Persistent pain management An update Dr Deepak Ravindran

Persistent pain management An update Dr Deepak Ravindran Consultant Pain Medicine, RBH

OPIOIDS

Aims l Opiate update l Newer opiates tapentadol l Opiate conversion ratios l Driving laws and advice from HCPs

Opioids update l BPS guidance on prescribing opioids https: //www. britishpainsociety. org/static/uploads/resources/files/book_opi oid_main. pdf l Opioid induced hyperalgesia l Opioid induced hypogonadism l No fentanyl for opioid naïve l Refer to specialist when needing more than 180 mg/Day morphine equivalent

Opioid induced hypogonadism l Occurs in both sexes. More than 100 mg/day equivalent l Features consistent with depressed pituitary function. Low testosterone, low FSH/LH, Low GH and thyroid function l Buprenorphine safest due to mixed action. All others can cause problems l If suspected, consider opioid switch to Buprenorphine, test for FSH/LH/Testosterone and refer to endocrine for advice and replacement

Conversion ratios l Please follow BNF l New document from CCG being reviewed l Remember Fentanyl 12 mcg patch is 45 mg Morphine equivalent and 25 mcg patch is 90 mg morphine l Problems with addiction medicine and methadone dosing

Driving laws and changes l Guidance for healthcare professionals on drug driving – July 2014 l Came into force March 2015 l Roadside drug screening devices developed to detect drugs from saliva l All benzodiazepines/methadone/morphine and amphetamines l Establishes a statutory medical defence l Must keep a copy of their prescription in the vehicle, duty to inform DVLA and insurer

Driving laws l Patient needs to decide what evidence they will share with police l Does not prevent being charged if police have evidence of impairment l Ulitmately driver responsibility but HCP expected to warn patient l Not to drive if experiencing side effects l Not to drive when increasing doses l If another medicine is being added or an OTC is added which can impair l Developing another medical problem l Co-existing alcohol use/abuse

Tapentadol l New analgesic. Similar to tramadol. l Better side effect profile compared to tramadol and most opioids l Has some Mu-opioid action but more noradrenergic action l Possibly useful as an opioid switch when all other drugs have failed l Presently low priority in Berkshire West l Possible role in future for patients on high opiates or neuropathics with side effects, no relief or poor QOL

ANTINEUROPATHICS

Topics l Combinations of amitryptiline and tramadol l Gabapentin and Lyrica (pregabalin) l Conversion and switch between both l BPS guidance on patient information for drugs: Website has leaflets on Gabapentin, Pregabalin, Nortyptiline, Amitriptyline and Duloxetine

Antineuropathics l Risk of serotonergic syndrome with high doses of amitriptyline and tramadol l Low doses are ok and tolerated l Maximum high dose of amitryptiline and nortryptiline for chronic pain is 75 mg/day l Imipramine and desipramine rarely used

Gabapentin and Lyrica l Pfizer and Lyrica for pain l Patient on 900 mg TDS gabapentin. No benefit. You want to switch to Pregabalin. l Do you A. Taper down and then switch B. Direct switch to high dose Pregabalin C. start Pregabalin and then taper gabapentin while increasing Pregabalin

Gabapentin and Lyrica l Gabapentin has non linear pharmacokinetics. Dose increase is gradual and plasma levels are unpredictable. l Transfer from stomach is saturated quickly l Effects of increasing the dose are a hit and miss in terms of efficacy and blood levels l Lyrica is linear pharmacokinetics. Non saturable. Double the dose and double the concentration.

Lyrica l Roughly 900 mg Gabapentin is equal to 100 mg Lyrica l No evidence regarding the safest method for switching l SO, upto 300 mg TDS of Gabapentin, switch to 50 mg BD of Lyrica l Any higher doses of Gabapentin, taper it first before switching l If any concern then taper further and switch to 25 mg BD of Lyrica

Fibromyalgia l More objective and better criteria for diagnosis l Symptom severity scale and Widespread Pain Index l No more 18 tender points l Evidence of f. MRI changes, biochemical changes l Central nervous system dysfunction l Newer treatments – lignocaine and LDN

Fibromyalgia – local developments l GP and Patient information booklets l IPASS has dedicated FMS pain management programmes l Patient support group active – branches in Wokingham, Thatcham and Reading l Mayors charity, House of Commons debate

Further resources l RBH pain management website for medication information and patient information leaflets l IPASS website being developed l British Pain Society website l Deepak. ravindran@royalberkshire. nhs. uk l Or via CAB advice and guidance

Any questions?