Chronic pain in adults - The use of opioids, gabapentinoids and antidepressants

The aim of this hot topic is to ensure that prescribing analgesics in chronic non-malignant pain is safe and effective with ongoing review to reduce and cease analgesic use where appropriate with a person-centred approach.

Chronic pain, also called persistent pain, is defined as persistent or recurring pain that lasts longer than three months despite medication or treatment and is a recognised long-term condition.¹⁵³

Moderate to severe chronic pain affects one in five people in Scotland.¹⁵⁴ Chronic pain can significantly impact an individual’s quality of life, mood and function. Many people living with pain need to be supported and empowered to manage their pain, considering non-pharmaceutical options in the first instance. This reduces the risk of over-medication and side effects which can increase the risk of adverse effects, especially if there is multimorbidity or frailty. Total eradication of pain is unlikely, and evidence reviews frequently consider an intervention effective if it reduces pain by 30%¹⁵⁵ to 50%.¹⁵⁶ Individuals should have access to personalised information and support with an awareness that chronic pain is a long-term condition. The goal is increased function and improved quality of life.

Opioids are not considered essential medicines, but they should not be stopped abruptly (see later sections). Essential medicines are defined as those that may cause rapid symptomatic decline or loss of disease control if discontinued and that should only be stopped on specialist advice.²

Use of the terms “opiate” and “opioid” can cause confusion. Opiates are naturally occurring alkaloids derived from the opium poppy. Opioids are synthetic drugs which produce an opiate like effect. All act at receptors in the body defined as opioid receptors. For the purposes of this hot topic, the term opioid(s) is used to refer to both opioid and opiate based medicines.

Antidepressants and anticonvulsants may also be prescribed for chronic pain alongside management of depression, epilepsy and other conditions. These conditions need to be carefully considered when altering drug dosages, including the dosage of any opioid medication. Those experiencing chronic pain with co-existing depression should have their antidepressant therapy optimised, rather than adding a subsequent antidepressant medication.¹⁵⁷

This hot topic does not consider acute pain, e.g. post-operative; or use in other settings such as palliative care or management of terminal disease, including conditions such as breathlessness in the advanced stages of respiratory disease. Further information is available via the Scottish Palliative Care Guidelines.¹⁵⁸

Individuals living with pain should feel empowered to self-manage their condition. A person’s experience of pain is influenced by multiple factors. This can include a variety of emotional and psychological factors (e.g. anxiety, distress, depression, previous trauma), in addition to social and biological factors. A concise history, examination and biopsychosocial assessment, identifying pain type (neuropathic/nociceptive/mixed/unknown), severity of pain, functional impact and context should be conducted in all those with chronic pain. This will inform the selection of treatment options most likely to be effective.

It is good practice to establish and record the baseline level of pain experienced and functional capacity for future reference and comparison. Tools to support this are available, e.g. the British Pain Society Pain Rating Scale (and see chronic pain resources section).

Healthcare professionals and individuals should have honest conversations about the role of medication in the management of chronic pain:

• considering the holistic nature of pain
• explaining that analgesia is unlikely to completely eliminate pain but may lessen pain intensity
• there should be an understanding that pain is both a physical and emotional experience, often associated with stress, health beliefs or trauma in their lives
• supported self-management strategies can be more beneficial to overall well-being
• there can be an over reliance on pain medicines as an intervention with unrealistic expectations that there will be complete pain resolution
• any treatment prescribed should be reviewed regularly and withdrawn if not effective, with individuals supported in taking the minimum dose of medication that results in the maximum benefit to their wellbeing while minimising medication-related harm.

Key areas for consideration include:

• biopsychosocial model of pain
• understanding their diagnosis
• activity management and pacing
• diet and lifestyle
• sleep
• emotions and mood
• value based goal setting
• flare-up planning

Opioids, gabapentinoids and antidepressants are associated with a risk of dependency.^159,160 Individuals should be made aware of risks on initiation and supported to withdraw as appropriate.

Healthcare professionals should be aware of the possibility that some individuals may present with ‘drug seeking behaviour’, due to the potential for addiction and discontinuation/withdrawal reactions from gabapentinoids, opioids and antidepressants. To minimise this risk, they should have honest conversations with people at the onset of prescribing about the limitation of medication for the management of pain (see resources section). Further information about this is also given in the case study on drug dependency and requests for out of hours medication.

Numbers needed to treat (NNTs) in the management of chronic pain may appear relatively low, e.g. the NNT for pregabalin for managing post herpetic neuralgia is four. However, this means that for every one person with reduced pain intensity, there are three people who receive no benefit, with increased risk of adverse effects. Ineffective medication should be safely stopped.

Total eradication of pain is unlikely, and evidence reviews frequently consider an intervention effective if it reduces pain by 30%¹⁵⁵ to 50%.¹⁵⁶

There is a high placebo effect, highlighting that biopsychosocial effects are contributory factors in pain management. For example, a Cochrane review showed pregabalin 300mg daily reduced pain intensity by 30% in 47% of patients, but the placebo was similarly effective in 42% of patients.¹⁵⁶

It is important to not only assess the impact of these medicines on pain levels, but also consider the effect on physical function, mental health and emotional factors (e.g. mood, anxiety, sleep, social and sexual function) that also contribute to effective pain management.

These medicines can be stopped but should not be done abruptly. Reduction of therapy should be controlled, not sudden, to manage the risk of discontinuation/withdrawal symptoms.

Successful reduction requires shared decision-making and the individual’s participation in a person-centred review that considers the personal context. A person-centred assessment of risk versus benefit should occur before reducing or stopping medication to determine the effectiveness of treatment.

Generally:

• Potentially fatal interactions between medicines that cause CNS depression, particularly opioids, gabapentinoids and benzodiazepines

Discuss withdrawing medication if:

• the condition for which the medicine was prescribed has resolved
• it is no longer benefiting the patient
• problems associated with dependence have developed
• the adverse effects of the medicine outweigh the benefits
• there are drug interactions, e.g. where other central nervous system depressants are being used or prescribed (e.g. alcohol, opioids)the individual wants to stop taking the medicine
• with gabapentinoids, if the individual is planning or becomes pregnant.

General:

• Any reduction should be gradual, according to the individual’s needs, unless urgent safety issue.
• Individuals should be supported through the dose tapering process, maintaining regular contact with the healthcare team involved in their treatment, to allow for ongoing assessment of discontinuation/withdrawal symptoms, pain control and impact on function and quality of life.
• Tapering can be paused if an individual is experiencing difficulty and can be revised and continued with a more gradual reduction.
• There should also be planning for short-term pain flares and for any withdrawal effects for example
  • opioids - agitation, muscle aches, restlessness, anxiety
  • gabapentinoids - agitation, anxiety, insomnia, or flu-like symptoms, confusion, headache, lethargy and a return of nerve pain
• Discuss discontinuation/withdrawal symptoms.
  • explain that withdrawal can be difficult and may take several months or more.
  • although discontinuation/withdrawal symptoms do not affect everyone, it is not possible to predict who will be affected.
  • discontinuation/withdrawal symptoms vary widely in type and severity, can affect both physical and mental health, may occur at any time during withdrawal or be delayed in onset and can change over time or persist over a prolonged period.

Supporting people who do not or cannot reduce/stop

These are not classed as essential medicines but should not be stopped abruptly. Individuals who cannot stop their medication should be encouraged to reduce to the lowest effective dose.

Individuals should be regularly encouraged to self-manage and use non-pharmacological treatments of chronic pain where appropriate. Avenues for reducing or stopping medication should remain available to the individual.

Good practice point: Clinicians should consider prescribing naloxone for those prescribed an opioid and who may be at risk of an opioid overdose.^200,201

Take-Home Naloxone Programme is available across all boards in Scotland. The naloxone website has information on how to spot signs of overdose and how to administer naloxone.

Specific areas/situations where medication may need to be introduced or increased

If the presenting pain condition changes or symptoms worsen, undertake a further pain assessment, considering potential cause of flare-up and consider appropriate management (which may include rest, heat packs, pacing, use of short-term non-steroidal), dependent on the cause for the presenting pain.

Does the person understand the outcomes of the review, including risk and benefits?

• Ask individuals whether they would like to have support during appointments from a family member, carer, advocate or other person close to them.
• Discuss with the person the benefits and risks of continuing the current dose, adjusting the dose or stopping the medicine. Base decisions on these discussions and ensure ongoing regular reviews are in place.
• Provide written materials to support discussions and decisions, or before the review/consultation to inform and support informed decision-making.
• Consider whether the individual needs support with taking their medicines, such as a medication chart or adherence aid, or if they need further information.

Is drug therapy tailored to the individual?

• Ensure the individual is provided with a plan for withdrawal that is tailored to their situation, and the medicine they are taking, and that they are aware of how the withdrawal will be carried out.
• Ensure they understand that if side effects are a problem, solutions such as adjusting dosages, timings or switching to an alternative can be considered.

Agree the plan

• Continuity of care is important to foster collaborative, trusting and supportive relationships with people, considering medication at all stages of prescribing. Shared decision-making allows people to actively participate in their care.
• Supported self-management encourages, supports and empowers people to manage their long-term conditions and live well with their conditions.
• Consider providing details of peer support services including national and local support groups for people who are withdrawing from a medicine.
• Have clear expectations of future benefit assessment, potential harms from medication and reasons to stop.

• self-management/support tools
• decision aids for healthcare professionals

NHS Inform: Patient information on chronic pain
Includes: General overview, Self-help activities - What can I do for myself? Link to chronic pain self help guide and links to other organisations.

Flippin’ Pain™ website
A public health campaign with a clear goal: to change the way we think about, talk about and treat persistent pain. Includes information on chronic pain, real life stories and resources to help understand pain and move towards recovery.

Brainman™ Understanding Pain in less than five minutes
5-minute video explaining chronic pain and options to support recovery.

Pain Association Scotland website
A national charity that delivers professionally led self-management pain education in the community with local groups, pain management courses and assorted videos.
Tel: 0800 783 6059 (to join a group)

Arthritis UK website (merger of Arthritis Care and Arthritis Research UK)
Information on: arthritis and musculoskeletal conditions, how to manage symptoms including pain, sleep, fatigue and local groups.
Tel: 0800 5200 520

Live Well with Pain website
Created by a small group of healthcare professionals working in pain management, using a self-management approach with their patients. Also includes input from people who themselves live with persistent pain. Includes: Ten Footsteps programme and self-management resources.

Pain jigsaw
Interactive version of pain jigsaw from NHS Fife

Patient led videos on chronic pain
Produced by NHS Greater Glasgow and Clyde pain team. Covers understanding of chronic pain, activity, flare ups, sleep, and stress.

Increased pain and tolerance with morphine-like medicines
Video from NHS Ayrshire and Arran

Not just painkillers – Your pain and how you can help it
Booklet from NHS Lothian with information on pain in general, opioid analgesics and self-help advice.

Reducing and stopping opioids
Information for patients leaflet from Oxford University Hospitals including information on side effects of opioids, why stop, help during reduction

Pain data website
Medication information leaflets for patients includes leaflets on co-codamol, tramadol, dihydrocodeine and others.

Pain Concern Helpline 0300 123 0789

• self-management/support tools
• decision aids for healthcare professionals

Resources for healthcare professionals

Live Well with Pain website
Wide range of leaflets and information sheets to download and print, including self-management information leaflets and tools, medicines information for people with pain and information posters for public waiting areas.

GP pain assessments

Live Well with Pain Health Check tool/questionnaire

The Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain score assessment tool

British Pain Society Pain Scales
Single page pain assessment. Suitable for ongoing use to evaluate effectiveness of therapies.

Opioid information

Pain Management opioid reduction calculator
Select opioid, starting dose, target (complete reduction or switch to another), weekly percentage reduction and website calculates weekly doses.

Increased pain and tolerance with morphine-like medicines
Video from NHS Ayrshire and Arran.

DIRE score for opioids
Assesses candidacy for long-term opioid analgesia based on seven multiple choice questions.

GP Practice prescribing management and review systems

Pain management consultation model for primary care
Suggested content for 3 consultations:

1. build trust, exclude differentials
2. pain management plan
3. promote self-management

Primary care chronic pain management MDT
Includes: primary care MDT management pathway and exemplars letters for chronic pain medication reviews.

National Therapeutic Indicators (NTIs)
Practice specific prescribing data

Deprescribing practice lessons learned
Top 10 tips and action plans from GP practices.

Education

NES Chronic Pain Knowledge Hub on TURAS
Free but requires NES TURAS account

Webinar: Chronic pain: why it can only be in the brain (free)
Discussion of a radical new perspective on the neurobiology of chronic pain and how this can revolutionise practice.

NES webinar on challenging consultations and recorded consultation of patient with fibromyalgia with drug seeking behaviour.
Free but requires NES TURAS account.

Webinar: Dealing with drug seeking behaviour
Presentation with practical hints and tips on how to recognise and manage drug seeking behaviour.

National therapeutic indicators (NTIs) use prescription data in specific areas to provide a measure of prescribing activity for comparison across NHS Boards, Health and Social Care Partnerships (HSCPs), GP clusters and GP practices.
NTIs are available to view online.

NTIs benchmark prescribing across set parameters and are presented in a variety of ways. Examining variation over time can indicate where improvements in prescribing can be made. The indicator detail provides further information and suggested actions.

Indicators for this hot topic include:

• Opioid and gabapentinoid dependency: high dose opioids (morphine daily equivalent 50mg or more) see the chart below
• Analgesics: opioids (excluding tramadol) defined daily doses per list size
• Opioid and gabapentinoid dependency: high dose opioids (morphine daily equivalent 90mg or more)
• People receiving three or more of benzodiazepine/z-drug, opioid (including tramadol), gabapentinoid, antidepressant or antipsychotic (excluding depots)

High dose opioids (morphine daily equivalent 50mgor more)

(Click on image to enlarge)