It makes your heart sink when you receive referrals along the lines of ‘Please see Mrs Smith for support with reducing opioids. She has been on fentanyl patches 100mcg and Oramorph 20mg PRN for ten years for her back pain, and has tried reducing her medication but had issues with withdrawal. She is struggling with managing all aspects of daily life and her mental health’.
Around a decade ago, we were seeing many people with similar stories — no surprise, perhaps, as we work in a tertiary pain service, but we have rather different professions: one working as a pharmacist and the other in psychology.
In these situations, producing a well thought out reducing schedule was not enough, nor was trying to address the person’s mental health without considering their medication.
We felt stuck — at the time, there were no evidence-based strategies in the literature and no consensus on the best approach to opioid reduction. So, we decided to combine our skills by offering a joint consultation to each patient, lasting 1.5 hours, which blends a review of medicines with ideas from motivational interviewing and acceptance and commitment therapy (ACT), which explores someone’s social support, thoughts and feelings, and their values.
People arrive at different stages in terms of their readiness to change, from the person who feels there is no problem at all, to those who want to make changes straightaway. We believe it is our relationship with the person that becomes the vehicle for progress. We aim to develop a relationship of trust, which then gives us the opportunity to sow the seeds of change.
In the consultation, we look at the medication being taken, as well as how the person takes it. We offer a non-judgemental space where the patient can speak openly, as no effective changes can be made unless people feel able to be honest.
Education about opioids is important, and we want to draw attention to the side effects, but we are aware that simply telling the person they’ve got a problem is counterproductive. Instead, we encourage the person to lead the discussion. Many people are resistant to change, but we try to “roll with resistance”, rather than challenge them directly.
From a psychological point of view, we are keen to understand the person’s unique situation and the factors maintaining their medication use. Using an ACT ‘matrix’ we aim to move away from an endless quest for pain reduction towards finding out how people can engage in meaningful activities, alongside their pain.
Our hope is that people recognise that, despite taking high doses of strong opioids, they are still in significant pain and are also having to manage the side effects, both of which have a significant impact on quality of life.
The patient is always at the centre of deciding where to start with their medication reduction — this may be choosing which medication to reduce first, which dose to tackle or how quickly to reduce. They then leave with a mutually agreed plan. The GP then takes forward any prescribing, and we offer individual review appointments, if wanted.
We are aware that our clinic requires considerable time and resource, but it is a luxury that provides us with the opportunity to develop the relationship that is essential for this work. We hope this initial investment gives a better long-term outcome, with the person not only taking less medication, but also seeking fewer healthcare appointments in future.
It is tricky to measure our outcomes as we don’t routinely see people again at a particular time point, and some of the outcomes we hope for are difficult to measure. We hope that people develop a better relationship with their pain and a good understanding of the part that medication plays in managing it. Validated tools for measuring this are yet to be developed.
A combined pharmacy/psychology clinic is unusual, but working together has been a powerful experience for both of us. From a psychological point of view, working with a pharmacist brings credibility to medication discussions and allows a deeper understanding of how and why the patient takes their medication. From a pharmacy point of view, working with a psychologist has enabled greater consideration of people’s relationships with their medication.
Exploring a person’s expectations of their medication can really help in understanding how they choose to use it. This concept feels important to consider in the management of many long-term health conditions, not just chronic pain.
So, does our approach stop the sinking feeling when reading a difficult referral letter? No! But having a tried and tested framework with which to approach the issue helps us to feel more confident that we can support someone through making these difficult changes.
Lis Farquhar is an advanced clinical pharmacist for chronic pain management at Leeds Teaching Hospitals NHS Trust
Vivienne Laidler is principle clinical psychologist (chronic pain service) at Leeds Teaching Hospitals NHS Trust