Roger Knaggs

Evidence-based clinical practice guidelines on management of pain in older people

Pain in older people is not only under-recognised, but is also under-treated. Many professional bodies have documented that pain in this rapidly growing population is poorly controlled [1–7]. This may be related to attitudes and beliefs held by older people, which in turn affects their reporting of pain [8] but also due to misconceptions and educational deficits by health professionals [9, 10]. Treatment when prescribed is often limited to basic medication seldom tailored to the individual [11–14]. There is also a general failure by professionals to consider alternative pain relief options [2]. No doubt more needs to done and national guidance on the management of pain in older people is long overdue. Older people are different; the bio-physiological changes that occur with ageing, the accumulation of co-morbidities and co-prescription of medication, frailty and psychosocial changes make older people rather unique when considering treatment modalities for pain control. The British Geriatric Society and British Pain Society have collaborated to produce the first UK guideline on the management of pain in older people. The recommendations follow an extensive systematic review of the available literature and will help health professionals consider the options available when managing pain in older patients. The guideline has been categorised into sections dealing with pharmacology, interventional therapies, psychological interventions, physical activity and assistive devices and complementary therapies. This article provides a summary of the recommendations. The full guideline is available in the supplement accompanying this issue of the journal.

Changes in trends and pattern of strong opioid prescribing in primary care

This study evaluated the prescribing trends of four commonly prescribed strong opioids in primary care and explored utilization in non‐cancer and cancer users.

Retention behavior of morphine and its metabolites on a porous graphitic carbon column

SummaryThe chromatographic behaviour of a series of morphine-based opiates has been investigated using a porous graphitic carbon packing material at acid and alkaline pH. The effects of mobile phase pH, mobile phase organic percentage, column temperature and ionpairing agents were studied. All six opiates were separated within a close retention window despite large differences in measured lipophilicities of the individual opiates. The retention order was not related to the log P values of the opiates and strong retention of the fully ionised compounds was observed, particularly those with acidic functional groups. The effect of pH on the retention of the compounds indicated that the degree of ionisation of the individual compounds was important in the separation mechanism, suggesting that hydrophobic interactions were present in addition to the polar retentive effects observed above. The strong retention of the ionised glucuronide and sulphate conjugates of morphine is a particularly useful feature of the porous graphitic carbon packing material which has general applicability to the analysis of polar or ionised drug metabolites.

Is tapentadol different from classical opioids? A review of the evidence

Tapentadol is a single molecule able to deliver analgesia by two distinct mechanisms, a feature which differentiates it from many other analgesics. Pre-clinical data demonstrate two mechanisms of action: mu-opioid receptor agonist activity and noradrenaline re-uptake inhibition. From these, one may predict that tapentadol would be applicable across a broad spectrum of pain from nociceptive to neuropathic. The evidence in animal models suggests that norepinephrine re-uptake inhibition (NRI) is a key mechanism and may even predominate over opioid actions in chronic (and especially neuropathic) pain states, reinforcing that tapentadol is different to classical opioids and may, therefore, be an a priori choice for the treatment of neuropathic and mixed pain. The clinical studies and subsequent practice experience and surveillance support the concept of opioid and non-opioid mechanisms of action. The reduced incidence of some of the typical opioid-induced side effects, compared to equianalgesic doses of classical opioids, supports the hypothesis that tapentadol analgesia is only partially mediated by opioid agonist mechanisms. Both the pre-clinical and clinical profiles appear to be differentiated from those of classical opioids.

Opioid prescribing: Balancing overconsumption and undersupply

Opioids continue to be a topic of much discussion and controversy. At a packed special session at the World Congress on Pain to discuss the role of opioids in pain medicine, the speakers aimed ambitiously to find a path between undersupply in many developing countries and overconsumption elsewhere, particularly in the United States and Canada. Global consumption of opioids has increased at an alarming rate over recent decades. While the number of people in the United States accounts for only 5% of the world’s population, 80% of opioid consumption occurs there. There are many developing countries that struggle, as a result of unwieldy regulation and legislation, to obtain or supply opioids resulting in avoidable pain and suffering, particularly for those at the end of life. The beneficial analgesic effects of opioids have been long recognised for centuries, and opioids are usually regarded as some of the most potent analgesics available. Evidence for the benefits of opioids in acute pain and pain at the end of life is substantial, but there remain many unanswered questions about the appropriate use of opioids for non-cancer pains in the long-term, particularly, the lack of data demonstrating long-term effectiveness and the potential for opioids therapy to result in dose-related harms. In addition, the association between opioids and addiction have an equally long history, with varying degrees of societal acceptance or legal control towards recreational use of opioids. Prescribing opioid medicines for pain should reflect good principles in prescribing generally and should be similar to prescribing medicines for other long-term conditions, such as hypertension, diabetes mellitus or asthma. It is essential for both patients and healthcare professionals to have realistic expectations of the intended benefits of any treatment including a trial of opioids. If any medicine, including opioids, fails to attenuate the symptoms for which they are prescribed, they should be tapered and stopped. Changing clinical practice in opioid prescribing is not going to be quick or easy. Providing knowledge and improved understanding is important, but they are only the first small steps required in order to support the cultural changes in healthcare and society that are required in order to ensure that opioid use does not become regulated even more. The principles of the World Health Organization (WHO) analgesic ladder in which increasingly strong medicines are prescribed according to reported pain intensity improved the lives of thousands of patients living with cancer. Treating persistent pain is much more complex given the myriad experiences that shape the perception of pain and its likely trajectory. We need to embrace new ways of thinking about pain with a better understanding of patient needs and attention to the important principle that causing harm with medicines is worse than doing nothing.

Rapid acting fentanyl formulations in breakthrough pain in cancer. Drug selection by means of the System of Objectified Judgement Analysis

Drug selection of rapid acting fentanyl formulations in the treatment of breakthrough pain in patients with cancer is performed by the System of Objectified Judgement Analysis method. All seven available formulations were included in the analysis. The following selection criteria were used: number of available strengths, variability in the rate of absorption, interactions, clinical efficacy, side effects, ease of administration and documentation. No direct double-blind comparative studies between two or more formulations were identified and the clinical documentation of all formulations is limited. The most distinguishing criterion was ease of use. This led to slightly higher scores for Abstral, Instanyl and PecFent than for the other formulations. The pros and cons of each formulation should be discussed with the patient, and the most suitable formulation selected for each individual patient.

Evidence-based clinical practice guidelines on the management of pain in older people: executive summary.

The British Pain Society and British Geriatric Society have collaborated to produce comprehensive pain management guidelines based on an extensive systematic review of the available literature by a professional multidisciplinary group. This guidance reviews the epidemiology and management of pain in older people with the aim of providing best practice recommendations for the management of pain by all health professionals working with older adults in any care setting and emphasises the importance of a multimodal approach in the management of pain in older people. Assessment of pain in older people has not been covered within this guidance but can be found in a separate document (http://britishpainsociety.org/book_pain_older_people.pdf).

Pain after surgery

Pain After Surgery offers an in-depth, comprehensive overview of basic and clinical research in the field. It presents the current knowledge and expertise of top global researchers on changes in central nervous system function accompanying and following surgery, as a model of chronic pain development. It also translates scientific understanding into effective clinical management of acute and persistent pain after surgery, including preoperative interventions to decrease the risk of chronification of postsurgical pain.

Imaging pain relief in osteoarthritis (IPRO): protocol of a double-blind randomised controlled mechanistic study assessing pain relief and prediction of duloxetine treatment outcome

Introduction Osteoarthritis (OA) pain is a major cause of long-term disability and chronic pain in the adult population. One in five patients does not receive satisfactory pain relief, which reflects the complexity of chronic pain and the current lack of understanding of mechanisms of chronic pain. Recently, duloxetine has demonstrated clinically relevant pain relief, but only in half of treated patients with OA. Here, the aim is to investigate the neural mechanisms of pain relief and neural signatures that may predict treatment response to duloxetine in chronic knee OA pain. Methods and analysis This is an ongoing single-centre randomised placebo-controlled mechanistic study (2:1 (placebo) allocation), using a multimodal neuroimaging approach, together with psychophysiological (quantitative sensory testing), genetics and questionnaire assessments. Eighty-one subjects with chronic knee OA pain are planned to power for between-group comparisons (placebo, duloxetine responder and duloxetine non-responder). Participants have a baseline assessment and, following 6 weeks of duloxetine (30 mg for 2 weeks, then 60 mg for 4 weeks), a follow-up evaluation. Brain imaging is performed at 3T with blood-oxygen-level dependent functional MRI at rest and during pin-prick nociceptive stimulation for main outcome assessment; arterial spin labelling and structural imaging (T1-weighted) for secondary outcome assessment. Questionnaires evaluate pain, negative affect, quality of sleep and cognition. Ethics and dissemination The study has been approved by the East Midlands, Nottingham and is being carried out under the principles of the Declaration of Helsinki (64th, 2013) and Good Clinical Practice standards. Results will be disseminated in peer-reviewed journals and at scientific conferences. Trial registration number This trial is registered at ClinicalTrials.gov (NCT02208778). This work was supported by Arthritis Research UK (Grant 18769).

Describing the characteristics, treatment pathways, outcomes, and costs of people with persistent noncancer pain managed by community pain clinics and generating an indicative estimate of cost-effectiveness: feasibility study protocol

Background Low back pain (LBP) and fibromyalgia (FM), also known as chronic widespread pain (CWP), are highly prevalent chronic painful conditions that have substantial impact on patients, health care systems, and society. Diagnosis is complex and management strategies are associated with various levels of evidence for effectiveness and cost-effectiveness. Multidisciplinary pain services have been shown to be effective in some settings and therefore are recommended by clinical practice guidelines as a rational treatment option to manage these patients. Knowing that these services are resource intensive, evidence is needed to demonstrate their cost-effectiveness. This study aims to describe the management of patients with LBP and FM in two community pain clinics to derive an indicative estimate of cost-effectiveness compared with standard practice. Methods This is a prospective observational multicenter study, using patient-level data. The data from this study will be combined with modelling of the long-term economic impact of community pain clinics in treating people with LBP and FM. Newly referred patients with LBP and FM who provide written consent will be included. We will collect data on functional disability, pain intensity, quality of life, and health resource utilization. Follow-up data at the 3- and 6-month points will be collected by patient-completed questionnaires and health care contact diaries. Health care resource use from diaries will be compared with patient electronic records to assess the agreement between these recording methods. Patient cohort characteristics, treatment pathways, resource use, and outcomes derived from this study will be integrated in a decision analysis model to assess the cost-effectiveness of community pain clinics compared with standard care. This feasibility study will address key methodological issues such as sample estimates and retention rate to inform the design of a future randomized controlled trial.