Dr Farrukh Alam

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IntroductionA rise in global opioid consumption has led to an increase in negative consequences associated with prescription opioids Opioid analgesic dependence (OAD) has become a global concern but is poorly documented in Europe Populations who misuse over-the-counter (OTC) or prescription only (POM) opioid analgesics are at risk of developing OAD More guidance is required to aid healthcare professionals in the clinical management of OAD*

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Opioid analgesic consumption is increasing on a global scale outside of Europe *Canadians are the second largest per capita consumers of narcotics and prescription opioidsOpioids were involved in 43% of all drug overdose deaths in the US in 2010. They were responsible for more than twice the number of deaths from heroin and cocaine combined Prescription opioids are the most abused opioids in BrazilNon-medical use of pharmaceutical opioids doubled between 2007 and 2010 in AustraliaSource: INCB report 2012; INCB statistics for 2011, 2012; CM Jones et al. 2013; I Giraudon et al. 2013; A Roxburgh et al. 2013. Canadian Centre on Substance Abuse, Prescription Drugs http://www.ccsa.ca/Eng/topics/Prescription-Drugs/Pages/default.aspx

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The size of the OAD problem in Europe is poorly defined*An estimated 455,000 people dependent on prescription opioids in 2013The true extent of non-medical uses of OTC and POM medications is unknown: treatment seekers often cite OTC/ POM meds as their drug of choice17 European countries reported 10% or more of first-time opioid patients entering specialised treatment were using opioid medications other than heroinSource: H Alho ISAM 2013; European Monitoring Centre for Drugs and Drug Addic6on. European Drug Report: Trends and developments. 2014. L Weich et al. 2015

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People dependent on opioid analgesics are different from those dependent on heroinOAD populations may result from: Iatrogenic dependence on prescription only (POM) or over the counter (OTC) opioid analgesic preparations following treatment for pain Dependence on illegally acquired/ diverted POM and OTC analgesic preparations *OADIllicit heroin dependenceSource: RGCP 2013 Addiction to medicines Factsheet 4

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6 factors highlight individual OAD risk; personal family history of dependence is strongest predictor *Source: J Højsted et al. 2007; TJ Ives et al. 2006; MJ Edlund et al. 2007; J Elander et al. 2014;

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Physical, psychological and social consequences highlight the importance of treating OAD*PhysicalSocialPsychologicalLoss of employment Marital & family breakdown Loss of friendships Loss of interest in regular activities Financial problems Mood instability Agitation Anxiety DepressionVary with opioid intoxication, overdose or withdrawal Long term effects:1 Endocrine changes Hyperalgesia Immunological effects Sleep disordersSource: British Pain Society. Opioids for persistent pain: Good practice. 2010

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Challenges for addiction specialists in OAD management*ChallengesHow to help a patient address their opioid misuse without diminishing their pain controlHow to accommodate and treat patients that do not fit the traditional model of treating street drug usersUnderstanding how these new patients’ needs relate to the needs of existing patientsHow to develop effective and collaborative joint working methodologies with local pain services

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Patient pathway highlights challenges of OAD Case Study*Illicit opioid useDependencePain problemsOpioid analgesic prescriptionPresentationMr X, 33 year old male, full time employment as estate agent Traumatic amputation of 0.5cm of his right thumb whilst tiling his bathroom One year on: Remnant nail bed developed hypersensitivity/ hyperalgesia/ phantom/ chronic painPresentation

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Patient pathway highlights challenges of OAD Management*Illicit opioid useDependencePain problemsOpioid analgesic prescriptionPresentationGP options: Investigate further Refer back to surgeons Refer to pain clinic Prescribe opioid analgesics Opioid analgesic prescription

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Patient pathway highlights challenges of OAD Continuing problems/ presentation*Illicit opioid useDependencePain problemsOpioid analgesic prescriptionPresentation6 months later patient requests extra medication for break through pain, GP prescribes more opioid analgesics Patient presents to several locums requesting opioid analgesics for pain/ internet purchasesPain problems

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Patient pathway highlights challenges of OAD Referral to formal addiction services*Illicit opioid useDependencePain problemsOpioid analgesic prescriptionPresentationPatient re-presents to GP 3 years later with 4 times higher opioid analgesic dose than original prescription requesting more opioids for break through pain Client referred to local addiction service who agree to support client in their group programme while GP reduced the opioidsDependence

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Patient pathway highlights challenges of OAD Negative consequences*Heroin useDependencePain problemsOpioid analgesic prescriptionPresentationUnknown to the clinic, within three months client is introduced to heroin and drops out of addiction service group programme Re-presents to GP requesting that script stays exactly the same Two years later: wife presents to GP, currently separated from husband, a heroin user who she can no longer live with, she is seeking treatment for panic attacksIllicit opioid use

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An integrated treatment plan, multidisciplinary team with adjunctive therapy is recommended*Team Planning

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Specific Management Tool *Recovery from dependenceDependence on opioid analgesics requires specific management which is supported by international guidelines and a body of evidence A decision-tool may be useful in OAD management There is an opportunity to improve outcomes in OAD by making clear choices in management Future work should define better outcomes in OAD with different interventions Treatment assessmentTreatment selectionTreatment monitoring OAD Treatment Algorithm

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Last Updated: 8th March 2018

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