Targeted high dose opioid reduction: A collaboration with primary care

Abstract Title: Targeted high dose opioid reduction: A collaboration with primary care

Background:

The county of Kent (U.K.) is a national outlier in levels of primary care opioid prescribing, even if adjusted for factors that may influence it, including high levels of deprivation. Pain Services in the region are oversubscribed and do not have the capacity to take on patients purely for the purpose of supporting opioid rationalization. General Practice services are overwhelmed and clinicians do not have the expertise required to undertake this work.  A way of working needed to be found to reduce harmful and excessive prescribing of drugs with addictive potential and long-term metabolic consequences, in a supportive environment.

Purpose/Objectives:

Following a successful pilot project with a few surgeries of the highest need, reproducible protocols were drawn up, funding was agreed and a service commissioned in East Kent, comprised of senior specialist pain clinicians from the Kent Community Chronic Pain service working collaboratively with pharmacists based in General Practice, who would each be supported by a dedicated GP within their surgery. The funding allowed 20 practices within East Kent to participate in the service in a phased approach over a 2-year period, commencing November 2020. Priority was given to those practices within the region who had the highest levels of >120mg Morphine equivalent items per 1000 patients, identified and targeted by the Medicines Optimisation team of the CCG (Clinical Commissioning Group). The purpose was to upskill general practice staff in managing their own deprescribing in future,  in line with the county ambition of reducing opioid prescribing by 50% by 2024.

Method:

The model for each practice consisted of 7 supported sessions, followed by further support only if required, spread over a 12month period for each practice (total 24 hours). The practices identified 10 patients to work on. The initial session was education to all of the surgery staff with extensive resources provided afterwards Most work took place virtually, necessitated by Covid-19 guidelines.

For all patients the following data was collected at the start and the end of their reduction; Names, doses and monthly cost of opioids, Best and worst pain scores out of 10 and EQ5D-5L (EuroQol) questionnaires as a measure of quality of life.

Other information gathered was their pain diagnosis, whether they had contact with a specialist pain service, were on benzodiazepines too or required referral to a substance misuse team.

Patients were considered completed once they reached lower than 120MME but some elected complete cessation.

 

Results:

The results represent the first year of data  up to October 2021.
Fourteen surgeries had enrolled, of which five had completed. One hundred-and-ten
patients were enrolled, with 37 completed and seven withdrawn (moving away, palliative care or death).

The commonest pain diagnosis was low back pain (46 %). The majority of patients were on 2 opioid formulations. Nineteen patients had benzodiazepine co-prescriptions. Five patients required Naloxone home rescue pack prescriptions and referral to a Substance Misuse Team. Only 15 % of patients required referral to a Specialist Pain Service during the project.

Average MME (milligram morphine equivalent) reduced from 216 to 77.5 and average monthly cost of opioids reduced by £61.46.

Best and worst pain scores out of 10 reduced in completers. EQD5 health scores indicated either improvement or remained stable.

Pharmacists reported general improvement in skills, enabling opioid reductions outside the project and improved review of hospital discharge letters.

 

Conclusions: • Outcomes for patients align with those seen elsewhere following high dose reduction, in that their pain is not worse and general health either improved or the same.
• Significant cost savings can be made by reducing high dose opioids.
• Primary care can successfully manage high dose opioid reductions if the right support is provided.
• The protocol provided improved care for patients on long term opioids in terms of review of diagnoses, review and rationalisation of all medication including benzodiazepines, gabapentinoids and antidepressants, and identifying those that required comprehensive pain services. Surgeries were encouraged to involve social prescribers.
• Problems encountered were the significant impact of Covid-19 illness and vaccination programmes on practice staffing levels, resulting in poor data collection by surgeries, as well as frequent rescheduling and protracted contact required.

References: Devlin NJ, et al (2018) Valuing health‐related quality of life: An EQ‐5D‐5L value set for England. Health Economics; 27:7–22
Frank JW et al (2017) Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Annals of Internal Medicine; 167:181-191.
Nicholas MK et al (2020) Reducing the use of opioids by patients with chronic pain: an effectiveness study with long-term follow-up. Pain;161 (3): 509–519