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Pain Concern’s response to NHS England’s proposal to restrict prescribing of certain pain medicines by general practitioners

Pain Con­cern is a nation­al char­i­ty that sup­ports those who live with long term pain, and those who care for them, by pro­vid­ing infor­ma­tion on pain and its man­age­ment through a vari­ety of media plat­forms. We also raise aware­ness about pain and the need to improve the pro­vi­sion of pain man­age­ment ser­vices through cam­paign­ing and research.

We wish to express our con­cerns regard­ing NHS England’s pro­pos­al to restrict pre­scrib­ing of cer­tain pain med­i­cines by gen­er­al prac­ti­tion­ers. Analy­sis of infor­ma­tion from our online forum and helpline, sup­ports nation­al and region­al audits and sur­veys (Nation­al Pain Audit, The Painful Truth), and con­firms that many, but by no means all, who live with long term pain derive ben­e­fit from their pain med­i­cines enabling them to have a more active and pro­duc­tive life and reduc­ing the bur­den on health­care services .

We recog­nise that long term pain is more preva­lent in old­er peo­ple, often with co-mor­bidi­ties, who are at greater risk of drug inter­ac­tions and falls when tak­ing cer­tain anal­gesic and seda­tive medicines.

We are also aware that there is region­al vari­a­tion in the pro­vi­sion of sec­ondary care pain clin­ics and fear that pre­scrib­ing restric­tions on Gen­er­al Prac­ti­tion­ers and Inde­pen­dent Pre­scribers may cre­ate addi­tion­al pres­sures on these ser­vices; they will require addi­tion­al resources to meet demand.

Our spe­cif­ic com­ments are as follows:

  • 8% lido­caine plas­ters. In the treat­ment of localised neu­ro­path­ic pain, for exam­ple post-her­pet­ic neu­ral­gia. These appear to offer a safer alter­na­tive to tri­cyclic or oth­er anti­de­pres­sants, anti epilep­tic drugs, and gabapentin/pregabalin, par­tic­u­lar­ly in old­er adults, the demo­graph­ic most vul­ner­a­ble to neu­ro­path­ic pain. A pro­por­tion of such patients have tried these oral med­i­cines and found them to be inef­fec­tive or to have intol­er­a­ble side effects, and have found relief from lido­caine plas­ters. Skin reac­tions appear to be rare, although fail­ure of adhe­sion can be troublesome.
  • Oxy­codone and Nalox­one Com­bi­na­tion, Targin­act. A pro­por­tion of peo­ple who have been unable to con­trol their con­sti­pa­tion when tak­ing oral mor­phine, oxy­codone or oth­er strong opi­oid with lax­a­tives (often in com­bi­na­tion) report a sig­nif­i­cant improve­ment when changed to Targin­act. If this med­i­cine were not avail­able to them we would wish to see Clin­i­cal Com­mis­sion­ing Groups make Nalox­e­gol pre­scribed in con­junc­tion with oxycodone.
  • Co-Prox­i­mol. We recog­nise the risk of res­pi­ra­to­ry depres­sion in over­dose and the lim­it­ed ben­e­fit of paracetamol/weak opi­oid com­bi­na­tions in the man­age­ment of long term pain, so do not have con­cerns regard­ing restric­tions to pre­scrib­ing this medicine.
  • Tra­madol with parac­eta­mol com­bi­na­tion tablet. No con­cerns if this is to be replaced by pre­scrip­tion of parac­eta­mol and tra­maol as sep­a­rate medicines.
  • Dosulepin. Our con­cern here would be regard­ing access to this med­i­cine for those who are intol­er­ant of the side effects of old­er tri­cyclic anti­de­pres­sants. We are aware that the dose used in pain man­age­ment is low­er than that for the treat­ment of depres­sion yet the risk of harm has been stud­ied in those receiv­ing treat­ment for depres­sion. We would cau­tion against extrap­o­la­tion of this data to the low­er dose.
  • Trim­ipramine. Again it is impor­tant to remem­ber that this drug is used for pain man­age­ment at dos­es much low­er than for depres­sion and yet the risk data relat­ed to its use at high­er dose.
  • Imme­di­ate Release Fen­tanyl. While recog­nis­ing the val­ue of this med­i­cine in the con­trol of break­through pain in end-of-life care, we have con­cerns regard­ing the use of imme­di­ate release strong opi­oids in the con­text of long term pain and do not pro­mote their use. We have no con­cerns regard­ing restric­tions to its pre­scrip­tion in pri­ma­ry care in this context.
  • Over the counter med­i­cines. There is a strong asso­ci­a­tion between pover­ty and long term pain. One quar­ter of those who live with long term pain will lose their jobs because of this. Despite a lack of sci­en­tif­ic evi­dence for their use as sole agents in the man­age­ment of long term pain, many rely on sim­ple anal­gesics (parac­eta­mol/­codeine/non-steroidal anti-inflam­ma­to­ry drugs) to aug­ment the ben­e­fit of stronger anal­gesics or to min­imise their dosage. Pay­ing for OTC med­i­cines places anoth­er finan­cial  bur­den on such people.

Long term pain degrades phys­i­cal and men­tal health, and is a sig­nif­i­cant bur­den on the suf­fer­er, their fam­i­lies, soci­ety and  health and care ser­vices. Many peo­ple report that it has tak­en years to find that com­bi­na­tion of med­i­cines, phys­io­ther­a­py and psy­cho­log­i­cal sup­port that allows them a bet­ter qual­i­ty of life, and we would not wish to see access to ben­e­fi­cial med­i­cines restrict­ed. We applaud NICE in its efforts to pro­vide a frame­work for appro­pri­ate pre­scrib­ing in long term pain and its recog­ni­tion that this needs be tai­lored to the spe­cif­ic needs of the indi­vid­ual patient., and hope that NHS Eng­land will take a sim­i­lar view.