It is well established that opioids are a high-risk medication and national statistics showed that half of all drug poisoning deaths involved an opioid during 2020 so they pose a real risk to patient safety.
There is little evidence that they are helpful for the management of chronic pain and the risk of harm increases significantly with doses above 120mg morphine equivalent per day without much increase in benefit but creating a risk of increased mortality and unintentional death, as well as other significant metabolic side-effects.
Prescribing data for East Kent has been a concern for several years with prescribing of high-dose opioids well above national and ICB average. Prior to the project, primary care was struggling to tackle this challenging problem and some practices in the area were prescribing three to four times the number of high dose opioid items than ICB average.
To address this a local service, using a multidisciplinary approach, was designed to support practices to manage opioid reductions in ten of their most complex patients with chronic pain to safer levels, below the 120mg threshold, or stop entirely, in compliance with NG193 and national recommendations of the Faculty of Pain Medicine. Funding was agreed on an invest to save basis and allows twenty practices to participate in the project phased over 2 years, targeting those with the highest levels of high dose items.
Practices were supported by a specialist pain clinician who provided training to staff and mentored the practice/PCN pharmacist with regular meetings as patient management plans were developed and implemented. After jointly working through these patients, clinicians were able to continue the same approach for other patients within their practices and those within their PCN providing a legacy.
Outcome measures were collected for each patient at the start and end of their reduction so that the impact of the project could be measured, including names of opioids and their morphine equivalence, costs of opioids, EQ5D (quality of life) questionnaire and pain scores.
The project has contributed to a 25% reduction in high dose opioid items in East Kent during the 2021/22 financial year. Of the first 37 patient completers all but two have achieved opioid doses of less than 120MME and five have stopped their opioids entirely, in the majority of cases without detriment, and in some even improvement, in pain control and quality of life scores. This has also contributed to a £260K per annum reduction in spend on potent opioids.
