Schedule 8 medicines prescribing opioids for chronic non malignant pain
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Schedule 8 medicines: Prescribing opioids for chronic non-malignant pain. Pharmaceutical Services Branch January 2014. Version: C20140101AG1. Aims of presentation.

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

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Schedule 8 medicines prescribing opioids for chronic non malignant pain

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

Pharmaceutical Services Branch

January 2014

Version: C20140101AG1


Aims of presentation

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 options

  • pharmacological or non-pharmacological treatment

  • difficult patients

  • documentation

  • practice monitoring.


Initiation of opioid therapy for cnmp

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.


Initiation of opioid therapy for cnmp1

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).


Initiation of opioid therapy for cnmp2

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.


An opioid contract

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


Initiation of opioid therapy for cnmp3

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.


Initiation of opioid therapy for cnmp4

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.


Prior to proceeding to long term prescribing consider

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.


Monitoring

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.


Monitoring1

Monitoring

  • Regularly review the pain diagnosis

    and co-morbid conditions using the 4As

    • Analgesia

    • Activity

    • Adverse effects

    • Aberrant behaviour


Monitoring2

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.


Monitoring patients at high risk of substance misuse

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.


Pharmacological treatments for pain

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


Non pharmacological pain management

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


Non pharmacological pain management1

Non-pharmacological pain management

  • patient support groups

  • complementary therapies

    • massage

    • reflexology

    • aromatherapy

    • acupuncture

    • nutrition


Interventional therapies for pain

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


Summary of opioid management for cnmp

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


Summary of opioid management for cnmp1

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


Resources

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


Pharmaceutical services branch contacts

Pharmaceutical Services Branch contacts

  • Telephone: (08) 9222 4424

  • Fax: (08) 9222 2463

  • Email: [email protected]

  • Post: The Pharmaceutical Services Branch

    PO Box 8172

    Perth Business Centre

    WA 6849


Other contacts

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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