Impact of Multiple Interventions on the Co-prescribing of Gabapentinoids and Opioids in Pain Management (2025)

Birmingham and Solihull Integrated Care Board, Medicines Management and Optimisation Team

Project summary

Background

Gabapentinoids (gabapentin and pregabalin) are often co-prescribed with opioids for chronic non-cancer pain, despite the increased risk of opioid-related death [1]. Both NICE and MHRA have raised safety concerns regarding this combination. NICE (NG215 2022) Medicines associated with dependence or withdrawal symptoms guidelines recommends shared decision-making, individual risk assessment, and personalised treatment plans [2]. Prescription data (ePACT2) for Birmingham and Solihull (BSol) Integrated Care Board (ICB) reported a 31% rise and 18% reduction in the number of patients prescribed concurrent pregabalin-opioid and gabapentin-opioid respectively (per 1000 patients) between March 2017 and March 2023. Notably, both figures remain below the national averages. [3].

The aim of this project was to improve the safety of concurrent gabapentinoid and opioid prescribing for pain management throughout NHS Birmingham and Solihull Integrated Care System. 

Method

A retrospective audit was conducted by BSol ICB’s Medicines Management Optimisation Team (MMOT) across 181 GP practices between April 2023 and March 2024. A patient cohort (random sample) from each practice was audited by reviewing patient electronic records against predefined criteria to assess prescribing practises in line with NICE (NG 215) [2]. 
MMOT pharmacists uniquely supported practices by facilitating a multidisciplinary review of audit findings, including reflective discussions on Sean’s Story [4] (featured by NHS England) and development of a tailored action plan. Insights from these sessions informed system-wide recommendations.
Furthermore, the BSOL MMOT implemented a range of interventions to support safer prescribing. These included organising targeted training sessions for primary care, the dissemination of success stories through ICB newsletters and contributions to the updates of the local formulary. The team also developed resource toolkits for healthcare professions, promoted a self-recovery app for patients with musculoskeletal conditions and established a system wide Pain Management Advisory Group (PMMAG). To evaluate the impact of these interventions, a re-audit was conducted 12 months later (April 2024–March 2025).

Measured Outcome

In 2023, 1,906 patients on concurrent gabapentinoid-opioid prescriptions were reviewed across 159 practices. In comparison, during the 2024 re-audit review, 1,687 patients were reviewed across 158 practices. Re-audit findings showed improvements across all audit standards, for example: documented pain management plans increased from 21% to 40%, information provision increased from 37% to 57% and documented consideration of MHRA information in women of childbearing age rose from 38% to 64%.

Prescription data showed a 1% reduction in the number of patients prescribed concurrent pregabalin-opioid therapy (per 1,000 patients) and a 9% decrease for gabapentin-opioid use in BSol ICB between March 2023 and March 2025 [2].

Impact

The re-audit showed improved safer co-prescribing, supported by patient education and prescribing review tools. However, ongoing challenges remain in primary care, necessitating a system-wide focus on reducing waiting times for pain management referrals, enhancing communication across the interface, and promoting access to non-pharmacological interventions. PMMAG has been established to drive this collaboration, with initial focus on standardising discharge letters and mapping of available non-pharmacological services for chronic (non cancer) pain management. 

Return on Investment

Although a formal cost–benefit analysis has not been completed, the project delivered measurable system value through reduced risk of medication-related harm and long-term dependence, increased use of safer alternatives and access of digital tools, improved patient education and enhanced team collaboration, leading to more consistent care. Insights from the project have been used to inform broader ICB pain management strategies. Ongoing evaluation has been carried out through regular reviews of prescribing data, stakeholder feedback, and monitoring of practice-level action plans.

[1] Lyndon A, Audrey S, Wells C, Burnell ES, Ingle S, Hill R, Hickman M, Henderson G. Risk to heroin users of polydrug use of pregabalin or gabapentin. Addiction. 2017 Sep;112(9):1580-1589. doi: 10.1111/add.13843. Epub 2017 May 15. PMID: 28493329; PMCID: PMC5635829.

[2] National Institute for Health and Care Excellence (NICE), Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults: NICE Guideline [NG215]. 2022. Overview | Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults | Guidance | NICE [Accessed 22nd May 2025]

[3] Safer Management of Controlled Drugs Comparators dashboard. National Business Service Authority. [Online] 7 May 2025. [Cited: 13 May 2025.]. Available at: https://www.nhsbsa.nhs.uk/access-our-data-products/epact2/dashboards-and-specifications/safer-management-controlled-drugs.

[4] NHS England. Sean’s Story [Online]. NHS England South: 2019 Jun 25 [cited 2025 May 24]. Available from: https://www.england.nhs.uk/south/2019/06/25/seans-story/