policy-and-research/public-and-population-health/prescribed-drugs-dependence-and-withdrawal

Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain–HostedbytheFacultyofPainMedicineAvailableat:https://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware

Core Standards for Pain Management Services in the UK–FacultyofPainMedicineAvailableat:http://www.rcoa.ac.uk/system/files/FPM-CSPMS-UK2015.pdf

The hidden suffering of chronic pain–TheChronicPainPolicyCoalitionAvailableat:http://www.policyconnect.org.uk/cppc/research/hidden-suffering-chronic-pain-booklet-parliamentarians

Pain Management Services: Planning for the future: Guiding clinicians in their engagement with commissioners – RoyalCollegeofGeneralPractitioners Available at: http://www.rcoa.ac.uk/system/files/FPM-Pain-Management-Services.pdf

National Pain Audit Final Report 2010-2012(EnglandandWales)Availableat:http://www.nationalpainaudit.org/media/files/NationalPainAudit-2012.pdf

Guidance on the management of pain in older people (2013) – BritishGeriatricsSocietyAvailableat:http://www.bgs.org.uk/pdfs/pain/age_ageing_pain_supplement.pdf

https://www.bma.org.uk/collective-voice/policy-and-research/public-and-population-health/prescribed-drugs-dependence-and-withdrawal

https://www.bma.org.uk/collective-voice/policy-and-research/public-and-population-health/prescribed-drugs-dependence-and-withdrawal

https://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware

http://www.rcoa.ac.uk/system/files/FPM-CSPMS-UK2015.pdf

http://www.policyconnect.org.uk/cppc/research/hidden-suffering-chronic-pain-booklet-parliamentarians

http://www.policyconnect.org.uk/cppc/research/hidden-suffering-chronic-pain-booklet-parliamentarians

http://www.rcoa.ac.uk/system/files/FPM-Pain-Management-Services.pdf

http://www.nationalpainaudit.org/media/files/NationalPainAudit-2012.pdf

http://www.bgs.org.uk/pdfs/pain/age_ageing_pain_supplement.pdf


Appendix1–classificationofchronicpain

ThebelowtablehighlightstheclassificationsofchronicpainthathavebeendevelopedbytheIASPforinclusioninthe11threvisionoftheWHOInternationalClassificationofDiseases.

ClassificationofchronicpainforICD-11

ThecurrentversionoftheWHO’sInternational Classification of Diseases(ICD-10) includesdiagnosticcategoriesforchronicpainconditions.Forthe11threvisionoftheICDataskforceledbytheIASPhasdevelopedanewclassificationofchronicpain,dividedintothefollowingsevengroups.

1. Chronic primary pain –Chronicprimarypainispainin1ormoreanatomicregionsthatpersistsorrecursforlongerthan3monthsandisassociatedwithsignificantemotionaldistressorsignificantfunctionaldisability(interferencewithactivitiesofdailylifeandparticipationinsocialroles)andthatcannotbebetterexplained byanotherchronicpaincondition.

2. Chronic cancer pain – Chroniccancerpainincludespaincausedbythecanceritself(theprimarytumorormetastases)andpainthatiscausedbythecancertreatment(surgical,chemotherapy,radiotherapy,andothers).

3. Chronic post-surgical and post-traumatic pain – Painthatdevelopsafterasurgicalprocedureoratissueinjury(involvinganytrauma,includingburns)andpersistsatleast3monthsaftersurgeryortissuetrauma.

4. Chronic neuropathic pain –Chronicneuropathicpainiscausedbyalesionordiseaseofthesomatosensorynervoussystem.

5. Chronic headache and orofacial pain – Chronicheadacheandchronicorofacialpainisdefinedasheadachesororofacialpainsthatoccuronatleast50%ofthedaysduringatleast3months.

6. Chronic visceral pain – Chronicvisceralpainispersistentorrecurrentpainthatoriginatesfromtheinternalorgansoftheheadandneckregionandthethoracic,abdominal,andpelviccavities

7. Chronic musculoskeletal pain – Chronicmusculoskeletalpainisdefinedaspersistentorrecurrentpainthatarisesaspartofadiseaseprocessdirectlyaffectingbone(s),joint(s),muscle(s),orrelatedsofttissue(s).

Source:TreedeRD,RiefW,BarkeA(2015)AclassificationofchronicpainforICD-11.Pain 156(6):1003–1007


Appendix 2 – specialist training in pain medicine

TheFPMistheprofessionalbodyresponsibleforthetraining,assessment,practiceandcontinuingprofessionaldevelopmentofpainmedicinespecialistsintheUK. Itdescribestheroleofpainmedicinephysiciansasundertaking“[…] the comprehensive assessment and management of patients with acute, chronic and cancer pain using pharmacological, interventional, physical and psychological techniques in a multidisciplinary setting.”

Traineeanaesthetiststhatwishtospecialiseinpainmedicinemustundertake 12monthsormoreofadvancedpaintrainingindesignatedspecialistcentres.Successfulcompletionofthistraining,alongsidecontinuousassessmentandpassingoftheFPMexaminationleadstotheawardofFFPMRCA(FellowshipoftheFacultyofPainMedicineoftheRoyalCollegeofAnaesthetists)ortheDiploma(DFPMRCA)forthosetraineeswhohaveaqualificationthatisequivalenttoFRCA.133,134


Acknowledgements

Editorial boardBoard of science chair ProfessorParveenKumarPolicy director RajJethwaHead of public health and healthcare LenaLevyHead of science and public health GeorgeRoycroftResearch and writing RobertWilson ThomasAndrews

Board of science ThisreportwaspreparedundertheauspicesoftheBMAboardofscience,whosemembershipfor2016-17wasasfollows:Professor Pali Hungin PresidentDrMarkPorter CouncilchairDrDavidWrigley CouncildeputychairDrAndrewDearden TreasurerDrAntheaMowat Representativebodychair

ProfessorParveenKumar BoardofsciencechairDrPaulDarragh BoardofsciencedeputychairDrJSBamrahProfessorPeterDangerfieldDrShreelataDattaDrKittyMohanMrRamMoorthyDrMelodyRedmanProfessorMichaelRees(deputymember)DrPenelopeToffDr Ian Wilson

JacquelineAdams(BMAPatientliaisongrouprepresentative)DrIainThomasRobertKennedy(BMApublichealthmedicinecommitteerepresentative)

TheAssociationisgratefulforthehelpprovidedbytheBMAcommitteesandoutsideexperts.Wewouldparticularlyliketothank:

– DrBeverlyCollettOBE(FacultyofPainMedicine) – DrCathyStannard(FacultyofPainMedicine) – DrPaulWilkinson(FacultyofPainMedicine) – ProfessorAndrewRice(ImperialCollegeLondon) – ProfessorRogerKnaggs(UniversityofNottingham) – DrMartinJohnson


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chronic pain: supporting safer prescribing of analgesics · opioid analgesics, figure 1 provides a...

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