Reducing Opioid Prescribing in Primary Care
The EHS and H & R Medicines Management team are currently supporting local GPs to review patients prescribed oxycodone or an opioid patch (fentanyl / BuTrans) for chronic non-malignant pain. All patients prescribed opioids for chronic pain can benefit from regular review and most patients reviewed are expected to be suitable for a trial withdrawal.
Opioid prescribing was identified through benchmarking against other CCGs as a therapeutic area where there is potential to improve quality and reduce costs locally. The reviews will provide an opportunity to educate prescribers regarding appropriate initiation of opioids for chronic pain and the need for regular review. Review of oxycodone and opioid patches are being prioritised, to provide a manageable cohort of patients for GP review.
Chronic non-malignant pain is difficult to treat with medication. Opioids in particular are not very effective; with minimal evidence of significant pain relief and improved function when prescribed for this indication. The aim of management is empowerment of patients to self-manage pain and increase function. See local opioids in chronic pain clinical guidance doc here:
Opioids Aware is a website that hosts a wealth of useful information for both healthcare professionals and patients, provided by the Faculty of Pain Medicine, to support best practice in opioid prescribing. Community pharmacists are well placed to reinforce the messages of Opioids Aware; http://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware.
Patients who have been identified as suitable for a trial reduction of oxycodone will be converted to the equivalent dose of solid oral morphine (where there are no contraindications to doing so, e.g. severe renal impairment), to increase dose flexibility. Oxycodone is approximately twice as potent as morphine (conversion will be to a lower than usual equivalent morphine dose in elderly, frail, and those with mild to moderate stable renal impairment). Fentanyl and BuTrans patches will be reduced as a patch; there will not be a switch to morphine or other strong opioid (patients can be stopped from transdermal fentanyl 12micrograms/hour). See local oxycodone / opioid patch suggested dose reduction protocols and opioid dose equivalence doc. here:
There are many ways community pharmacists can support the opioid review process and patients who are undertaking a trial reduction / withdrawal of their opioid
(please utilise ‘Opioids in Chronic Non-Malignant Pain Patient Information Leaflet’):
Managing patient expectation; patients with chronic pain prescribed a strong opioid should not expect complete pain relief. A reduction in pain of more than 30% is unlikely to be achieved.
- Counselling on the importance of function as an outcome; efficacy should be considered to comprise both pain relief and function.
- Counselling on the adverse effects of opioids; side effects are very common with opioid therapy, with up to 80% of patients report at least one side effect.
- The most commonly experienced side effects include nausea, vomiting, constipation, pruritus, dizziness, dry mouth and sedation (risk of falls / fractures).
- Long-term there is a risk of dependence and addiction, opioid induced hyperalgesia (the only effective management is to reduce opioid dose), hypogonadism, increased cardiovascular risk and early death.
- Counselling patients who have been switched from oxycodone to morphine; there is little evidence that one opioid is more effective and associated with fewer adverse effects than others. Oral morphine is the first-line strong opioid of choice.
- Raising awareness of non-pharmacological methods of managing chronic pain; increasing activity and physical fitness, physiotherapy, hot or cold pack application, transcutaneous electrical nerve stimulation, cognitive behavioural therapy and meditation techniques such as mindfulness.
- Reinforcing the message that if patients taking opioids remain in pain and do not show improved function, they are not effective and should be stopped (even if there is no other drug treatment option).
- Signposting patients to the Opioids Aware patient resources; https://www.rcoa.ac.uk/node/21133
For Questions and Answers around Opioids: Opioids QA
Please do not hesitate to contact the Medicines Management team if you have any queries; 01424 735633.