Delivering a primary care review for people prescribed opioids for persistent pain: a qualitative study on the facilitators and barriers facing practice pharmacists

Experience of consulting in primary care

Experiential knowledge gained from consulting with patients in primary care was considered to be a prerequisite for delivering a PROMPPT review. Specifically, experience of consulting with people with persistent pain was seen as desirable because these patients often had comorbidities and their cases were described as complex.

Pharmacists also needed to know the services that were available for referral, as well as the associated policies and processes.

In addition, pharmacists told us they would be uncomfortable conducting this type of review when newly qualified or if they had recently become a prescriber. What constituted ‘enough’ experience varied, although most participants agreed that 6–12 months’ experience of consulting in general practice was desirable, and that those with less experience would benefit from training.

Knowledge about pain, pain management, and opioid deprescribing

Being knowledgeable about the biopsychosocial nature of persistent pain was considered to be important for supporting patients.

Specialised knowledge of medicines, associated side effects, and long-term effectiveness was considered an advantage when reviewing pain medicines and optimising medication regimes.

Participants also said that having knowledge around non-pharmacological approaches was valuable in terms of being able to support patients’ pain management. Participants drew on experiential knowledge when describing their understanding of deprescribing, but some desired additional training around polypharmacy and deprescribing opioids specifically:

‘I’d have to brush up on my clinical knowledge around what combinations and how we should go about deprescribing them so, the clinical aspects behind it, like what interventions and how do we make those interventions.’ (Focus group 1)

Patient knowledge of a PROMPPT review

Pharmacists suggested that it would be helpful for patients to know the role of the pharmacist and what to expect before attending a PROMPPT review. They liked the idea of a pre-consultation form that encouraged patients to consider their concerns about pain and pain medicines, suggesting it would help patients to prepare for the consultation.

Person-centred shared decision-making

Most pharmacists suggested patient-centred consultation skills were needed to deliver a PROMPPT review. Skills mentioned included:

• managing patient expectations about persistent pain and pain relief;

• offering information about medicines;

• addressing concerns;

• listening to what matters most;

• understanding barriers to reducing opioids;

• showing empathy and compassion; and

• involving patients in decision-making.

As one interviewee noted:

‘The patient needs to feel that they’ve been included [in] all of the decisions… they don’t want to feel like it’s happened to them, they want to feel they’ve been the one to decide things.’ (Interview, participant 19)

Participants also expressed that it is important to find out patients’ readiness to reduce opioids and to adapt the consultation accordingly:

‘The danger we have with pharmacists is we fix things and the danger is, if you see it as a cycle of change model, we launch straight into the action phase, forgetting actually there are four steps before that.’ (Interview, participant 15)

Participants told us that the person-centred skills that are required to conduct a PROMPPT review effectively — such as facilitating patient motivation to reduce opioids — go beyond what is required for a regular medication review, and recognised a need for further training.

In contrast, some participants suggested times when a more paternalistic approach might be appropriate, for example, when patient safety was at risk or to encourage patient attendance. As an example, it was suggested that repeat prescriptions could be paused until the patient had attended a PROMPPT review.

Supporting patient pain management

Participants spoke about skills in developing and supporting individualised pain management and tapering plans. To do this effectively, they felt pharmacists needed to be independent prescribers, skilled in deprescribing, and able to manage patient expectations (for example, around withdrawal symptoms and the timing of doses). When plans include a tapering schedule, participants suggested any reduction be presented as a trial and the impact of making this change be regularly reviewed. As such, they emphasised the need for skills in mentoring and supporting patients to problem solve potential barriers during the process of reducing their opioids.

Part of pharmacist’s role in primary care

Many participants saw a PROMPPT review aligning with their current professional responsibilities of medicine management and safe prescribing. As relatively new members of the primary care team, the opportunity to lead such a service was viewed favourably and something that could help to clarify their expertise to colleagues:

‘It’s very important that pharmacists get embedded and are seen to be [in] the role where we will be reviewing these medications, we will be making sure that they’re prescribing safely around these areas that are such high risk.’ (Interview, participant 21)

Confidence to deliver PROMPPT reviews

Participants expressed variability in confidence regarding conducting PROMPPT reviews. Greater confidence was anticipated when consulting with patients who were willing to discuss their pain management and were open to opioid tapering.

Pharmacists spoke about being confident in arranging referrals and consulting with colleagues for complex cases where needed, although they were less confident in producing a plan for pain self-management.

Some pharmacists also highlighted the potential difficulty of health professionals who had initiated opioids then recommending opioid deprescribing:

‘They think you got them there. I think I had that conversation with one of the patients and I said, “You're on this high dose of opioid”, and she said “It was a doctor from your surgery that got me here”.’ (Focus group 2)

Many pharmacists expected that not all patients would want to reduce their opioids and anticipated there being challenging conversations around tapering with patients who had been taking opioids for a long time, perceived them to be beneficial, want a pharmacological alternative, or had previous negative experiences with healthcare services:

‘It’s difficult if they think “No, that’s my pain relief and that helps me. Leave me alone. You're not touching anything”. If they really truly believe that’s helping them, it’s quite difficult to have that conversation.’ (Focus group 2)

Participants felt their confidence could be maintained if they acknowledged that not all patients would be ready to reduce their opioids; in these instances, they felt it was important to avoid patient conflict.

Patient benefits

Pharmacists thought a PROMPPT review could benefit patients by providing education around pain and pain management, showing patients they were valued, and identifying a named point of contact regarding pain in primary care. Further benefits anticipated were:

• deprescribing of inappropriate opioids;

• improved pain management;

• reduced adverse side effects;

• enhanced quality of life;

• improved understanding of pain and pain medicines; and

• using medicines more appropriately (for example, regarding the timing of doses).

Intention to review patients

Pharmacists suggested PROMPPT reviews should target specific patient groups because ‘there are going to be thousands of patients’ (Focus group 1), especially in larger practices situated in areas of deprivation. They told us that they would prioritise delivery of PROMPPT reviews for ‘the high-dose ones’ (Focus group 1) who were perceived to be at greatest risk, as well as those who were more likely to engage in a pain review.

Do what’s best for the patient

Participants said their goal was to help improve patients’ quality of life by reviewing their current pain management and opioid therapy in relation to what was important to the individual. Some recognised that what they considered best for patients might not align with the patient perspective, so it was important to find a shared agenda to support patient engagement:

‘Finding out what their experiences were, what they wanted from the pain, how the pain was impacting their life, what they thought of their medication, and where they wanted to go with the medication.’ (Interview, participant 22)

Participants said that finding a shared agenda might be challenging when patients’ expectations exceeded what a PROMPPT review could offer, such as seeking a pharmacological alternative to opioids.

Pain reviews are emotionally demanding

Pharmacists spoke of conversations with patients who were living with persistent pain leading to both positive and negative emotions, and said they could be stressful and worrisome. Some participants suggested negative emotions could be experienced long after a consultation and strategies to protect their own wellbeing were important:

‘I mean there’s some very sad stories when you’re dealing with these people, when you listen, I mean you probably know, er, you can’t help but be affected by them.’ (Interview, participant 19)

Capacity and resource to deliver PROMPPT reviews

Time was the most discussed resource, with all interviewed participants and focus groups highlighting that PROMPPT reviews needed to be longer than the standard 10-minute consultation. Lack of time was considered a barrier to successful deprescribing and a contributing factor to prescribing. Many suggested an initial review would require 30 minutes to 1 hour, ideally delivered in person; however, they noted that follow-up appointments could be done remotely.

Follow-ups were considered to be ‘very important’ (Focus group 1) for patients to feel supported and to monitor the impact of changes to medicines, with the option for patients to contact the pharmacist between appointments if needed.

Participants also spoke about a wide range of services that might be relevant for patients, including other health professionals, smoking cessation services, a crisis team, social prescribers, wellbeing advisers, and the Citizens Advice Bureau. Potential barriers to meeting patient need were discussed, including variation in the availability of different services, wait times, and practice-level permissions to make referrals.

Participants felt that evidence-based resources that were accessible to patients (for example, available online or in print, and in different languages) would be valuable and had multiple potential benefits for building rapport, as well as supporting the delivery and receipt of information:

‘I always find that quite useful by showing the videos and then printing out the literature, rather than just giving them a website.’ (Focus group 1)

Lack of definitive tapering guidelines

Pharmacists told us that, although local guidelines existed for deprescribing, there was nothing definitive. They felt a tapering template would be helpful and could reduce the risk of patients experiencing withdrawal symptoms or other negative effects.

A consistent approach

Participants noted that there was likely to be variation in the implementation of the PROMPPT intervention:

‘I suppose there’s going to be variations across different practices. Some people will have really bought into it, some people want their pharmacist to do other things they perceive to be more important.’ (Interview, participant 22)

Several participants supported a consistent approach being taken within each practice to guard against mixed messaging and an unintentional reversal of plans agreed at a PROMPPT review (for example, colleagues reinstating a higher opioid dose).

They also felt that all general practice staff should be aware of the PROMPPT review and that it should be documented in the patients’ medical record. With practice-wide support, pharmacists felt they could discuss complex cases at multidisciplinary meetings or seek GP input. To facilitate a consistent approach, participants recommended embedding a clinical template into the patients’ medical record that included the review structure, key questions, and the care plan agreed.

Pharmacists also suggested that PROMPPT reviews would benefit from being an incentivised service to be prioritised by practices, and that pharmacists’ time should be protected for its consistent delivery.

Pharmacist social support

Pharmacists noted that social support for delivering PROMPPT reviews would be beneficial and help them to discuss complex cases, monitor prescriptions, support the completion of referral processes, and learn from experienced colleagues (for example, via shadowing opportunities, the sharing of best practice, and role play):

‘[It would be useful to have access to, or hear from] pharmacists who have got experience dealing with these patients, telling us about different consultations, how well they’ve gone, and practising role plays and things like that, because I think that’s the most important thing.’ (Interview, participant 19)

Patient–pharmacist rapport

Participants shared strategies that might help them to develop and maintain patient trust and develop rapport, such as reassuring patients that consultations were confidential, introducing themselves to patients by their first name, supporting patient priorities, having honest conversations about the tapering process, and having regular follow-ups. It was noted that establishing trust and rapport with patients takes time to develop and, given the potential of the PROMPPT review to involve deprescribing, this might be challenging to achieve:

‘The relationship, so you’re saying they’ve seen a GP for years and then they go to someone random and, if we just start talking about reduction straight away, it’s not going to go well.’ (Interview, participant 23)