Across the world, opioid prescribing for managing long-term pain increased 30-fold between 1980 and 2010. And in 2019, Public Health England estimated that more than half a million people in the UK have been taking opioids for more than three years, despite recommendations that they should not be used for more than three months.
Opioids are effective for managing both acute pain and for those nearing the end of their lives, but there is little evidence of their benefit in managing long-term pain.
There is now mounting proof that doses above 120mg morphine equivalent per day are ineffective in the treatment of non-cancer chronic pain, and can lead to harm and addiction. Furthermore, the risk of harm increases substantially at these doses, with no improvement in pain control.
Following 2018’s Gosport Report — which investigated the deaths of 450 patients after they were prescribed inappropriately high doses of opioids between 1988 and 2000 at Gosport War Memorial Hospital — we decided, as a surgery, that we should review local practice and address any issues we may have with opioid prescribing.
With my background in hospital pharmacy and experience in general practice, and having completed further training in pain management, I took the reins alongside Beera Patel, a senior GP and partner who leads on substance misuse at the practice.
In July 2019, we started the process with an audit to review high-dose opioid prescribing for non-cancer chronic pain. We set out an agreed lower threshold of 80mg morphine equivalent to enable us to better scope out the scale of the problem and identified 16 patients for further review.
For each patient, we detailed the timeline of their opioid use, the indication, any secondary care involvement or historical input, any side effects and if the prescription frequency was appropriate. The findings were documented in the patients’ notes and a plan was formulated.
Additionally, all 16 patients were coded and we added an alert that pops up on opening their record. This highlighted to clinicians that the patient was taking high-dose opioids and that any change should be discussed first with the practice pharmacist or GP partner. This created continuity of care for the patient and also prevented inappropriate escalation of doses.
After reviewing the patients virtually, Beera and I set up a specialist face-to-face clinic, attended by Arun Bhaskar, a consultant in pain medicine at Imperial College Healthcare NHS Trust, who advised on specific aspects of patient management. Working alongside a specialist with years of experience was invaluable and helped address the patient’s needs and concerns, as well as formulate a detailed treatment plan.
Following the multidisciplinary review, a range of treatment plans were agreed. This included referrals for specialist interventional procedures and addiction support services; and also more novel treatment strategies, such as reducing patients’ fentanyl doses by cutting their matrix patch by 10% each month to facilitate a slower dose wean (note that cutting a fentanyl matrix patch renders the use of the drug as ‘off licence’).
Each patient was followed up monthly to review their progress with the dose reduction. The process was easier for some, and doses were able to be decreased more quickly, whereas for others the process was slower, with some patients exhibiting mild to moderate withdrawal symptoms. This highlighted the importance of establishing individualised targets and plans for each patient. It also showed the need to build a relationship and rapport with the patient to better address their concerns and expectations.
Throughout this process, we shared opioid-aware resources from the Royal College of Anaesthetists with patients, and these were invaluable in helping to educate and guide them through their reduction.
Over the course of a year, we achieved great success, with a 40% average reduction in opioid dose for the 16 patients identified. Furthermore, we reduced the practice’s total opioid prescribing for these patients by nearly 1,000mg morphine equivalence.
Feedback from patients was very positive. Some patients struggled initially with the dose reduction and some believed it to be a cost-reduction exercise; however, after the initial consultation and further follow-up appointments, these apprehensions were eased and gradual dose reduction plans were agreed.
Overall, it has been such a rewarding experience, and it has really highlighted how important it is to tackle this issue, showing what can be achieved when you work as a multidisciplinary team.
But our work doesn’t end there. We plan to re-audit in 12 months and we are set to review our patients taking long-term gabapentinoids as part of a wider project.
Rory Donnelly, senior GP pharmacist, Shepherds Bush, London; principal teaching fellow (post-graduate pharmacy education), King’s College London