It is widely recognised that the use of medications has limited evidence of benefit in non-neuropathic pain but can cause significant harm. Nationally there has been a focus on reducing harm associated with opioid prescribing, however reductions in gabapentinoids (pregabalin and gabapentin) have been slower to be realised.
In 2021 County Durham was the highest prescriber of gabapentinoids in the country, and had been increasing. The North East and North Cumbria (NENC) ICB Medicines Optimisation (MO) team in County Durham recognised that this increase may be due to patients being prescribed gabapentinoids as an alternative to opioids, and that this needed to be tackled in a focussed way.
The MO team identified 3 high risk groups to target to make this task more manageable
1\. Patients prescribed high doses over the recommended maximum
2\. Elderly patients prescribed gabapentinoids
3\. Women of childbearing age prescribed pregabalin (in-line with MHRA warning published in April 2022)
A workstream was developed and commissioned for GP practices to review all patients prescribed high strength gabapentinoids, and target those on doses greater than the maximum recommended (Pregabalin at 600mg per day or greater or Gabapentin at 3.6g per day or greater). This workstream was implemented in Q2 2021 and led to 1,307 patients on high strength gabapentinoids being reviewed.
The MHRA alert about the use of pregabalin in pregnant women was circulated and a template letter drafted to support practices to meet the recommendations about informing patients of the risks.
A rolling workstream was developed and commissioned for GP practices to review elderly patients prescribed gabapentinoids. Those aged over 85 were reviewed in Q2 2022 and those aged 80-85 were reviewed in Q3 2022. In total 1,699 patients were reviewed and 495 were reduced or stopped (29%).
Total tramadol ADQs reduced by 6% in March 23 compared to March 21 prior to any of the interventions being implemented. A greater reduction of 11% was seen in ADQs in patients over 80. Further work on reducing age bands is planned for 2023-24.
The commissioned workstreams cost £130k to implement but has led to 277 fewer patients per month being prescribed an opioid compared to before the intervention; this has significant benefits associated with morbidity and mortality and hospital admissions. There have also been savings in the cost of these medicines of £6,433 per month (£77k per year). These savings are lower than expected due to price concessions, but the patient safety impact and cost avoidance due to morbidity, mortality and hospital admissions is difficult to quantify.
