Pain Dependency Better Together Dr Rebecca Lawrence Consultant

Pain & Dependency Better Together Dr Rebecca Lawrence Consultant Psychiatrist in Addictions NHS Lothian November 2014

Acknowledgements Thank you to my colleagues, Dr Lesley Colvin & Dr Colin Baird, for shared expertise / input to slides

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)

Overview § Background / brief epidemiology § Lothian Pain & Dependency Clinic • History • Criteria for referral • Patients seen § Other possible models of service delivery in the future center-for-addiction-recovery. com

Chronic Pain and Dependency the 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 Scotland’s Relationship with Alcohol: A Framework for Action, 2009)

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 )

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

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

• No demographic / clinical factors that consistently differentiate CNCP (chronic noncancer 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, 488– 497. doi: 10. 1016/j. pain. 2010. 009

Per-capita consumption in UK = US 10 years ago US: 5% of world’s population, consume 80% of world’s opioids Opioid prescriptions are increasing Painkiller Addict – From Wreckage To Redemption Cathryn Kemp

Has increased opioid use improved patient outcomes? A number of comprehensive reviews have failed to show compelling evidence for opioids in chronic noncancer pain. Manchikanti L, Vallejo R, Manchikanti KN, Benyamin RM, Datta S, Christo PJ. (2011). Effectiveness of long-term opioid therapy for chronic non-cancer pain. Pain Physician; 14: E 133– 56. Chaparro LE 1, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC. (2014). Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane review. Mc. Nicol ED 1, Midbari A, Eisenberg E. (2013). Opioids for neuropathic pain. Cochrane Database Syst Rev. 29; 8: CD 006146. doi: 10. 1002/14651858. CD 006146. pub 2.

Pain & Opioid Dependency § Physical Dependence § Tolerance (side effects/ analgesia) § 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

It’s not just opioids. . . Substance misuse clinic § 79% (102/129) prescribed methadone for opiate dependency § 19% of these (19/102) using additional nonprescribed methadone § 7% of these (7/102) continuing to use heroin Prescribed Non-prescribed Gabapentin 7% (9/129) 19% (25/129) Pregabalin 1. 5% (2/129) 3% (4/129) Baird CR, et al. (3013). Gabapentinoid Abuse in Order to Potentiate the Effect of Methadone: A Survey among Substance Misusers. European Addiction Research 20(3): 115 -118

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.

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

Other treatments for pain, mental disorders & substance misuse § § § § Valproate § Ketamine infusion Gabapentin § Deep brain stimulation Topiramate Lamotrigine Other antidepressants Baclofen Opiates Benzodiazepines

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)

What is the PAD Clinic? § Multidisciplinary – Pain Specialist – Addiction Psychiatrist – Specialist Nurse – Clinical Psychologist

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

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 > 150 mg methadone (guide) § Iatrogenic opioid misuse / dependence § Misuse of over the counter or other prescribed medication § Concern regarding gabapentin or pregabalin use (prescribed or unprescribed)

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

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

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

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

Review of last 36 new patients seen in PAD § § § § 25 male, 11 female Average 41(26 -59) None in employment Addiction first – 18 Pain first – 7 Unstable use of opioids – 19 Mental health problem - 26

Review of last 36 new patients § § § § 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

Comments - last 36 new patients § Previously on gabapentin, stopped as possible misuse § On methadone, MST & sevredol; also diazepam 95 mg daily § Prescribed oxycodone, difficulty reducing § High dose prescribed MST, oramorph, pregabalin & baclofen

Comments - last 36 new patients § Clonazepam dependence, converted to diazepam § Prescribed both diazepam and nitrazepam § Possible iatrogenic benzodiazepine misuse § Unexplained +ve benzodiazepine § Prescribed nitrazepam, diazepam & baclofen § Previous NPS induced psychosis

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

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

Other Models? ? • Managing pain within substance misuse services • Outreach to community services, including primary care • Liaison services in general hospitals • Consultation by video link

The Future? § Wider access to specialist care – where 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 § Better liaison with acute hospitals & primary care