Outcomes and GP perceptions of reviewing patients at risk of harm from opioids
Authors: Wilcock M , Motta M , Trevena L 
Published: November 2023

Abstract

Introduction
The Clinical Commissioning Group (CCG) Medicines Optimisation workplan for 2021-22 had a focus on reducing harm from opioids.1,2 In particular, asking GP practices to identify and review two cohorts of patients: those on a combination of oxycodone and amitriptyline or similar high-risk combinations, and those over the age of 65 prescribed fentanyl transdermal patches. Practices were then expected to consider actions on how to reduce the risk for patients and also to provide feedback to the CCG on how the reviews had progressed.

Aim
We aimed to understand the outcomes, challenges and learning points experienced by practices in reviewing these patients.

Methods
Sixty practices were invited to participate. A feedback form was received from each practice that completed either or both reviews (covering anonymised outcomes of each review, challenges encountered, and practice-level learning points / changes made). Quantitative data were collated for each action, and feedback comments were categorised into broad groups. No patient details were collected. As this project was a service evaluation, ethical approval was not required.

Results
Forty-three practices completed the review of the combination of oxycodone and amitriptyline, though 5 of these had no patients to review. Overall, 185 patients were identified. Of these, 21 (11%) patients had the combination prescribing ceased, 22 (12%) were commenced on a reduction plan, and another 46 (25%) have been made aware of the risk and to report respiratory symptoms. Forty-three practices completed the fentanyl review, though one of these had no patients to review. Overall, 272 patients over 65 years were identified with 64 (24%) invited for a review with their GP or other allied health professional, 39 (14%) patients were put on a fentanyl patch dose reduction plan, and 14 (5%) had prescribing ceased.
Practices reported various difficulties encountered with these reviews, including patient engagement in making changes to their pain medication which patients are reluctant to reduce; counselling and raising awareness of long-term effects of opioids to help gain patient understanding; how to manage complex patients who had been stable on their regimen over many years; and that it was time consuming to regularly check in with the patient and plan reduction regimens. Changes made by practices included recording risks discussed with patient in their medical record for easier future review; ensuring regular reviews, including by practice-based pharmacists, of patients prescribed opioids; trying to make time to see patients face to face; raising awareness of the risks of prescribing amitriptyline alongside oxycodone e.g. serotonin syndrome; and recognising that a collaborative process and patient engagement is necessary.

Discussion/Conclusion
The actions undertaken by practices link into national recommendations,1 with some GP feedback similar to the challenges and opportunities to improve patient safety on opioid use as reported elsewhere.3 Even with this small targeted patient cohort, this work demonstrates difficulties encountered by GPs in refraining from opioid prescribing. Other limitations of this small-scale review include lack of certainty whether reductions in opioid prescribing were always clinically appropriate, and reliance on practice feedback.

References
1. Taylor S, Annand F, Burkinshaw P, Greaves F, Kelleher M, Knight J, et al. Dependence and withdrawal associated with some prescribed medicines: an evidence review. Public Health England, London. 2019.
2. Regulation 28 Report to prevent future deaths. Available at: https://www.judiciary.uk/wp-content/uploads/2019/11/Graham-Saffery-2019-0301_Redacted.pdf (accessed 20 March 2023)
3. Punwasi R, de Kleijn L, Rijkels-Otters JBM, Veen M, Chiarotto A, Koes B. General practitioners’ attitudes towards opioids for non-cancer pain: a qualitative systematic review. BMJ Open 2022;12:e054945.