To reduce the number of patients historically receiving high dose opiates (>120mg Morphine equivalent per day) in Practice in line with national Opiate Aware guidance, to reduce patient harm.
The project was started in early 2017, after the Practice became aware of a national programme raising awareness of high dose opiate prescribing. One of the Practice's sites was within a CCG which had one of the highest national levels of high dose opiate prescribing, and an audit of the Practice (provided by NHS England) revealed 105 patients receiving opiates for long term chronic non-cancer pain at doses > 120mg Morphine equivalent per day. The audit gave insight into how this had happened over several years, with people with chronic pain attending the hospital pain clinic and historically having opiate doses escalated at each visit, with the GP continuing the prescribing.
A Practice meeting was held, attended by GPs, Pharmacists and nurses, at which the audit results were presented and discussed, All agreed to proceed with an opiate reduction programme on the group of people receiving doses >120mg morphine equivalent per day as identified through the audit. Resources to support opiate reduction were developed and agreed for use by all clinicians when in consultation. These were based on previous work produced by Opiate Aware, PrescQIPP and a successful similar project in Cornwall. Resources were put on the Practice intranet for ease of access.
Patients were booked in to dedicated Pharmacist opiate reduction clinics for review, or seen by GPs where needed. Pharmacist clinics ran simultaneously with the GP clinic to improve collaborative working. Although initially the local pain clinic was not directly involved, as some patients were referred to the clinic for specialist advice, their support and help provided reassurance for the patient that all health care professionals were working together to provide the best outcome for them. The pain clinic had also started a similar Opiate Aware programme at about the same time.
The consultation format started with an explanation to the patient of the recent findings of harms of opiates in chronic non-cancer pain, and how this evidence related to their own personal situation, and how we could support them in helping them to reduce their opiate use and find different methods to control their pain. As local non-pharmacological pain control interventions were limited, this led to an honest discussion that in some cases it would mean living with an element of pain, but the benefit would be a reduction in the harmful side effects of the high dose opiates.
The appointments have to be longer than usual (minimum 20 minutes) because the conversation must not be rushed and most patients are suffering from other illness. The appointments also have to be more frequent, typically seeing each patient every month as the dose is incrementally reduced and most appointments need to be face to face to keep the patient well supported. As such it means an increase in appointments and an increase in staff costs for dedicated clinics, at Practice expense. However, it was felt that this was a priority for investment in reducing harm and delivering good quality patient care
The main beneficiaries of this project are the patients receiving the high dose opiates for long term chronic non-cancer pain. In dedicating this extra time to their care, and in spending time in talking and agreeing with them the way forward and journey ahead, they are able to choose to reduce their opiate intake and so reduce the side effects caused by the high doses, leading to a better quality of life even though for some it still means managing a degree of pain.
Locally the health economy benefited also from a reduction in prescribing costs, though this was limited, and also a reduction in the overall level of opiate prescribing. In the year following the start of the project the local CCG decided to include opiate reduction in its incentive scheme to encourage others to do the same
The Practice also benefited in good working between different staff toward the same end of patient benefit. In having a unified approach to the patients, it helped ensure consistent support not just for patients but for clinicians working within the team. Our learning was shared within our GP cluster in early 2018 to help others in the same situation start a reduction programme.
An unexpected benefit was the finding that clinical pharmacists are ideally placed to undertake such a time intensive programme with the patient. The doses are so high that any reduction must be gradual, and clinical pharmacists in Practice, working in collaboration with GPs in the Practice and with the patient's community pharmacist, have the knowledge, skills and patient centred approach to deliver this work which requires intensive patient support.
The main aim was to see a reduction in the numbers of people receiving harmful doses of opiates >120mg morphine per day. By July 2017, 94 people were receiving these high doses, by February 2018 this had reduced to 77 people and by July 2018 to 61 people, a reduction of 42% since the project start. The work is ongoing and by its very nature is a slow process as reductions are incremental month by month, but the main aim is being achieved, even though there is still some way to go
Another aim was to stop the cycle of ever increasing opiate doses, and this has been happening at the other end of the scale, where together GPs decided not to escalate doses as they had done before, but to discuss frankly with patients the lack of benefit in increasing the dose. This has been a culture change not just in the Practice but within the local health economy, as the message is spread more widely
Unexpected outcomes were the positive benefits we saw in patients who had reduced or stopped. Though many still had some element of pain, most had found real benefit in having less side effects, especially sedation. Several have thanked the Practice staff for the help and support and in 'giving them their life back'. Some who were heavily sedated and so unable to be very mobile can now walk more, and this has improved their quality of life and fitness.
Some patients have not accepted a reduction well, and this has been more difficult to undertake, but is worked through with the support of the pain clinic and CCG as it occurs.
