It is widely recognised that opioids for non-cancer chronic pain have limited evidence of benefit but can cause significant harm. In 2021 County Durham was the highest prescriber of opioids in the country, and a large proportion of the prescriptions were for weak opioids for chronic pain.
The North East and North Cumbria (NENC) ICB Medicines Optimisation (MO) team in County Durham identified three groups of high-risk patients with chronic pain and targeted these for intervention;
1\. Patients prescribed oral morphine sulfate 10mg/5ml solution - Concerns have been raised nationally regarding the risks, including unintentional or intentional overdose and death.
2\. Patients prescribed dihydrocodeine – Dihydrocodeine is a shorter-acting opioid with effects that are more likely to lead to dependence and misuse.
3\. Elderly patients prescribed tramadol – Tramadol has both opioid side effects and anti-cholinergic side effects due to its dual mechanism of action. Elderly patients are at increased risk.
A workstream was developed and commissioned for GP practices to review all patients prescribed oral morphine sulfate solution 10mg/5ml. This workstream was implemented in Q3 2021. 1423 patients were reviewed and 793 had the medication stopped, reduced, or switched to an alternative (55.7%). This has led to a maintained reduction in prescribing; Feb 23 shows a 30.5% reduction in dispensed ADQs compared to Sept 21.
The formulary status of dihydrocodeine was reviewed by the local Area Prescribing Committee and was changed from green to red in May 2022. This has supported GP practices with discussions about reductions with their patients and has led to a 39.6% reduction in dispensed ADQs in Feb 23 compared to Feb 22.
A rolling workstream was developed and commissioned for GP practices to review elderly patients prescribed tramadol. Those aged over 80 were reviewed in Q3 2022. 786 patients were reviewed and 249 were reduced or stopped (32%). Total tramadol ADQs reduced by 8.9% in Feb 23 compared to Feb 22, with a greater reduction of 12.2% in patients over 80. Further work on reducing age bands is planned for 2023-24.
The two commissioned workstreams cost £108k to implement but has led to 1882 fewer patients per month in the identified high-risk groups 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 £12,632 per month (£151k per year) and overall reduction in opioid costs of £417k.
