Leeds Health Pathways

Leeds Analgesia Pathway for Chronic Pain

1 Background information / scope of pathway

Quick info:

This guidance is intended to aid high quality, cost-effective care and improve clarity of understanding between primary and
secondary care. It is recommended for use in primary care for Leeds patients age 18 years and over.
Recommendations assume the absence of established contraindications or cautions and that other established interventions are also considered. Refer to the BNF, relevant NICE guidance and summaries of product characteristics for more information. Legal and clinical responsibility lies with the prescriber.

2 Development and updates to this pathway

Quick info:
Approved Feb 2013 by Leeds APC
Updated and approved October 2014 Leeds APC
Review date 28.2.2016
Review Jun 2019

3 Information Resources for Patients and Carers

Quick info:

Faculty of Pain Medicine Patient Resources:
https://fpm.ac.uk/opioids-aware/information-patients

Types of pain: Faculty of Pain Medicine Patient Information Leaflet

What is chronic pain? Patient Information Video & leaflet links: https://www.leedsth.nhs.uk/a-z-of-services/pain-management/living-with-pain/

British Pain Society ‘Understanding and Managing Long-term Pain’ - Full Length Patient Information PDF – Suitable for emailing to patient on request (44 page in-depth patient resource) https://www.britishpainsociety.org/static/uploads/resources/LeedsPathways/files/Understanding_and_Managing_Long-term_Pain_Final2015.pdf

Leeds Social Prescribing Links>

Linking Leeds is the new citywide social prescribing service for the people of Leeds Monday to Friday (8am until 6pm) including weekend availability.
Telephone: (0113) 336 7612. Download the introductions form from the website https://www.commlinks.co.uk/wp-content/uploads/2016/07/Linking-Leeds-Introduction-Form.docx
Email the completed form to the Linking Leeds secure email address: linking.leeds@nhs.net

4 Further Healthcare Professional Resources

Quick info:

Ten top tips for GPs managing pain summary

Self-managing with confidence is the aim of management.
Expect persistent pain to be a long term condition, so you can take your time.
Listen to the pain story from start to finish (appointment one).
Form with patient person-centred goals for the future (appointments two and onwards).
Metaphors can be used to explain persistent pain concepts to patients.
Analgesia should be kept simple and effective.
Neuropathic pain may require special attention.
Ask about life – it’s not all about the pain. Consider sleep, mood, activity etc.
Give strong opioids with extreme caution and careful review.
Encourage continuity with a limited number of involved healthcare professionals.

By Dr Tim Williams. www.paintoolkit.org

Video Link: Ten Top Tips for Self-Management of Persistent Pain https://youtu.be/XFhBRVACrMo

Further reading: https://www.britishpainsociety.org/british-pain-society-publications/professional-publications/

5 Assessment of Type of Pain

Quick info:

Persistent (chronic) Pain is described as pain persisting more than six months or persistent pain irrespective of the number of sites/s
Persistent pain is different to short acting 'acute' pain and often doesn't respond to usual treatments.
This is because the problem is with the pain system itself, rather than being related to a specific problem in the body.

Assess patient to establish type of pain, either nociceptive, neuropathic or mixed.
Faculty of Pain Medicine: Types of pain Patient Information Leaflet

Types of Pain

Nociceptive pain

Peripheral sensory neurones (nociceptors) respond to noxious stimuli.
Painful region localised at the site of injury.
Often described as throbbing, aching or stiffness.
Usually time-limited but can be chronic (e.g. Osteoarthritis)
Responds to conventional analgesics.

Neuropathic pain

Lesion or disease in the peripheral or central nervous system.
Described as shooting, electric shock-like, burning.
Commonly associated with tingling or numbness.
Painful region not necessarily same as site injury.
Pain occurs in the neurological territory of the affected structure (nerve, root, spinal cord, brain).
Almost always chronic condition (e.g. Post-herpetic neuralgia, post-stroke pain).
Responds poorly to conventional analgesics.

6 Review of Medication

Quick info:

Ensure steps in the persistent (chronic) pain pathway have been followed.
Check OTC medicine use and from any other sources.
Only add analgesics to repeat prescription when pain control is stabilised and need is long term. Consider whether to prescribe analgesia regularly, rather than just when required. If pain present constantly regular analgesia likely to be more effective
If a patient is unable to self-administer, review frequency of analgesia.

7 Provide Information about realistic expectations and role of medication in pain

Visit: https://fpm.ac.uk/opioids-aware-understanding-pain-medicines-pain/role-medication-pain-management

8 Consider Analgesic Options with Patient

Quick info:

When choosing an appropriate analgesic it is worth considering the below factors plus any compelling indications:
Factors include:

What has been tried already - what dose and for how long? Was it a proper therapeutic trial?
Success with current medication
Side effects with medications e.g.
- constipation
- nausea / vomiting
- drowsiness and light-headedness
Drug interactions
Past medical history
Contraindications
Co-existing mental health issues
Any prescription drug dependence
Any street drug misuse
Does patient understand how to use medication appropriately
Activity
Sleep disturbances
Prepare them for side-effects of analgesic options and likely delay before they see any benefits from treatment

Pain (long-term and flare-up): medication options
Pain (nerve type): medication options

9 Paracetamol

Quick info:

Paracetamol is an appropriate first line analgesic for nociceptive milder chronic pain, for example mild osteoarthritis.
Encourage patients to take 1g four times a day regularly (caution in low body weight individuals <50kg).

10 Mild Opioids

Quick info:

Mild Opioids may be appropriate for some patients with nociceptive chronic pain.
Patients should be educated on risk of dependency and high rate of side effects e.g. Constipation

Do not use combinations of weak opioids together, although different weak opioids maybe tried sequentially as response varies between individuals.
Review responsiveness early and manage side effects, particularly constipation.

First line
Codeine phosphate 30-60mg tablets four times a day,to a maximum of 240mg daily in divided doses.
Dihydrocodeine can be used as an alternative to codeine,to a maximum of 240mg daily in divided doses.

Alternative Mild Opioids –NOT first line:

Tramadol is generally no more effective or better tolerated than other weak opioid analgesics. Consider where significant codeine intolerance or codeine not giving adequate pain relief (10% of the population are non/partial responders to codeine). Only prescribe generic capsules 50mg 1-2 four times a day.

Only consider slow release tramadol when four times a day dosage provides a short duration of response.

Co-codamol 8/500mg and 15/500mg and co-dydramol 10/500mg are no more effective than paracetamol and can cause side effects particularly constipation. Do not initiate unless sub therapeutic dose previously found to be effective for an individual patient. If combination preparations are prescribed - state strength clearly. Co-codamol 30/500mg can be prescribed once patients are stabilised.

Butrans (buprenorphine low dose, 7 day patch), reserve only for patients who cannot take large, oral, regular doses of weak opioids or non-opioid and opioid combination analgesics and patients who are unable to comply with a frequent analgesia regimen. May be considered for patients with renal impairment and opioid non/partial responders.

Black Listed Mild Opioids –Not to be prescribed:
Tramacet (tramadol / paracetamol), significantly more expensive than the individual products and contains sub therapeutic doses of tramadol and paracetamol.

11 NSAIDS

Quick info:

NSAIDs may be appropriate for some patients with chronic pain who may have an inflammatory component.

First line is ibuprofen tablets 400mg to 600mg three times a day, increased to a maximum of 2.4g daily in divided doses.

Use the lowest dose possible for the shortest possible time, review responsiveness regularly. Advise to take with food.
Naproxen 500mg tablets twice a day can be used as an alternative when ibuprofen partially effective.
Consider gastro-protection if appropriate, lansoprazole 15mg daily / omeprazole 20mg daily / pantoprazole 20mg daily.
If a PPI is not suitable then ranitidine 300mg twice a day, (unlicensed) can be considered as an alternative.

12. Amitriptyline

Start low and go slow
Amitriptyline is an appropriate first line agent where tolerated for chronic neuropathic pain.
Start low and go slow, advise patient of high chance of side effects immediately but pain relief benefits may be delayed until optimum dose reached.
Elderly patients are particularly susceptible to many of the side effects of Amitriptyline, so caution should be used.

Patient Information Leaflet

Imipramine and nortriptyline were recommended in the previous NICE guideline on the pharmacological management of neuropathic pain but due to a lack of good quality evidence to support their use, they are no longer recommended for the management of neuropathic pain.

13 Gabapentin / Pregabalin

Gabapentin and Pregabalin are appropriate first line agents where tolerated for chronic neuropathic pain.
Advise patient of high chance of side effects immediately but pain relief benefits may be delayed until optimum dose reached.
Advise patient that some people respond to one and not the other, and some people tolerate one better than the other – it may be required to try both.
Elderly patients are particularly susceptible to many of the side effects, so caution should be used.

Patient Information Leaflet
Please see attached patient information leaflets on:

Pregabalin PIL
Gabapentin (slow dose increase) PIL
Gabapentin (fast dose increase) PIL

14 Other agents – many of these have very specific licensed indications, see details below

Quick info:

Capsaicin cream 0.075% is licensed for neuropathic pain but the intense burning sensation during initial treatment may limit use.
Capsaicin 0.025% is licensed for osteoarthritis only.

Duloxetine is licensed for diabetic neuropathy. The initial dose is 60mg daily up to a maximum of 120mg per day in divided doses.Maximum of 2 month’s supply before treatment response review to confirm if to continue.

Grey Listed Drugs –Should only be initiated by a pain specialist for specific indications

Lidocaine plasters, do not initiate. Classified as grey drug for post herpetic neuralgia where alternative treatments have proved ineffective or contraindicated. NICE do not recommend this treatment in primary care due to a lack of consistent evidence.

Tapentadol MR, do not initiate. Leeds grey list medication. Should only be initiated by a pain specialist for severe chronic pain as a third line option.

15 Strong Opioids – High Risk Step

Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long-term pain.
A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation.
The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increase benefit; tapering or stopping high dose opioids needs careful planning and collaboration.
If a patient has pain that remains severe despite opioid treatment it means they are not working and should be stopped, even if no other treatment is available.
Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detailed assessment of the many emotional influences on their pain experience is essential.

Consider referral to community chronic pain service before initiation of strong opioids – link to chronic pain pathway

“Thinking about Opioid Treatment for Pain” patient information leaflet - Royal College of Anaesthetists

Discuss the potential harms of opioid treatment including: -

Sedation
Nausea
Constipation
Effects on hormones
Effects on the immune system
Potential for the drugs to worsen pain
Potential for problematic drug use and addiction
Effect on cognitive function - how brain takes in, processes and stores information

ALL patients should read and agree to opioid initiation contract before being issued with opioid prescription

Patient Opioid Agreement

Patient Information – All leaflets available from FPM Opioids Aware HERE: https://fpm.ac.uk/opioids-aware

“Taking Opioids for Pain” patient information leaflet - Royal College of Anaesthetists

RCGP Top Ten Tips: Dependence Forming Medications:
https://www.rcgp.org.uk/-/media/LeedsPathways/files/CIRC/Desktop-guides/Top-Ten-Tips-Dependence-Forming-Medications-April-2019

The OPIOID TRIAL
If deemed necessary to commence strong opioids – initiate Opioid Trial – see details below and on SystmOne & Emis Chronic Pain Template

https://fpm.ac.uk/opioids-aware-structured-approach-opioid-prescribing/opioid-trial

Starting the Trial
The patient and the prescriber should agree some readily assessable outcomes that indicate that opioids may play a role in the patient’s management. These will usually include reduction in pain intensity and ability to achieve specific functional improvement facilitated by the medication. For patients in whom sleep is significantly impaired by pain, improved sleep would be a reasonable outcome.

Duration of the Opioid trial
This will depend on the periodicity of the patient’s pain. If the patient has constant pain, the opioid that may be concluded in one or two weeks. If the patient has intermittent disabling flare ups of pain on a background of more manageable symptoms, the trial should be long enough to observe the effect of opioids two or three episodes of increased pain.

Choice of Opioid Formulation and Dose
Where possible, the usefulness of opioids should be explored by prescribing a short (1-2 week supply) of immediate release morphine tablets or liquid. The patient may be advised to explore different doses within a specified range e.g. morphine 5-10mg. If reduction in pain is not achieved following a single dose of immediate relief morphine 20 mg, opioids are unlikely to be beneficial in the long term. A trial of fixed dose regimens using modified release preparation needs to allow for one or two upwards dose adjustments and may therefore take three weeks or more.

Assessing whether the Opioid Trial is a Success
The patient should keep a diary during the opioid trial. This should include a twice-daily report of pain intensity, comment on sleep, note of activity levels and how any of these are changed following a dose of opioid. All doses of opioid should be recorded in the diary with a comment on side effects. If the opioid trial is not successful, the drugs should be tapered and stopped within one week.
If the patient reports no improvement in symptoms following the trial it is very unlikely that long-term opioid therapy will be helpful.

Documentation
All stages of the opioid trial should be clearly documented and if appropriate, a copy of the agreed aims of therapy and how these may be monitored should be given to the patient. Documentation should also include the agreed starting dose and formulation of drug and details of planned dose escalation. If the opioid trial demonstrates that the medicines are unhelpful, the reasons for this (lack of efficiency/intolerable adverse effects) should also be clearly documented. If the patient reports reduction in pain but at the cost of side effects that preclude achievement of functional goals. It is reasonable to explore different dosing regimens with active management of side effects to see if a useful balance between benefits and harms can be achieved.

If the opioid trial demonstrates some benefit from opioids, further exploration of opioid treatment may be helpful. A successful short-term opioid trial does not predict long-term efficacy. Click here for guidance on long-term prescribing of opioids

Strong Opioids will only be appropriate for a very small number of patients with chronic pain. They should be used with extreme care and caution, (particularly in opioid naïve patients) due to the high risk of side effects in both the short and longer term, and the risk of dependency.

Further Resources For Patient Information – All leaflets available from Opioids Aware HERE: https://fpm.ac.uk/opioids-aware

Further Resources For Healthcare Professionals – Opioids Aware Materials HERE: https://fpm.ac.uk/opioids-aware/structured-approach-opioid-prescribing

Provide patient with information about the harmful effects of using opioids incorrectly and ensure you ask patient to read and sign opioid agreement

Morphine slow release orally would be the strong opioid of first choice.
Zomorph capsules are the most cost effective option. 10mg capsules twice a day, increased to a maximum of 180mg in 24 hours.
Take care when selecting from the drug list -double check the strength!
Zomorph is not available in 5mg or 15mg strengths.
Oramorph, morphine sulphate 10mg/5ml, and other opioid-based immediate release formulations can lead to rapid opioid dose escalation. Breakthrough analgesia is not recommended for patients with chronic pain; it can encourage dependence on medication as the way to manage pain.

Fentanyl patches are reserved for patients who cannot take oral morphine or do not respond.
MHRA Guidance - Transdermal fentanyl patches: reminder of the potential risk of life-threatening harm from accidental exposure
Oxycodone orally can be used in renal impairment.

16 Early Clinical Review

Monitoring Guidance – the 4 A’s
After starting or changing a treatment, perform an early clinical review of dosage titration, tolerability and adverse effects to assess suitability of chosen treatment. Following trial, stop treatment and reassess if not effective.

Prescribing Guidelines for Primary Care: Opioid Induced Constipation in Adults