September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk

1. September 5th – 8th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk

2. Analgesia For Spinal Pain First line approach for mechanical back pain and radicular pain MagsWigram, ESP, Pain Management 6th September 2013, N Spine, Nottingham

3. Successful pain relief is also likely to improve sleep, depression, fatigue, quality of life, function, and ability to work. Moore et al: BMJ 2013;346:f2690 doi: 10.1136/bmj.f2690 (Published 3 May 2013).

4. Some important principles Need to balance side effects with pain relief efficacy. The patient will decide what is worth it. Analgesia has a high failure rate. Our approach to advising patients and GPs needs to acknowledge this if we are to achieve success with analgesia. Moore et al: BMJ 2013;346:f2690 doi: 10.1136/bmj.f2690 (Published 3 May 2013).

5. Balancing pain relief and side effects Combine drugs: Two drugs achieves a greater effect. Can keep lower doses, reducing side effects of each individual drug. Tailor to the patient: Efficacy and side effects are multi-factorial, e.g. co-morbidity, age, other medication, individual response.

6. Practical implications of high failure rates No single drug will treat successfully more than a minority of patients with a painful condition. Experience (and some evidence) suggests that failure with one drug does not necessarily mean failure with others, even within a class. We do not know the best order in which to use drugs, in terms of efficacy, harm, or cost. Success or failure can be determined within 2-4 weeks, and success, when achieved, tends to be long lasting. Because success rates are low, a wide range of drugs is needed to do the best for most patients, especially in complex chronic conditions. Moore et al: BMJ 2013;346:f2690 doi: 10.1136/bmj.f2690 (Published 3 May 2013).

7. Mechanical Back Pain WHO Analgesic Ladder: Non-opioids e.g. paracetamol, NSAID, Non-opioid PLUS mild opioid e.g. codeine, tramadol, Strong opioids – avoid if possible. Multi-modal analgesia to maximise efficacy whilst keeping side-effects low.

8. Paracetamol few adverse reactions or contraindications. but be aware when educating patients: narrow treatment window, so easy to overdose, impairing renal and hepatic function, risks with alcohol. rare side effects; headaches or rashes. Effective if taken regularly and on empty stomach.

9. NSAIDS Side effects: gastric irritation/ulcers reduce renal blood flow in e.g. elderly, people with heart or kidney disease, hypovolemia, Increase hypertension or water retention in people with diabetes, heart failure, kidney or liver disease, Broncho-constriction or urticaria in people with asthma, Can trigger coagulation disorders, Increased risk of MI with heart disease, May delay healing response in tendinopathy. COX 2 inhibitors; lower incidence of gastric disorders but higher incidence cardiac and renal side effects. nausea vomiting diarrhoea abdo pain heart burn

10. Mild opioids Codeine-based Tramadol Commonest side effects: Drowsiness Constipation Nausea

11. Radicular or other neuropathic pain(at any level on the WHO analgesic ladder) NICE guidelines March 2010: Drug treatments for neuropathic pain (under review), 1st line treatment: amitriptyline or pregabalin (nortriptyline and gabapentin arguably equally valid), 2nd line treatment: drug not tried (of amitriptyline/ pregabalin), possibly in combination with the first, 3rd line treatment: consider tramadol instead of or in combination with the second-line treatment, Do not start treatment with opioids.

12. Maximising analgesic success with adjuvants Wean up reasonably fast, Find the dose that maximises benefits with tolerable side effects, If benefit does not outweigh side effect, wean down and try the next.

13. Amitriptyline(tricyclic antidepressant) Multiple side effects FOR PAIN: Started at a low dose usually nocte (10 or 25mg), and weaned up to 75mg, dependent on side effects. dry mouth drowsiness dizziness urinary retention weight gain

14. AmitriptylineContraindications and interactions Cardiovascular – M.I., precaution in arrhythmias, tachycardia and hypotension, Pregnancy and breastfeeding, Multiple interactions with other medications e.g. CNS meds for PD/alzheimers/epilepsy, SSRIs/MAOIs, warfarin, levothyroxine, cimetidine (heartburn), anticholinergics (atropine). Duloxetine, nortriptyline – ? more or less side effects

15. Gabapentin and Pregabalin - anticonvulsants FOR PAIN: Gabapentin Start with 300 mg daily increasing every 2-3 days in 300 mg increments as tolerated aiming for 600 mg tds. Pregabalin Start with 75 mg bd for 1 week, increasing to 150 mg bd for the second week, and then 300 mg bd for a four week period. If there are no clear benefits or side effects outweigh them, then wean and cease.

16. Gabapentin and PregabalinSide effects and precautions Drowsiness/unable to focus, ? more side effects with gabapentin, Peripheral oedema, nausea, dizziness, weight gain, agitation, itching, diarrhoea, arthralgia, etc. Contraindication in pregnancy/breastfeeding, Caution in the elderly, or those who have renal impairment. • Minimal reactions with other drugs

17. Strong opioids, changing guidelines and other matters... Dr Greg Hobbs Consultant in Pain Medicine