Opioid Prescribing

Safer Opioid Prescribing

Clinical evidence shows limited effectiveness for opioids in chronic pain, and patient safety concerns due to risks associated with long-term use of opioids.

The Isle of Wight is launching a programme to tackle over-prescribing of opioids. The first step in this programme is providing clinicians with resources which can be used to help improve the safety of opioid prescribing in chronic pain.

Support for managing patients with chronic pain can be found on the IOW Chronic Pain team’s website

The resources are not applicable to the use of opioids in acute pain or palliative care (please see symptom control guidelines for palliative care patients)

 

The following key messages are expanded on in the IOW Safer Opioid Prescribing for Chronic Pain Resource Pack 2019

• Strong opioids are only effective in 10 to 20% of patients with chronic pain (pain with a duration of >3months) – a four to six week trial of strong opioids is appropriate to ensure they are effective
• Patients requiring rapid increases in strong opioid dose are likely to have opioid resistant pain – their opioids should be down-titrated and stopped even if there are no other analgesic options
• Patients requiring strong opioid doses of >60mg/day should be reviewed carefully as they are more likely to have tolerance to opioids or become dependent on them
• Strong opioids at doses >120mg/day morphine equivalent carry a substantially increased risk of harm without additional analgesic benefit and should not be used in chronic pain
• Adjuvant analgesics (e.g. amitriptyline, duloxetine, gabapentin or pregabalin) should be initiated before strong opioids. Patients with chronic pain will inevitably have features of neuropathic pain.
• If a trial of strong opioids is felt appropriate, morphine (Zomorph®) is the first choice strong opioid (there is no evidence of better efficacy or tolerability with other opioids)
• Opioids (whether weak or strong) should not be “put on repeat” unless prescribers are confident they are appropriate and effective.
• The development of tolerance to opioids (whether weak or strong) in chronic pain is inevitable, therefore patients should be reviewed every 6 months to ensure opioids remain effective, well tolerated and are being used appropriately
• This 6 month review should include a trial downtitration/withdrawal of strong opioid to ensure patients are taking the minimum effective dose
• If patients continue to have pain with strong opioid doses >60mg morphine/day they are more likely to have opioid non-responsive pain. Opioids should be downtitrated to stop.

Clinicians may find the following resources useful (many of these are also available on SystmONE):

Discussing starting opioids with patients

• Opioid Trial Checklist 
• Opioid Risk Tool
• Ten Footsteps: Your Journey to Living Well With Pain – patient information leaflet
• Explaining Pain: Understanding More About Your Persistent Pain and How it Affects Your Life – patient information leaflet
• Thinking About Opioid Treatment for Pain – patient information leaflet
• Taking Opioids for Pain – patient information leaflet
• Pain diary

Undertaking an opioid trial

• Opioid Trial Treatment Agreement
• Pain diary
• Taking Opioids for Pain – patient information leaflet
• Driving and Pain – patient information leaflet

Reviewing ongoing prescriptions for opioids

• Letter Inviting Patients for a Strong Opioid Review
• Letter Inviting Patients to Try a Drug Holiday from their Weak Opioids
• Letter inviting patients for a review of tramadol and SSRI
• Approximate Equi-analgesic Potencies of Opioids in Adults
• Patient Agreement for Opioid Based Medication for Non-Cancer Pain
• Driving and Pain – patient information leaflet
• CQC and NHSE Checklist for safer use of Oxycodone Medicines
• CQC and NHSE Checklist for safer use of Fentanyl and Buprenorphine CD Transdermal Patches
• MHRA Fentanyl Skin Patches - patient information leaflet
• Preparation for Opioid Dose reduction
• Reducing and Stopping Opioids: Information for Patients – patient information leaflet

Other resources – please feel free to adapt to your practice’s needs

• Useful Ardens Templates and Read Codes
• Suggested Opioid Policy for Patients New to the Practice
• Suggested Policy for Issuing Opioid Prescriptions
• Suggested Practice procedure for lost/stolen Controlled Drug Prescriptions
• Suggested Practice procedure for Patients Where Dependence On, or Diversion Of, Controlled Drugs Has Been Identified
• Reporting of Controlled Drug Incidents via cdreporting.co.uk