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At the heart of general practice since 1960

Drinking on duty

The Shipman Inquiry has made many GPs cautious about strong opioids – Dr Richard Potter offers

advice on how to prescribe them

One in 10 GP consultations involves a chronically painful condition. The 7-10 per cent of the adult population suffering from chronic pain are frequent consulters in general practice. The condition is not only a considerable burden on the individual, but also on their families, the NHS and social services. The central role occupied by GPs in managing the complex condition of pain is outlined in box 1.

Having been comfortable with the use of strong opioids in terminally ill patients, GPs are now gaining experience of these drugs in non-cancer patients supported by the Pain Society's guidelines.

The Shipman inquiry has increased concerns about the use of strong opioids but this should not hold us back from entering this exciting new era of effective pain control and the benefits this entails for patients.

It is worth noting there have been cases where patients have taken legal action against health care professionals because of inadequate pain relief.

Analgesics in primary care

GPs are familiar with prescribing NSAIDs, simple analgesia (paracetamol) and weak opioids (dihydrocodeine, tramadol) and this is represented in the WHO analgesic ladder in box 2 (right). The next step is the use of strong opioids.

The dosage of weak opioid should be increased to the maximum BNF recommendation before Step 3 is considered unless the pain is thought to have a neuropathic component – in which case antidepressant (eg amitriptyline, lofepramine) or anticonvulsant (eg carbamazepine, gabapentin) drugs may be tried.

The familiar strong opioids are the long-acting oral morphine preparations. More recently for patients experiencing unacceptable side-effects oxycodone has been used. The full list of opioids is detailed in the table below.

The newer transdermal delivery systems (fentanyl and buprenorphine) have been shown to be especially effective, well-tolerated and to improve quality of life. It is suggested that these drugs potentially offer considerable benefits not only to patients with terminal cancer but also those condemned to live with chronic non-malignant pain.

Patient selection

For some patients with acute pain prescribing strong opioids is straightforward – for instance postoperative, in trauma and leg ulcers in the elderly. But in the main GPs will be considering initiating these drugs in patients with chronic pain. The assessment of these patients is complex and involves a review of the organic, psychological and behavioural dimensions.

In primary care we know our patients well from seeing them during multiple brief consultations over months or years; in the chronic pain clinic the assessment is performed in one or two longer interviews. A formulation of the patient's pain problem is made and negotiated with the patient based on the information set out in box 3 (see page 53).

Having discussed the level of pain I then move on to how the pain impairs the patient. I find it helpful to work through the following WHO functional categories:

•fitness and health

•impairment – loss of structure or function

•disability – loss of ability to perform a task

•handicap – disadvantage through inability to fulfil a role

•terminal phase – dependent on others for day-to-day living.

To the patient it is helpful to discuss activities relevant to their lives and use, say, three activities as goals to be achieved through better pain relief – these could be walking the dog, preparing a meal, going shopping.

Certain patients may require other specialised assessment such as those with more complex multidisciplinary needs who should be referred to the chronic pain clinic, or those with current or previous psychiatric or substance or alcohol abuse problems. If a household member has any of these psychological problems, extra care will need to be given to the safe storage of drugs at home.

Initiating treatment

Having assessed the patient and negotiated the aims and objectives of prescribing, specific information on the drugs will need to be shared with the patient. Comprehensive information for patients can be found at www.painsociety.org but the checklist in

box 4 may also be covered.

The choice of drug should be one with which the GP is familiar and knowledgeable and should be a long-acting preparation. When first changing from weak to strong opioids the latter should be started at the lowest available dosage. Allow for breakthrough pain by providing analgesic cover for the first 24 hours.

The patient will usually be reviewed in two to four weeks, with telephone contact arrangements made in case of difficulties in the interim.

Monitoring

Close monitoring of the patient will be required as the dose of medication is gradually increased until optimal analgesic effect is obtained and any side-effects become tolerable. A change of preparation may be required.

Some patients will reach a point where further increases in dosage yield no further benefit in analgesia and at this point I reduce the dose to the previous level and reassess the situation. It is quite possible the limit of benefit on the organic component of their pain may have been reached.

On reaching a stable dosage the monitoring should be regular but not necessarily frequent (three to six monthly) while repeat prescribing will be subject to the practice's vigilant procedures.

The ongoing review would include assessing the level of pain relief, encouragement of the maintenance of functional gains, inquiring about side-effects and looking for warning signs of abuse (see box 5 below). If you suspect that tolerance is developing the patient should be referred to a local pain service.

Richard Potter is a GP in Congleton and director of the Eastern Cheshire Chronic Pain Service – he represented the RCGP in the preparation of the Pain Society guidelines

1 Applying GPs' skills to

pain management

•The solution of undifferentiated problems – formulating the biological, psychological and social aspects of the patient's pain experience

•Preventive skills – the prevention of development of unnecessary chronicity or disability

•Multidisciplinary therapeutic approach – recruiting the help of a range of professionals

•Resource management - preventing multiple inappropriate and mutually frustrating specialist referrals

Paraphrased from McWhinney's

A Textbook of Family Medicine. Ian R McWhinney. OUP 1989, (p15)

2 WHO analgesic ladder

Step 1 Mild pain Non- opioids or NSAIDs or both +/- adjuvant drugs

Step 2 Mild to moderate Step 1 analgesics + weak opioids +/- adjuvant drugs

Step 3 Moderate to severe Step 1 analgesics + strong opioids +/- adjuvant drugs

3 Assessing patients with chronic pain

•History and current description of pain

•Associated levels of anxiety/ depression (eg HAD questionnaire or informally)

•Diagnoses previously given to the patient; patient's ideas and beliefs about their pain problem; results of investigations

•Current medication

•Ensuring that both patient and doctor are satisfied that no definitive curative treatment is possible

•Pain score eg scale 0 (no pain) – 10 (worst pain imaginable)

•Patient's current level of function

•Patient understands rationale for using strong opioids ie both better pain relief and functional improvement with other gains such as improved sleep, reduced anxiety, increased social functioning or weight loss through increased activity

4 Checklist: advice to give patients

starting opioids

•Basic information on weak and strong opioids, for example the names of preparations with which they may be familiar and the concept of moving from a high dose of a weak drug to a low dose of a strong one

•Clarification of the rationale for prescribing strong medication for improved pain relief associated with the attainment of specified functional goals

•Side-effects:

Early – nausea, itching, confusion, drowsiness, respiratory depression

Delayed – constipation, weight loss or gain

Late – impaired libido/fertility

Breathing difficulty in a newborn infant

•Work/driving/alcohol issues: sedation may be a particular problem after increases in dosage, alcohol will have an additive effect with strong opioid medication

•Addiction/dependence/tolerance are widely feared but appear to be rare problems in clinical practice

5 Problem drug use

The following behaviours may suggest problem drug use:

•Early prescription seeking

•Claims of lost medication

•Intoxication

•Frequent missed appointments

•Use of other scheduled drugs

Approved name formulations available

(Some proprietary names)

•Buprenorphine sublingual, transdermal

(Temgesic, Transtec)

•Diamorphine (heroin) oral

•Dipipanone oral (Diconal)

•Fentanyl transdermal, transmucosal oral

(Durogesic, Actiq)

•Hydromorphone oral

(Palladone, Palladone SR)

•Methadone oral

•Morphine oral

(Oramorph, Sevredol, MST Continus, MXL, Zomorph)

•Oxycodone oral

(OxyNorm, OxyContin)

•Pentazocine oral

•Pethidine oral

•Tramadol* oral (Zydol, Zamadol)

*Tramadol may behave as a strong or a weak opioid depending on the dose used

Oral formulations may be immediate or

modified release

Taken from the Pain Society's recommendations for appropriate use of opioids for persistent non-cancer pain

Non-opioid pain management

Dr Amanda Williams outlines some simple self-management techniques that can serve as adjuncts to opioid prescription

While opioids may provide good analgesia for some patients, clinical experience and randomised controlled trials show they do not completely remove disability and distress.

Analgesic benefits can be outweighed by adverse effects for some patients. Certain pain mechanisms are not opioid sensitive and many patients prefer to minimise drug use and deal with their pain autonomously.

Understanding pain

Patients need to understand their pain as far as possible. In particular they should know that hurt does not mean harm, and that persistent pain is a dysfunction of the pain signalling system, not a sign of damage or disease. It is difficult to suspend the almost instinctive reaction of alarm, guarding, resting, and waiting for recovery.

There are few texts for patients explaining pain (the initial chapters of Wall, 19991, are excellent but demanding). An explanation from a trusted family doctor is therefore very powerful.

Activity planning

Many patients push themselves to continue activity until the pain becomes intolerable, at which point they rest to recover, often discouraged and fearful. It is worth identifying what activities they wish to achieve. These range from responsibilities and chores to creative or recreational pursuits. These can be broken down into shorter-term goals of positions and movements that pain makes difficult. A physiotherapist can then help the patient achieve their goals using exercise and stretching.

Pacing

This is the technique of being active little and often, building up to regular, predictable longer activity without intolerable pain. Most activities can be described by a quota system. For instance, many patients who find sitting increases pain, avoid long car journeys and lose touch with far-flung friends and family. But regular stops, and even stretches while stationary at lights, make longer journeys feasible without significant pain increase.

The pacing times are often short, a matter of 10 minutes with a few minutes' rest, which is hard to achieve without a bleeping timer as a reminder, and the rest activity should be planned (reading a newspaper, for instance, in a different position) in order not to be skipped.

With increasing fitness, the activity times are lengthened and rests shortened, and the patient is quickly able to do far more than in the previous pattern.

Sleep improvement

Patients need to know that sleep hours are very variable and that eight solid hours is not an absolute requirement. Patients may spend part of the day reclining to recover from activity, feeling defeated and isolated from the rest of the household. It is better to keep the bedroom for sleeping and to find other places to lie down when wakeful, and for those waking times to be sociable or productive (for example listening to a taped book). A routine, and regular bedtime will also help. Many patients accept that problems are not best solved at night and learn to postpone worrying to the daytime when they are alert and can share their concerns with others.

Attention control

While distraction is useful for milder pains or those that rapidly remit, it is far less applicable to persistent pain. Instead, the patient can try directing attention towards the pain, but cultivating a dispassionate focus and redescribing the pain in unthreatening terms. Reference to the fact that the patient has borne 'unbearable' pain many times, and without lasting ill effects, can give confidence that the pain can be observed as if from a comfortable distance. This takes practice but gives the patient a real sense of strength.

Amanda Williams is reader in psychology at University College, London

Suffering in persistent pain arises from

•Anxieties about cause and implications of pain

•Frustrations over interference with daily life

•Depressed mood over interference with goals

•Social isolation through lost roles and activities

Pain self-management includes

•Understanding pain better

•Reducing interference by improving fitness

•Planning and pacing increases in desired activities

•Reducing demands of pain on attention

References and information

1. Wall PD (1999) Pain: the science of suffering. London: Weidenfeld & Nicolson

•Nicholas M e al (2003). Manage your pain. London: Souvenir Press

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