APPG for prescribed drug dependence Dr Jane Quinlan

APPG for prescribed drug dependence Dr Jane Quinlan MB BS FRCA FFPMRCA Consultant in anaesthesia and pain management Trust lead for pain Oxford University Hospitals Trust Honorary senior clinical lecturer University of Oxford Core member of Opioid Painkiller Dependence Alliance

Key messages • Chronic pain is common (28 million people in UK) • Inappropriate opioid prescribing for chronic pain is common • There are large numbers of pain patients taking high dose opioids which are ineffective, harmful, addictive and difficult to stop Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. BMJ Open June 20 2016 • There is little acknowledgement of patients with pain and

Impact of opioid prescribing Rates of opioid pain reliever overdose death, treatment admissions and kilograms sold - United States, 1999 -2010. Morbidity and mortality weekly report (MMWR). Centers for disease control and prevention.

Use of opioids in UK Zin CS, Chen L-C, Knaggs RD. Eur J Pain 18 (2014) 1343– 1351

Lessons from palliative care • In 1985, WHO produced the pain ladder for treatment of cancer pain • Simple, effective with drugs that were cheap and widely available • Evidence from palliative care that opioids effective and non-addictive in pain World Health Organization. Traitement de la douleur cancéreuse. Geneva, Switz: World Health Organization; 1987. Mc. Quay H. Lancet 1999; 353: 2229– 32

Acute and cancer pain Appropriate pain reflecting ongoing tissue damage Tissue damage after trauma, surgery, cancer Brain Opioids are an effective and important part of acute and cancer pain management Neuropathic (chronic) pain Nerve damage with no tissue damage Inappropriate pain signalling with no tissue damage Brain No evidence that opioids are safe or effective in the long term management of chronic pain

Long term opioid use and outcomes • 228 opioid users compared with 1, 678 non-opioid users • Opioids usage significantly associated with: • reporting of severe pain • poor self-rated health • inactivity during leisure • unemployment • higher healthcare utilization Eriksen et al. Critical issues on opioids in chronic non-cancer pain: An epidemiological study. Pain • poor health orientated quality of life 2006; 125: 172 -9

Spectrum of prescribed opioid use Chronic pain No pain but pain reported No pain Stable prescribed opioids Increasing dose of opioids Prescribed drug seeking Diverted opioids Risk of dependence Dependence and problem opioid use Addiction pain dependence Pain services No current service Addiction services

Current recommendations • Short trial of low dose opioid to see if functional improvement • Current recommendations in morphine equivalent dose (MED) per day: • UK: Opioids Aware – FPM, BPS and PHE - max 120 mg MED • • • https: //www. fpm. ac. uk/faculty-of-pain-medicine/opioids-aware Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United • States, USA: caution over 50 mg MED and a 90 mg MED limit 2016. MMWR Recomm Rep 2016; 65(No. RR-1): 1– 49. Häuser W, Bock F, Engeser P, Tölle T, Willweber-Strumpf A, Petzke F: Clinical practice guideline: Long-term opioid use in non-cancer pain. Dtsch Arztebl Int 2014; 111: 732– 40.

Global opioid availability Current inequity of under-availability and overconsumption Source: International narcotics control board

Current needs • Programmes to screen and identify patients taking opioid painkillers who may be at risk of developing dependence • Early access to effective treatment in a suitable environment • Support and information services for patients and their families • More informed communications to the public and