Title: OpTimising Acute Pain aftEr suRgery (TAPER study): Development and feasibility study of an intervention to optimise opioid use to ensure patient safety
Funder: Health Education England

Abstract: BackgroundPoorly controlled acute post-surgical pain is detrimental to both the patient and wider healthcare. Opioids remain the mainstay of post-surgical pain management but long-term use does not provide any additional analgesic benefit. Studies from North America have shown that opioids are often prescribed persistently in a large proportion of surgical patients due to chronic post-surgical pain. Interventions focused on the transition of care from secondary to primary care are the key approach in optimising acute pain to prevent chronic post-surgical pain (CPSP) and long-term opioid use. Despite the vast number of surgical procedures conducted, an epidemiological and interventional study to ensure the safe use of opioids for patients after surgery is lacking in the UK. Research questionWhat are the key features to be incorporated in an electronic audit and feedback (eA&F) intervention that will engage healthcare professionals in primary care to manage ongoing post-surgical pain and ensure appropriate opioid prescribing? Aims and objectivesThis study aims to develop a prescribing support tool (eTAPER) to manage ongoing post-surgical pain and ensure appropriate opioid prescribing in primary care. The objectives include: (1) To identify the characteristics of post-operative patients and their medicine utilisation pattern after discharge from surgery which are associated with developing persistent opioid utilisation and potentially opioid-related harms (2) To adapt an existing eA&F platform to develop an add-in module (eTAPER) which can be used to optimise opioid prescribing for patients at high-risk of persistent opioid utilisation after surgery (3) To explore the feasibility of engaging patients and healthcare professionals in using the eTAPER tool. MethodologyThis research programme takes a mixed method approach and includes three work packages (WP1-3): WP1: A population-based cohort study will be undertaken to better understand the long-term prescribing patterns of opioids following major surgery in the UK and to identify the characteristics for developing persistent use of opioids or opioid-related harm. WP2: An experience-based co-design approach will be used to develop the eTAPER intervention tool. An existing eA&F platform will be adapted using insights generated from applying the behaviour change wheel to identify features which are feasible and acceptable to both patients and healthcare practitioners. The tool will be developed in partnership between patients, pain specialists, GPs and clinical pharmacists at workshops. WP3: A feasibility study will be conducted to test the acceptability and usability of eTAPER in a sample of patients and their GPs. Timelines for deliveryThe epidemiological study will be undertaken in Years 1-2 of the fellowship. Developing and feasibility testing of the eTAPER tool will take place in Years 3-5. This intervention will then be evaluated at a larger scale in the future as part of a post-doctoral fellowship. Anticipated impact and dissemination This study will advance understanding of outcomes in patients on long-term opioids following surgery. It will produce a practical tool that can be implemented and further evaluated in GP practices in the future to manage ongoing post-operative pain following discharge and ensure appropriate opioid prescribing.

Lay abstract: BackgroundOpioids are a group of strong pain killers that are commonly prescribed for severe short-term pain. Increasing evidence from America and Canada has shown that many patients continue to use opioids long-term after surgery, despite having never used them before. This may be either due to poor pain control or because patients may develop addiction to them. We do not know whether this is the same in the UK, however we know that the number of prescriptions for strong opioids is increasing. Long-term opioid use is associated with significant negative effects to both patients and the wider society. AimTo develop a web-based tool (eTAPER) to support General Practitioners (GPs) and clinical pharmacists working in GP practices to review opioid painkillers in a timely manner and reduce the number of patients who remain on these drugs long-term following surgery. Design and methods I aim to develop this tool in 3 stages: Stage 1: Identification of 'high risk' patients I will study the characteristics of patients who persistently use opioids after surgery by extracting data from two large national datasets. By analysing this data, I will be able to identify patient groups that are most likely to receive long periods of opioid prescribing. Stage 2: Designing the intervention I will work with experts in health psychology, health services research and digital health at the University of Manchester to explore whether the addition of a new module to an existing web-based platform can prevent long-term opioid prescribing after surgery. Following this, I will work with patients, pain specialists, GPs and pharmacists to refine this new tool through discussion sessions and using the findings from Stage 1. I will analyse the new tool using behaviour change theories to find out the key features required to make sure GPs and pharmacists will accept and use it. Stage 3: Testing the interventionI will then test the tool with a small sample of patients and their GPs. Patients will be recruited from my current role as a surgical pharmacist at the Manchester University Hospitals NHS Trust. Once patients agree to take part in the study, I will then contact their GPs to see if they will be willing to trial the tool and if so, I will provide details on how to access the tool. Six weeks after granting access to the tool, I will undertake an interview with patients and GPs to explore their experiences of using the tool. At the end of this project, I aim to develop a useful tool that can be further tested and used in General practice in the near future. Patient and public involvement Patients are at the core of this research and will be involved at all stages. This idea has been discussed and supported by a patient user forum. Members from the forum suggested this project is of urgent need as they felt that opioids are prescribed excessively after surgery. Two patient representatives from this forum will be part of the study management group and will be involved in discussions around the project. Patient representatives will also be involved in the co-design of the intervention. I will also work with representatives from my NHS Trust's patient pain group (known as the 'Pain away group') to spread news of my work through their local networks. DisseminationResearch findings will be published in my PhD thesis and peer reviewed journals. They will also be presented to patients, carers and relevant NHS professional groups at relevant meetings and conferences. I will create infographics (charts and diagrams) to share the results via social media and my expert networks.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE