Medication Without Harm: Improving care for people living with chronic pain

Unsafe medication practices and medication errors are a leading cause of avoidable harm in healthcare systems around the world. That’s why Medication Without Harm is the theme of the World Health Organisation’s third Global Patient Safety Challenge. The HIN’s Ayo Chike-Michael writes about the part we are playing to address this.

The Impact of Opioid Over-prescribing

People living with chronic pain understandably want to limit its impact on their daily lives. I can relate to this, having had three caesarean operations in the past 19 years. For weeks after the surgery, I didn’t need anyone to remind me to take my pain-relieving medicines! In my experience the pain resolved in a few weeks. However there are many people who live with chronic pain (defined as pain lasting longer than 12 weeks), estimated to be between one and six per cent of the population in England (NICE 2021).

Where self-care pain-management approaches are not sufficient, most people typically depend on their doctor or increasingly their pharmacist to prescribe the right medication. Opioids (such as codeine, morphine, fentanyl and buprenorphine) are commonly prescribed and offer great benefits to many people living with pain. In the UK, most opioids require a prescription and are only meant to be used on a short-term basis.

What clinicians think good looks like may be different from what the patient thinks. The work is easier when both discuss and agree together on way forward - Lelly Oboh, Consultant Pharmacist for Care of Older People and SEL ICS Pharmacist Over-prescribing Lead

It is estimated over half a million people in England are prescribed opioid pain relief for longer than three months. When the source of long-term pain does not have a cause that can be treated, opioids can do more harm than good, especially in high doses. This leads to tolerance, which means higher quantities are needed for the same effect. This can cause overdependence, side-effects and worsened physical and mental health. In England, it is predicted that without action about 6,000 people a year could be hospitalised as a result of taking opioids for extended periods. (AHSN Network, 2021).
This is why prescribers should review progress with patients to reduce or stop opioid use as appropriate and offer patients alternatives Initiating and prescribing opioids safely is one of the many ‘wicked’ problems in healthcare. The prescriber needs to decide the right dosage, monitor progress and support the patient with information; while the patient needs to be well informed from the beginning, involved in decision making and feedback.

To help address the problem, NHS England commissioned 15 regionally based Patient Safety Collaboratives (PSCs) to address this issue through the Medicines Safety Improvement Programme (MedSIP). The programme aims to reduce high dose prescribing (>120mg oral morphine equivalent) for non-cancer pain by 50 per cent by March 2024. All PSCs aim to support clinicians in their region to prevent initiation of opioid use where possible, deprescribe when necessary, offer targeted support to patients prescribed opioids for chronic pain and aim to offer nonpharmacological alternatives.

“It's about working differently, not working harder” – Cleo Butterworth, Associate Clinical Director- Patient Safety, Health Innovation Network

Opioid Stewardship

At the Health Innovation Network we’ve developed a CPD-accredited quality improvement collaborative programme that brings together clinicians from across south London to develop their skills for safer use of opioids. Masterclasses are delivered by clinical experts and people with lived experience, focusing on the complexity of pain management and how to support patients. The programme has thirty-five participants who are mainly GPs and pharmacists. It will conclude in March 2023 when participants will test their improvement ideas through a pilot, and ultimately implement them across a wider population.

The opioids stewardship programme is championing empowerment of everyone involved with prescribing opioids – Sarah Dennison, Controlled Drugs Accountable Officer for NHS England – London

As one of the organisers, the masterclasses have helped me to better understand the nuances interwoven into the work of the prescribers, and frustration of people living with chronic pain. It’s important to hear the patient’s side and listen, question and collaborate with them.

Natasha Callender, the programme lead, has shared her reflections from the four sessions delivered so far below: 

• Clinicians should not initiate discussions with patients about complex pain with a primary focus on deprescribing opioids. Instead patients should be primed with information about the best ways to manage complex pain, harms from long-term high dose opioids and supported through regular follow-ups so they can be involved in decisions.
• Persistent pain is complex and has strong links to mood, emotional wellbeing, mental health, childhood experiences, patient expectations and fears, and previous experience of pain.
• Pain is not one single concept – it is important to understand the different type of sensations and the impact these have on patients’ lives.
• It is important to navigate the nuances of addiction and dependence through discussion with patients and raise awareness of non-pharmacological alternatives.

This project is featured in our Annual Report 2022/23.