Acceptability of a primary care-based opioid and pain review service: a mixed-methods evaluation in England

Collaboration between adult patients and practitioners when making decisions about prescribing opioid medicines for chronic non-cancer pain in primary care: a scoping review

BACKGROUND

Long-term opioid therapy (>12 months) is not effective for improving chronic non-cancer pain and function. Where patients are not experiencing pain relief with long-term opioids, the opioid should be tapered and discontinuation considered. Practitioners may find it challenging to tell patients experiencing pain that they are better off reducing or not taking medicines that do not help. This review aims to ascertain what is published about: (1) the interaction and (2) the nature of the relationship between practitioners and patients when prescribing opioids for chronic non-cancer pain in primary care.

METHOD

A scoping review of English-language qualitative, quantitative or mixed-method studies in databases including: MEDLINE, Embase, PsycINFO, AMED, BNI, CINALH EMCARE and HMIC. The identified papers were reviewed to provide a descriptive summary of the literature.

RESULTS

The review identified 20 studies. The studies used a range of methods including interviews, focus groups, audio and video recordings of clinical consultations, telephone survey and data from patient records. One study reported that researchers had engaged with a patient advisory group to guide their research. Patients expressed the importance of being treated as individuals, not being judged and being involved in prescribing decisions. Practitioners expressed difficulty in managing patient expectations and establishing trust. Opioid risk and practitioner suspicion shape opioid prescribing decisions. There is a paucity of literature about how precisely practitioners overcome interactional challenges and implement personalised care in practice.

CONCLUSION

The studies in this review ascertain that practitioners and patients often find it challenging to achieve shared decisions in opioid review consultations. Effective communication is essential to achieve good clinical practice. Collaborative research with PPI partners should be aimed at identifying communication practices that support practitioners to achieve shared decisions with patients when reviewing opioids for chronic non-cancer pain.

A pharmacist-led intervention to improve the management of opioids in a general practice: a qualitative evaluation of participant interviews

Background Opioid prescribing has escalated, particularly long-term in chronic noncancer pain. Innovative models of care have been recommended to augment regulatory and harm-minimisation strategies and to review the safety and benefits of opioids for the individual patient. Medication stewardship and pharmacist integration are evolving approaches for general practice. Aim To explore enablers, barriers, and outcomes of a pharmacist-led intervention to improve opioid management in general practice, from the perspectives of general practitioners (GPs) and practice personnel. Method The study was part of a mixed-methods investigation into a general practice pharmacist pilot. Qualitative data relevant to opioids were analysed. Data from 13 semi-structured interviews were coded, analysed iteratively and thematically, and interpreted conceptually through the framework of Opioid Stewardship fundamentals proposed by the National Quality Forum. Results Seven themes and 14 subthemes aligned with stewardship fundamentals. Participants considered organisational policy, supported by leadership and education, fostered collaboration and consistency and improved practice safety. Patient engagement with individualised resources, 'agreements' and 'having the conversation' with the pharmacist enabled person-centred opioid review and weaning. GPs reported greater accountability and reflection in their practices, in the broader context of opioid prescribing and dilemmas in managing patients transitioning through care. Receiving feedback on practice deprescribing outcomes encouraged participants' ongoing commitment. Patient communication was deemed an early barrier; however, learnings were applied when transferring the model to other high-risk medicines. Conclusion Improved opioid management was enabled through implementing pharmacist-led coordinated stewardship. The findings offer a practical application of guideline advice to individualise opioid deprescribing.

Opioids in the United Kingdom: safety and surveillance during COVID-19

PURPOSE OF REVIEW

Opioid use is prevalent in the United Kingdom and prior to the COVID-19 pandemic it had been recognized that the safety of opioids was an important issue to be monitored by the UK medicines regulatory agency. With the emergence of COVID-19, this requirement has been even greater. This review was undertaken to determine the impact of the pandemic on safety and surveillance of opioids in the United Kingdom.

RECENT FINDINGS

During the COVID-19 pandemic, the surveillance of opioids in the United Kingdom continued, although primary research was often conducted with data prior to the pandemic. Of those studies that were conducted while the pandemic was ongoing, access to opioids (or opioid substitution therapy) and the subsequent effect on patient safety was the main theme.

SUMMARY

In the United Kingdom, changes in accessibility to the healthcare system and how healthcare providers operated during the COVID-19 pandemic may have had unintended consequences on use and safety of opioids, due to the shift in focus to preventing COVID-19 from overwhelming the healthcare system. The findings from this review support the need to continue surveillance in the United Kingdom, including the impact of the COVID-19 pandemic on opioid utilization and safety.

Analgesic Opioid Misuse and Opioid Use Disorder among Patients with Chronic Non-Cancer Pain and Prescribed Opioids in a Pain Centre in France

(1) Background: Chronic non-cancer pain (CNCP) remains a public health challenge around the world. Opioids (PO) have been increasingly used in the treatment of CNCP in the last 20 years. This study aimed to assess the prevalence of opioid misuse and prescribed-opioid use disorder (p-OUD) among patients with CNCP in a pain centre in France, and to analyse risk factors for moderate or severe p-OUD. (2) Method: A cross-sectional study was conducted, including patients consulting for pain management in the pain centre of Brest University Hospital. A self-questionnaire was administered (sociodemographic data, medical data, PO misuse, and p-OUD according the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) criteria). Descriptive, univariate, and multivariate analyses were conducted, together with a principal component analysis, in order to identify factors associated with p-OUD. (3) Results: In total, 115 patients were included, the majority of whom were women, with a mean age of 52 years old [18–82]; 64.3% (n = 74) had a current prescription for opioid analgesics (weak or strong). In this group, 56.7% (n = 42) had no or only mild p-OUD and 43.3% (n = 32) had current moderate or severe p-OUD. Patients with moderate or severe p-OUD were more likely to have a current antidepressant prescription, to have had psychotherapy, to currently use strong opioids and oxycodone, and to report taking more frequent doses than prescribed and feeling dependent. (4) Conclusions: We showed that the prevalence of current moderate/severe p-OUD concerned 43.3% of the patients with a CNCP seeking treatment in a pain centre. According to these results, several measures are relevant in managing p-OUD among patients with CNCP.

Acceptability of a primary care-based opioid and pain review service: a mixed-methods evaluation in England

BACKGROUND

Primary care opioid prescribing to treat chronic non-cancer pain (CNCP) has progressively increased despite a lack of evidence for long-term safety and effectiveness. Developing primary care interventions to reduce opioid dependence in patients with CNCP is a public health priority.

AIM

To report the acceptability of the South Gloucestershire pain and opioid review service for patients with CNCP, which aimed to help patients understand their relationship with prescribed opioids and support non-drug-based pain management strategies.

DESIGN AND SETTING

A mixed-methods evaluation was performed on the service, which was based in two GP practices in South Gloucestershire, England, and delivered by project workers.

METHOD

Descriptive data were collected on delivered-within-service and community-based interventions. Twenty-five semi-structured interviews (n = 18 patients, n = 7 service providers) explored experiences of the service.

RESULTS

The enrolment process, person-centred primary care-based delivery, and service content focused on psychological issues underlying CNCP were found to be acceptable to patients and service providers. Patients welcomed having time to discuss their pain, its management, and related psychological issues. Maintaining a long-term approach was desired as CNCP is a complex issue that takes time to address. GPs recommended that funding was needed to ensure they have dedicated time to support a similar service and to ensure that project workers received adequate clinical supervision.

CONCLUSION

This service model was acceptable and may be a useful means to manage patients with CNCP who develop opioid dependence after long-term use of opioids. A randomised controlled trial is needed to formally test the effectiveness of the service.

Evaluation of a primary care-based opioid and pain review service: a mixed-methods evaluation in two GP practices in England

Background

Opioid prescribing to treat chronic non-cancer pain has rapidly increased, despite a lack of evidence for long-term safety and effectiveness. A pain review service was developed to work with patients taking opioids long-term to explore opioid use, encourage non-drug-based alternatives, and, where appropriate, support dose reduction.

Aim

To evaluate the service and its potential impact on opioid use, health and wellbeing outcomes, and quality of life (QoL).

Design and setting

Mixed-methods evaluation of a one-to-one service based in two GP practices in South Gloucestershire, England, which took place from September 2016 to December 2017.

Method

Quantitative data were collected on baseline demographics; data on opioid use, misuse, and dose, health, wellbeing, QoL, and pain and interference with life measures were collected at baseline and follow-up. Twenty-five semi-structured interviews (n = 18 service users, n = 7 service providers) explored experiences of the service including perceived impacts and benefits.

Results

Of 59 patients who were invited, 34 (57.6%) enrolled in the service. The median prescribed opioid dose reduced from 90 mg (average daily morphine equivalent; interquartile range [IQR] 60 to 240) at baseline to 72 mg (IQR 30 to 160) at follow-up (P<0.001); three service users stopped using opioids altogether. On average, service users showed improvement on most health, wellbeing, and QoL outcomes. Perceived benefits were related to wellbeing, for example, improved confidence and self-esteem, use of pain management strategies, changes in medication use, and reductions in dose.

Conclusion

The service was well received, and health and wellbeing outcomes suggest a potential benefit. Following further service development, a randomised controlled trial to test this type of care pathway is warranted.