·         Pain that lasts for more than 3 months is known as chronic or persistent pain. It is common and affects between 3 and 5 in every 10 people. Chronic pain can be caused by an underlying condition (for example, arthritis or endometriosis); this is known as chronic secondary pain. But in many cases the cause of the pain is unclear; this is called chronic primary pain. Pain is complex and many factors can affect or be affected by the pain, including your work and leisure time, relationships with family and friends, sleep and mood. Management of chronic pain should be individualised with a focus on self-management and maintaining daily function and quality of life despite ongoing pain.

·         Unlike acute pain, chronic pain is difficult to treat with most types of medication helping less than a third of patients. Medicines generally and opioids in particular are often not very effective for chronic pain.

·         Most treatments aim to help you self-manage your pain and improve what you can do. Some non-medicine treatments may be used such as electrical stimulating techniques (TENS machine), acupuncture, advice about activity and increasing physical fitness, and psychological treatments such as Cognitive Behaviour Therapy and meditation techniques such as mindfulness.

·         Helping you understand about chronic pain is important and in particular helping you understand that physical activity does not usually cause further injury and is therefore safe. It is important that you understand that treatments tend not to be very effective and that the aim is to support you in functioning as well as possible.

Information is from the faculty of pain medicine website.

 Resources to help you manage your chronic pain:

https://livewellwithpain.co.uk/resources-for-people-with-pain/

https://www.flippinpain.co.uk/understanding-pain/

https://www.paintoolkit.org/what-is-pain

Opioids include codeine, tramadol, morphine, oxycodone, fentanyl, buprenorphine and methadone.

·         There is evidence to suggest that opioids are very good painkillers when used for cancer pain, pain at the end of life or if used short term (for days to a few weeks) for some types of acute pain.

·         Recent evidence has shown that opioids are poorly effective for long-term or chronic pain. As a result, opioid medication has been removed from a number of the guidelines that GPs use when treating chronic pain. For a small proportion of patients, opioids may be successfully used as part of a wider plan including non-medication treatments and self-management. If this is the case, best results are achieved when the opioids are used intermittently and at the lowest possible dose.

·         When opioids are used, it is important to understand that the aim is not complete pain relief but rather reducing pain sufficiently to engage in self-management.

·         The potential harms of opioid treatment include drowsiness, nausea, constipation, effects on hormones, effects on the immune system, the potential for the drugs to worsen pain, the potential for problematic drug use and addiction.

·         If the pain remains severe despite opioid treatment, it means that it is not working and should be stopped, even if no other treatment is available, as the risks outweigh the benefits.  

Further information about pain and the use of opioid treatment for pain:

https://fpm.ac.uk/opioids-aware-information-patients/about-pain-patients

https://fpm.ac.uk/opioids-aware-information-patients/thinking-about-opioid-treatment-pain

https://fpm.ac.uk/opioids-aware-information-patients/taking-opioids-pain

Information and leaflets are from the faculty of pain medicine website

RATIONALE

This policy is based on MHRA recommendations, Faculty of pain and NICE Guidance. It is intended to outline a strategy to manage the risks and maximise benefits when prescribing opioid medications.

 Opioid medications (opioids) provide relief from serious short-term pain, however long-term use in chronic non-cancer pain (i.e. longer than 3 months) carries increased risk of dependence and addiction. The risk of addiction is present even when these medications are used at a therapeutic dose. Patients may find that treatment is less effective with long term use and therefore may feel the need to increase the dose to obtain the same level of pain control as initially experienced.

 There is a risk of tolerance, dependence and addiction to opioid drugs for all patients. There is also the risk of withdrawal reactions and additional risk of hyperalgesia – where a patient has increased sensitivity to pain due to the long-term use of opioids. This is not pain due to disease progression but pain induced by the use of the drugs themselves.

GENERAL PRACTICE STANDARDS

·      The decision to prescribe an opioid is taken after a shared discussion with the GP about goals, plans, risks and benefits.

·      The patient will be asked to read and agree to the Kearsley Medical Centre ‘Doctor-Patient Agreement for Opioids in Chronic Non-Cancer Pain’ that will detail the practice’s expectations when prescribing drugs of dependence. This agreement details the responsibilities of the patient around taking a drug of dependence; any prescriptions issues; advice on taking their medications; how we the practice will monitor their care and the standards of behaviour that are expected.

·      The patient may need to acknowledge that their care requirements are complex, and that referral for ongoing care for all or part of their healthcare may be required. It is our practice policy that patient care is matched with the level of complexity.

·      Patients are reminded that we have a zero-tolerance policy on issues relating to staff verbal or physical abuse. Any threats to staff will result in transfer of your care.

OPIOID PRESCRIPTIONS

Due to increasing reports of abuse of opioid drugs, Kearsley Medical Centre has established an opioid prescribing policy to ensure adequate treatment of a patient’s condition, while reducing the risk of problems.

·     Patients initiated on opioids will be asked to read and agree to the Kearsley Medical Centre ‘Doctor-Patient Agreement for Opioids in Chronic Non-Cancer Pain’.

·     All new opioids will be issued as acute prescriptions until all appropriate reviews are done.

·     All patients will need a review after 4 weeks of initiation of an opioid prescription; pain assessed, and a decision made as to the effectiveness of the drug.

·     If opioids are ineffective, they will be stopped, even if no alternative is available.

·     Where patients have been stabilised on an opioid which has been shown to be effective, this may be added to the patient’s repeat medication at the prescriber’s discretion.

·     Patients on long-term opioids will be reviewed every 6 months to discuss slowly weaning off their opioid medication. Treatment will only be continued where there is clear on-going evidence of benefit.

·     All opioids will be issued on prescriptions with a maximum duration of 1 month.

·     All opioid prescriptions will include full directions wherever possible, and use of PRN will not be used.

·     Where opioids are initiated by an external provider, the Practice will only take over prescribing once a written request has been received.

REVIEW OF OPIOID PRESCRIBING

There are some patients who have been taking these medications for a number of years. We will need to review these patients and discuss slowly weaning off their opioid medication. This will be done with either a GP or our in-house pharmacy team.

 We appreciate that for a patient who has been taking opioids for a number of years, there may be a sense that they won’t be able to cope without them. Evidence does show that we can reduce withdrawal symptoms by reducing the dose of the opioid medication slowly. The reduction schedule would be individualised for each patient.

FOR NEW PATIENTS TO THE PRACTICE:

It may take time to get accurate medical information about your condition. Until such information is available, your GP may choose to prescribe fixed quantities of your medication. It is our policy that GPs do not prescribe drugs of dependence until they have some evidence, for example, a repeat prescription slip.

Your GP may decide not to continue prescribing an opioid medication previously prescribed for you. It may be determined that such a medication is not suitable. It is our policy that GPs do not prescribe drugs of dependence if they feel that previous prescriptions were inappropriate. 

Your GP will evaluate your condition and only prescribe an opioid of the strength necessary for you. This may be different to the drug you had prescribed at your previous GP Practice.

RESOURCES

The ‘My Live Well With Pain’ website has a range of useful resources to help you learn the skills you need to become an effective self-manager of your pain. 

https://livewellwithpain.co.uk/resources-for-people-with-pain/

https://www.flippinpain.co.uk/understanding-pain/ 

https://www.paintoolkit.org/what-is-pain  

Doctor-Patient Agreement for Opioids in Chronic Non-Cancer Pain

 This agreement is designed to share information about the medications you will be taking to help with chronic pain. It will also aid you and your doctor to comply with controlled substance regulations.

Our goal is to improve your quality of life while balancing the risks of medication. The success of your treatment depends on trust, honesty and understanding how opioids and opioid-like drugs are used.

 We have agreed to use opioids as part of your treatment plan for chronic pain management. These drugs can be useful but can have significant side effects and therefore need to be closely monitored and regulated.

                                                                            *********************************************************************************************

 Your doctor understands that it is important for you to know that they will: 

·        Listen and try to understand your experience of living with pain.

·        Accept your reports of pain and response to treatment.

·        Thoroughly assess your pain.

·        Explain what is known and unknown about the causes of your pain.

·        Explain the meaning of test results or specialist visits/consultations, and what can be expected in the future.

·        Explain the risks, benefits, side-effects, and limits of proposed treatment.

·        Respect your right to participate in making pain management decisions, including the right to refuse some types of treatment. 

                                                                         *********************************************************************************************

It is equally important for your doctor that:

•     You have read the patient information leaflet and you are fully aware of the potential side effects of opioid therapy, including hormonal disorders, which may affect mood, stamina, sexual desire, and physical and sexual performance

• You understand that many drugs can interact with opioids increasing the risk of side effects. This includes alcohol, sleeping tablets, antihistamines, some cough medicines and other drugs, therefore you will read the warnings on all your medications and inform any doctor that you visit that you receive opioid medication.

• You do not ask for prescriptions earlier than agreed upon and take medicine only at the dose and time/frequency prescribed. 

• You understand that you should only be on one opioid at a time, so if your treatment plan is changed, some of your existing medications may be discontinued. 

• You do not ask for opioid medicines from other doctors or obtain them from unauthorised individuals.

·       You understand that the prescribed opioid medication is strictly for YOU.  It should not be given or sold to others because it is illegal and may also endanger that person’s health. You are responsible for keeping your pain medications in a safe and secure place, a locked cabinet or safe is ideal. If your medication is stolen, you will report this to the local police station and obtain a crime number. You will also report the stolen medication to your doctor. If your medication is lost, misplaced or stolen, your doctor may choose not to replace it.

• You understand that in most cases long-term opioid therapy is only blocking the pain signals, but is not treating the actual cause of the pain, therefore, you are willing to learn new ways to manage your pain by attempting step-by-step behaviour and lifestyle changes. Please visit our webpage for more information about this https://www.kearsleymedicalcentre.nhs.uk/chronic-non-cancer-pain-and-opioid-medications 

• You understand that long-term and/or high doses of pain medication may cause increased levels of pain known as opioid-induced hyperalgesia (pain medicine causing more pain) which may manifest as a completely different kind of pain or an increase in your present pain syndrome.  

• You are aware that continued use of opioids will lead to physical dependence. Physical dependence means that if your opioid use is markedly decreased or stopped, you will experience a withdrawal syndrome, with some or all of the following symptoms: runny nose, yawning, large pupils, goose bumps, abdominal pain and cramping, diarrhoea, vomiting, irritability, aches throughout body and a flu-like feeling. You are aware that opioid withdrawal can be very uncomfortable, but is not normally life-threatening. 

• You are aware that many opioid users develop a tolerance to opioids. If you become tolerant, it may be an idea to decrease the opioid dose very gradually under your GP supervision, stop taking the opioid for some time and then gradually start it again. This is much better than increasing the opioid dose and helps to avoid the side effects. There will be an upper limit of opioid that will be decided, beyond which it would be considered unsafe to increase the opioid dose. 

• You understand the implications on driving, specifically that it remains illegal in England and Wales to drive when taking prescription medicines if the medication impairs a patient’s ability to drive. 

• For female patients, if you plan to become pregnant or believe that you have become pregnant while taking the above medication, you are aware that, should you carry the baby to delivery while taking opioids, the baby will be physically dependent. You will inform your doctor of your pregnancy without delay.  

• You understand that initially you will be seen and assessed at short intervals to allow appropriate adjustment of the opioid dose and you will be asked about your pain scores, quality of life and sleep. If it appears to your doctor that there is no improvement in the quality of your life and daily functioning, your medicine may be discontinued even if there is no suitable alternative. 

• You will communicate fully with your doctor or other designated prescriber about your pain level and activities during your initial visits and during all follow-up visits. If asked, it is your responsibility to notify your doctor or specialist nurse of the side effects that continue or are severe (i.e. sedation, confusion).