Covering one of the most deprived counties in the country with high rates of opioid prescriptions for non-cancer pain (oxycodone and fentanyl) the CCG, NHS East Lancashire Chronic Pain Team along with the Local Authority and Substance Misuse Service took a collaborative approach to system redesign to develop new pathways for chronic pain and manage opioid reduction. A multi-agency approach was considered necessary due to the complexity of the issue and service provision.
The East Lancashire programme acknowledged and adapted the Wigan CCG opioid resource pack. The CCG commissioned licenses for PrescQIPP e-learning modules. This training was mandated for GPs in each practice identified as leading on opioid deprescribing. The programme used Faculty of Pain Medicines Guidance to set clinical expectations with key message reinforced by NICE Guidance Management of Chronic Pain, published April 2021.
The first step to a whole system approach was the creation of a multi-agency care pathway, which differentiated >300mg vs 120mg of morphine equivalent per day. This identified which patients required specialist management and which patients could be managed by GPs. Letters were drafted for referral to pain specialists and example of tapering schedule were provided.
The benefits of the programme have continued despite Covid with an 10% reduction across East Lancashire in prescribing of Total Opioid Burden (as morphine equivalence) per 1000 patients. One highly motivated PCN achieving a 16% reduction. These reductions were achieved by working with a small number of patients. GP/PCNs faced some challenges identifying where to refer complex patients for biopsychosocial interventions, such as exercise or psychological support.
PCN additional roles were repurposed, harnessing new work force including social prescribers, exercise coordinators and mental health nurses to provide non pharmaceutical support for patients with chronic pain management. PCN pharmacists were also trained to review opioids and gabapentinoids, as part of the structured Medication Review (SMR) Service contracted within PCN Service Specification.
The patient outcomes were very positive with three patient stories presented as evidence. Over and above opioid risk reduction and reduced side effects, the improvements in patients’ quality of life included family reconciliations, new lease of life and ability to take part in care home activities.
