Opioids Aware: a general practice audit of high-dose opioid prescribing NHS England Midlands and East

Discussion

The audit has some important limitations:

1. The response rate was low, so the results cannot be generalised.

2. The number of patients on high-dose opioids may have been underestimated: the search only identified one drug at a dose of ≥120 mg OME and did not detect combinations of opioids of ≥120 mg OME.

3. Patients on buprenorphine tablets or methadone were excluded but could have been prescribed these medications for pain.

4. The percentage of patients on high-dose opioids for chronic pain is inaccurate as the indication for prescribing was unclear in many patients.

5. Participants were not asked for duration of prescribing, which would have provided additional perspective.

6. The audit questions, though not the reflection, were completed by a non-clinical member of staff and no instruction was offered regarding how misuse and overuse should be identified.

While acknowledging the limitations, it was found that the prevalence of high-dose opioids for chronic pain was low (0.13%) but variable by practice. This is in keeping with national data which shows variation by clinical commissioning group (CCG),⁵ between practices, by geography, by deprivation, rurality, and other multiple factors.³

Prescribing quality was of concern with respect to clarity regarding indication and frequency of review. Addressing this may have a beneficial effect on patient safety.

Evidence of possible misuse or overuse was infrequent; this may be the case, or it may be that a more detailed instruction on how to detect this would have resulted in a higher figure. The findings in this respect are broadly in line with national data.²

Co-prescribing of other potentially DFMs¹ was particularly common for gaba drugs, which are known to produce potentially fatal interactions.^6–8 Again, there is potential for improving patient safety, both by avoiding combinations of DFMs and where appropriate deprescribing.

Overall, 80% of practices provided reflections.⁴ These demonstrated learning and change, with good ideas on how to tackle the issue of high-dose opioids for chronic pain. These are potentially generalisable to the wider primary care community. Further qualitative work investigating factors related to GP prescribing would help tailor interventions to address high-dose opioid prescribing for chronic pain.

Deprescribing was noted to be difficult and should be seen in the general context of emerging evidence on how to do this.⁹ There are examples of CCG work on high-dose opioid deprescribing.¹⁰

With respect to what practices should do when they recognise patients on high-dose opioids for chronic pain, they should, in our view, ‘treat high-dose opioids like any other high-risk drugs’. Some practices in this audit did this, placing high-dose opioids within existing systems and processes for high-risk drugs. In conclusion, it is difficult to generalise these results due to the low response rate, however, using this audit tool to identify and review patients on high-dose opioids for chronic pain could improve patient safety.