Schedule 8 medicines:Prescribing opioids for chronic non-malignant pain

Pharmaceutical Services Branch

January 2014

Version: C20140101AG1

Aims of presentation

This presentation will focus on the prescribing of opioid Schedule 8 (S8) medications for chronic non-malignant pain (CNMP) and includes:patient management optionspharmacological or non-pharmacological treatmentdifficult patientsdocumentationpractice monitoring.

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Initiation of opioid therapy for CNMP

Before a short term therapeutic trial (< 60 days): establish a definite pain diagnosis do not use opioids to treat headaches

(including migraine) and poorly or undefined general pain states such as fibromyalgia, chronic visceral pain or non-specific lower back pain

confirm that trials of non-opioid or non-drug treatment have failed.

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Initiation of opioid therapy for CNMP

Evaluate mental health issues and current/previous substance misuse (including alcohol and benzodiazepines).

Consider referral to a clinical psychologist or other allied health professional (physiotherapist, occupational therapist).

Ensure patient is not a registered drug addict (if a notified addict, consultant support is required prior to prescribing).

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Initiation of opioid therapy for CNMP

Have an exit strategy for each opioid trial. Agree on this exit strategy with the patient and

document this in the notes. Introduce an opioid contract before you initiate a

trial. A valid outcome of an opioid trial maybe the

decision not to proceed with opioids.

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An opioid contract: represents the gold standard is recommended for all patients as a form of informed

consent prior to initiating treatment clearly outlines both the patient’s and the prescriber’s

responsibilities describes the rules of prescribing states the need for adherence to the authorised dose specifies the need for GP to discuss adverse effects may contain additional conditions e.g. daily medication

pick ups is routinely used in specialist pain clinics may be issued as a condition of authorisation

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Initiation of opioid therapy for CNMP

Start cautiously with low doses of an appropriate long-acting or slow release opioid.

Be careful in particular with: opioid naïve frail elderly significant co-morbidities.

Individualise dose during trial with incremental dose escalations.

Avoid use of immediate release or short-acting opioids in chronic pain states.

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Initiation of opioid therapy for CNMP

Consider opioids only as one component of a multimodal treatment plan: Opioids should facilitate mobilisation, participation in

physiotherapy or other activation. Consider early referral for specialist pain

advice/management.

Opioids commenced as an inpatient: The pain team should consider: changing to Schedule 4 opioids before discharge the need to advise if S8s are to be continued on discharge (prior

to discharge) communication of plan back to the patient’s GP.

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Prior to proceeding to long-term prescribing consider:

progress toward meeting therapeutic goals including pain relief, but in particular improved level of function

presence of adverse affects changes in psychiatric or underlying medical co-

morbidities evidence of aberrant drug-related behaviours

e.g. doctor shopping and escalating S8 dose evidence of diversion.

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Monitoring regular monitoring required:

Is the treatment plan working? Is there functional improvement?

need for additional non-opioid therapies benefit outweighed by harm is referral (specialist, allied health, other) required? increasing the opioid dose is not always the

correct response to missed goals of treatment do not exceed recommended dose limits.

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Monitoring

Regularly review the pain diagnosis

and co-morbid conditions using the 4As Analgesia Activity Adverse effects Aberrant behaviour

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Monitoring

Documentation of: pain severity functional ability progress towards achieving therapeutic goals adverse effects signs for presence of

aberrant drug related behaviours substance abuse psychological issues.

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Monitoring – patients at high risk of substance misuse

Minimise risk via intense and frequent monitoring limiting prescription quantities and dispensing

intervals as a condition consultation / co-management with persons who

have expertise in mental health or addiction medicine

low threshold for referral to Next Step or other addiction service.

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Pharmacological treatments for pain

Nociceptive pain paracetamol NSAIDs

Neuropathic pain tricyclic antidepressants (e.g. amitriptyline) serotonin-noradrenergic reuptake inhibitors (e.g.

venlafaxine, duloxetine) anticonvulsants (e.g. gabapentin, pregabalin)

Nociceptive and/or neuropathic pain tramadol opioids

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Non-pharmacological pain management Physiotherapy

paced exercise programs hydrotherapy aquarobics (in public pools) any physical training e.g. gym membership

TENS treatment Psychological options

CBT: focuses on patients developing coping strategies for their CNMP to improve function. Has shown consistently to be effective in the management of CNMP

mindfulness training relaxation techniques

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Non-pharmacological pain management

patient support groups complementary therapies

massage reflexology aromatherapy acupuncture nutrition

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Interventional therapies for pain

Nerve blocks/steroid injections joint injections (including facet joints) epidural steroid injections

Destructive procedures facet joint denervation (rhizotomy)

Implanted devices intrathecal drug therapies dorsal Column Stimulators

Surgical options e.g. joint replacements

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Summary of opioid management for CNMP

Evaluation of the patient standard work up pain diagnosis appropriate for treatment? assess risk of misuse

Informed consent & contract inform of side effects/risks/potential of ineffectiveness outline expectations between provider and patient

Opioid trial including exit strategy

Periodic review of long-term treatment The 4 As: Analgesia, Activity, Adverse effects, Aberrant behaviour

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Summary of opioid management for CNMP

Specialist consultation referral registered drug addict (mandatory prior to prescribing) if patient is not responding or diagnosis is unclear high risk (e.g. dose refer to Schedule 8 Medicines

Prescribing Code). Review the four As (useful follow-up questions)

Analgesia Activities of Daily Living (ADLs) Adverse events Aberrant behaviours

Compliance with WA state legislation

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Resources

Pharmaceutical Services Branch: www.health.wa.gov.au/S8

Royal Australasian College of Physicians: www.racp.edu.au/page/policy-and-advocacy/public-health-and-social-policy

Drug and Alcohol Office: www.dao.health.wa.gov.au/Informationandresources/publicationsandresources/healthprofessionals.aspx

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Pharmaceutical Services Branch contacts

Telephone: (08) 9222 4424

Fax: (08) 9222 2463

Email: poisons@health.wa.gov.au

Post: The Pharmaceutical Services Branch

PO Box 8172

Perth Business Centre

WA 6849

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Other contacts

Medicare Australia Medicines Information Line 1800 631 181

Next Step Specialist Drug and Alcohol Services (08) 9219 1919

Alcohol and Drug Information services (ADIS) (08) 9442 5000 or 1800 198 024

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