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Review of high dose opioids in chronic non-malignant pain

Brighton & Hove CCG ·

Summary

Summary of the example

  • The Faculty of Pain Medicine (Royal College of Anaesthetists) states that the morphine dose for which harms outweigh benefits is 120mg oral morphine or equivalent/24 hours. Above this dose the risk of harm and mortality increases substantially but there is no increased benefit.
  • Figures from NHS Digital show that the number of prescriptions for opioids has risen dramatically in recent years in England, from 3 million in 1991 to 7.5 million in 2001 and 24 million in 2016.
  • Patients often confuse sedation/euphoria that is caused by opioids with pain relief
    Long term use leads to tolerance to the analgesic effects and can increase pain sensitivity (e.g. hyperalgesia and allodynia).
  • Long term risks of opioids include immunosuppression, hypogonadism and adrenal insufficiency in both men and women, and possible effect on cognitive function.
  • The MMT Medicines Management Team in Brighton & Hove CCG led baseline reviews to identify patients prescribed in GP practice  high dose opioids for chronic non-malignant pain.
  • These findings were passed to individual GP surgeries to review the identified patients that require intervention with an aim to reduce morphine equivalent dose to <120mg/day.

Why we think it’s important

The Faculty of Pain Medicine (Royal College of Anaesthetists) states that the morphine dose for which harms outweigh benefits is 120mg oral morphine or equivalent/24hours. Above this dose the risk of harm and mortality increases substantially but there is no increased benefit.
We identified 227 patients in Brighton & Hove on high dose opioids (>120mg morphine per day or equiv.) for chronic non-malignant pain (the actual figure is likely to be higher).
These patients were escalated to this dose historically due to the belief that chronic pain should follow the WHO analgesic ladder. We now know that opioids largely do not help for chronic pain and have substantial long term risks, as well as reducing patients quality of life (function, mobility, alertness, mood).
Reducing these patients doses in primary care has been ‘time consuming yet highly rewarding’ and has led to a ‘very apparent improvement in quality of life of patients’ who ‘feel more energised, engaged and happier’.

Learn more about the example

Aims and objectives of the work

To identify patients in primary care in Brighton & Hove with non-malignant chronic pain who were on >120mg morphine per day (or equivalent) and subsequently for GP surgeries to review with an aim to reduce the high dose opioids patients were taking. Therefore reducing the potential and real harm they are experiencing from these medications.

Methodology

This was a domain for the Prescribing Incentive Scheme in Brighton & Hove 2017/18 and as such GP surgeries who completed it (to a satisfactory standard) were awarded money that they could spend on specified items for their patients (see PIS 17/18 document for more details).
Medicines Management Team (technicians) granted access to GP surgery records in order to run a search to identify patients on >120mg morphine/day (or equivalent) for chronic non-malignant pain. Technicians calculated each identified patients total daily dose as an equivalence to morphine. The patient list and morphine equivalent dose were passed onto the practice for their review.

GP surgery reviewed identified patients that require intervention and if appropriate reduced the dose to <120mg morphine (or equivalent). Wherever possible the clinical pharmacists conducted a pain medication review and agreement of a reduction plan, with option for the community pharmacist to receive a copy of their reduction plan to enable extra support and advice. Regular follow up calls or appointments were provided. The Brighton & Hove CCG Chronic Non-Malignant Pain Prescribing Guidelines were used to support the pain management review in addition to national documents such as Royal College of Anaesthetists: Faculty of Pain Medicine (Tapering & Stopping of opioids) listed below.

27 out of 36 practices participated during the PIS year, with more surgeries now undertaking the work. Results were measured via the use of a ‘summary and data collection form’ ( see PIS 17/18 document for more details.

Key findings

  • 27/36 practices in Brighton & Hove took part.
  • 227 patients identified on high dose opioids (>120mg morphine equiv./day).
  • 123 patients (54%) originally had their dose increased to >120mg morphine equiv./day by primary care; 44 patients [19%] were increased by a specialist; 60 patients [26%] unknown origin).
  • 210 patients (93%) were reviewed.
  • 119 patients (52%) were undergoing a dose reduction.
  • 70 patients (31%) had their dose decreased to <120mg morphine equiv./day
  • 59 patients (26%) declined a dose reduction at this point.
  • Remaining 49 patients were not reviewed or commenced on dosage reduction due to awaiting a review by a specialist or GP surgery pharmacist.

Overall GP Feedback themes:

  • ‘Opioid reduction is a time consuming yet highly rewarding intervention.’
  • ‘The results are rewarding and well worth the efforts.’
  • ‘As the topic has been highlighted it has brought a higher level of opiate prescribing awareness amongst our prescribers.’
  • ‘Pharmacist and GPs worked together as a team and discussed patients at the weekly clinical meetings.’ ‘Patients were contacted by the practice pharmacist – and introduced as the expert in opiates who was able to build a trust relationship with the patient’.
  • ‘I have observed a very apparent improvement in quality of life of patients who have achieved reduction. Feedback from these patients is that they feel more energised, engaged and happier.’
  • ‘Small and gradual reductions have made very little impact on frequency and intensity of pain experienced.’
  • ‘This audit has encouraged us to look further into alternative ways to manage chronic pain and to ensure patients have the correct support to help them engage with their health needs.

Documents

Strong Opioid Reduction Summary and Data Collection Form

Attachments

Links

Background

National guidance, data and publications

  • Royal College of Anaesthetists: Faculty of Pain Medicine (Tapering & Stopping of opioids)
  • There are various online self-help and information services tailored specifically to chronic pain patients, such as the Pain Toolkit; the Faculty of Pain Management; Living with Chronic pain; and the British Pain Society, Live Well with Pain.
  • Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain – (produced by UK healthcare professionals and policymakers, funded by Public Health England and hosted by the Faculty of Pain Medicine, Royal College of Anaesthetists) publish a range of information available for both GPs and patients.
  • BMJ article: Pain specialists call for annual review of long term opioid use

Links