Understanding high dose opioid prescribing in our region

15th July 2021

The national Medicines Safety Improvement Programme (MedSIP) was established to create positive change and supports an initial set of projects linked to evidence base on medication errors and the NHS Long Term Plan.

The MedSIP programme is delivered regionally through the 15 Academic Health Science Networks (AHSNs) and aims to deliver on five Quality Improvement (QI) priorities, one of which was to reduce harm from opioid medicines by reducing high dose prescribing (>120mg oral morphine equivalent), for non-cancer pain by 50%, by March 2024.

In this blog Tracy Marshall, Project Lead for Medicines Safety at the AHSN North East and North Cumbria (NENC), takes us through a project delivered through the NENC Medicines Safety team to support this national programme by gaining more understanding of local level prescribing of high dose opioids.  

 

Over the course of February and March 2021, I, along with other members of the AHSN NENC Medicines Safety and Optimisation Teams, undertook several semi-structured interviews with colleagues across the region in connection with supporting NHS England and NHS Improvement in gaining a better understanding of the prescribing of high-dose opioids at a local level.

It was important that we gained this understanding of what was happening locally in the North East and North Cumbria to support the overall national objective. This particular project involved:

  • Identifying effective interventions that lead to a reduction in opioid prescribing for chronic non-cancer pain.
  • Identifying networks, partners, levers, and opportunities in the system that will support a culture around the safer prescribing of opioids.

We conducted nine interviews with our colleagues across the region to determine what initiatives had been tested in their areas already. All the interviews conducted were uploaded to Futures NHS together with the interviews conducted by Medicines Safety colleagues across the other 14 AHSNs nationally.

 

Outcomes from this collaboration will be evaluated and shared widely later in the year, however, at the AHSN NENC, we have collated the evidence provided by all our North East and North Cumbria colleagues and can provide the following summary of a selection of the great work being undertaken within our region.

 

We would just like to take this opportunity to thank all those who engaged with us on this important piece of work to share the work undertaken to reduce opioid prescribing across the region.

 

Campaign to Reduce Opioid Prescribing (CROP)

Sue Hart, Health Programme Manager, AHSN NENC [email protected]

The AHSN NENC commissioned support from North East Commissioning Service (NECS) to produce bi-monthly Practice Reports relating to the prescribing of opioids for chronic non-cancer pain throughout GP practices.  Support was also commissioned by the AHSN NENC to disseminate, by the CCG, the Practice Reports to all participating GP practices in the region.

Reports are based upon searches, which have been designed to provide an indication of how many prescriptions of both strong and weak opioids are being dispensed, to identify and prioritise patients for individual interventions.

 

Influencing opioid prescribing behaviours through commissioning and collaboration in primary care in Sunderland

Ewan Maule, Head of Medicines Optimisation – NHS Sunderland Clinical Commissioning Group (CCG) [email protected]

By working with their providers and using normal commissioning mechanisms, Sunderland CCG have sought to decrease opioid prescribing in primary care over the previous year. They have achieved this by issuing guidance and commissioning a communications campaign. This combination seems to have been successful in accelerating a reduction in opioid prescribing in comparison to a small national trend of reduction.

 

Pain Killers Don’t Exist

Rachel Berry, Advanced Medicines Optimisation Pharmacist, County Durham and Darlington CCG [email protected]

This public campaign involved creating public awareness regarding opioids and encouraging patients to access a healthcare professional to discuss reducing their opioids.

Patients were advised in the campaign to speak to a healthcare professional about their opioids by making an appointment at their GP practice. A tailored plan was developed by the healthcare professional at the appointment.

County Durham and Darlington CCG used the Sunderland CCG ‘Pain Killers Don’t Exist’ model and adapted.

 

Living Well with Pain Medicines Optimisation Review (LWWPMOR)

Fadwa Alesheh, Senior Clinical Pharmacist, Northumbria Healthcare NHS Foundation Trust [email protected]s.uk

There was a requirement for a Senior Clinical Pharmacist to join the newly developed Living Well with Pain (LWWP) team, which consists of Psychologists and Physios, due to increased demands from both patients and the LWWP team members for a service where medications have an impact on patients’ quality of life.

The pharmacist role was to develop a service with the LWWP team where referrals can be made to review pain medications and assess effectiveness and taper down if necessary, to minimise harm and improve quality of life.

 

Primary Care Pharmacist led opioid interventions and clinics initiative based on the I-WOTCH model (Improving the wellbeing of people with opioid treated chronic pain)

Alastair Monk, Medicines Optimisation Pharmacist, NHS North of England Commissioning Support [email protected]

Professor S Eldabe who specialises in chronic pain management, especially cancer pain treatment and invasive pain therapies, presented at a primary care meeting regarding the

I-WOTCH model. The idea was to try and develop a similar approach in primary care.  This consisted of delivering training to PCN pharmacists to take forward in their designated practices.

Training was delivered to practice/PCN/NECS MO pharmacists with an interest in opioid use. As sessions were online it allowed more pharmacists to attend. In total, 45 people including pharmacists, consultants and nurses attended the training.

 

Pathway persistent systems service (PPSS)

Elspeth Desert, Consultant Clinical and Health Psychologist, North Cumbria Integrated Care [email protected]

In 2016 it was identified that the North East and North Cumbria region were outliers in the prescribing of opioids. The North Cumbria CCG also anticipated a reduction in back pain injections, so a multidisciplinary team was set up consisting of a GP, a psychology practitioner, and a living well coach. They work holistically in a Medicines Optimisation clinic within the PPSS.

The PPSS team GP would gain background information before seeing the patient and gain a full medical history, enabling a shared understanding.  The PPSS team GP has full access to EMIS and the patient’s history and can then liaise with the patients usual GP regarding treatment options.

Reducing Inappropriate Opioid Prescribing

Jane Carruthers, Cumbria Clinical Commissioning Group [email protected]

Quality Improvement Scheme – practices were incentivised to reduce inappropriate prescribing of opioid medication utilising the measure of average daily quantity per cost based Specific Therapeutic group Age-sex Related Prescribing Unit (STAR-PU).

Practice pharmacists / medicines managers were free to utilise a range of resources to tailor their approach to the intervention in each practice.

 

Reduction of opioid prescribing especially in patients of 120mg or above morphine equivalent

Susan Acey, Pharmacist at Havelock Grange Practice [email protected]

A multidisciplinary team meeting (MDT) held with GPs agreed an action plan.  A letter was sent to identified patients (gained from prescribing data of patients prescribed over or equivalent to 120mg morphine) detailing the approach, providing information leaflets re chronic pain, including web links and app links as well as coping strategies. Once the patients had chance to absorb the information from the letter, they were then contacted over the phone to try and engage them in the programme.

A spreadsheet was kept of all the identified patients and it was RAG rated (Red-Amber-Green rating where green denotes a ‘favourable’ value, red an ‘unfavourable’ value and amber a ‘neutral’ value) as to where they were in the programme. Regular MDTs also highlighted other patients who were appropriate but were already on less then 120mg morphine equivalent.

Prescription clerks were also engaged to feedback e.g., patients discharged from hospital on opioids, a short supply is requested from the GP and a review is booked before the patient runs out of medication. Patients are told that they will only be prescribed for short periods of time. Following a pain clinic referral, a telephone consultation is held with the patient before the GP prescribes, highlighting that it will initially be for a trial and would be reviewed and potentially not for long-term use.

The practice also has a patient contract which details that the practice will not routinely prescribe benzodiazepines, this will be changed to add opioids and gabapentinoids and detail that a reduction plan will be initiated if they are already taking one of the mentioned medicines.

 

Primary Care Pharmacist led opioid interventions and clinics initiative based on the I-WOTCH model

Micheala Connolly, Senior Clinical Pharmacist McKenzie Group Practice, Hartlepool

[email protected]

Patients were identified using practice searches and were referred to the opioid’s reduction clinic by the GP.

Letters were sent to patient’s identified on searches providing advice and information materials. The letter explained that the patient would be initiated on a reduction programme (included their individual plan) and to get in touch with practice if there was a problem. Those that wanted an appointment at the practice were able to have one or be contacted to discuss their queries via telephone. Five letters per month are sent out to patients so that the workload does not become unmanageable in current Covid climate. Pain reassessments were not undertaken with patients during reduction plan.

 

This is a sample of the excellent work being carried out across NENC and is not an exhaustive list, if you or any of your colleagues have some initiatives or areas of good practice you are willing to share, please contact the team on one of the following email addresses:

Helen Seymour, Senior Medicines Optimisation Pharmacist [email protected]

Sue Hart, Health Programme Manager [email protected]

Lindsay Caulfield, Prescribing Adviser [email protected]

Emily Whales, Project Lead for Medicines Safety [email protected]

Tracy Marshall Project Lead for Medicines Safety [email protected]