Opioid Stewardship QI Collaborative

This masterclass was co-delivered with Dr Cathy Standard, Consultant in Complex Pain and Pain Transformation Programme Clinical Lead for NHS Gloucestershire ICB who provided an overview of complex pain management and Clare Howard, Wessex AHSN. Clinical Lead for the Wessex Medicine Optimisation Programme who provided an overview of the NHS BSA Opioid Prescribing Comparators dashboard.

Key learning

• Persistent pain is complex and has strong links with mood, emotional well-being, mental health, adverse childhood experiences, patient expectations, fears, and previous experience of pain.
• There is not a strong association between the perception of persistent pain and the extent of tissue injury at the pain site.
• Clinicians must work as a team to support the management of complex cases, acknowledge the complexity of persistent pain and assess appropriately with consideration of patients’ preferences and recognise high dose opioid prescribing is a sensitive marker of complexity.

This masterclass involved an expert by lived experience of persistent pain, Katie Campion, Patient Experience Programmes Lead, Point of Care Foundation and Natasha Curran, Medical Director, Health Innovation Network and Consultant in Anaesthesia and Pain Medicine at University College London Hospitals (UCLH) who provided lived and learnt experience insights of living with on-going pain and how to communicate effectively with patients.

Key learning:

• Persistent pain is a real sensation and feeling for people, therefore conversations between healthcare professionals and people living with persistent pain should focus on the impact on daily living.
• Patients should be given options to support better self-management of persistent pain which includes alternatives to pain medicines to help people live well with pain.
• Healthcare professionals need to actively listen to patients and learn to ask questions about what is important to the person living with persistent pain.

This masterclass involved Deborah Jardine-Banes, Consultant Nurse in Chronic MSK Pain at King’s College Hospital NHS Foundation Trust and Lelly Oboh, south East London ICB Pharmacist Overprescribing Lead who provided insights on how to have meaningful conversations with patients.

Key learning:

• The rationale for reviewing high risk opioid prescribing should be explained to patients with a focus on the changes to how clinicians manage persistent pain and alternative options to support self-management should be offered.
• Clinicians should explore the impact of living with persistent pain on patient’s mental health and wellbeing.
• It is important to assist patients with identifying who in the local healthcare system can best support the patient e.g., social prescribers, link workers, talking therapies, physiotherapy and third sector organisations.

Key learning:

The main opportunities for improvement identified by QI collaborative participants are summarised below:

• To have greater confidence in managing patients prescribed high-dose opioids for persistent pain.
• To enhance multidisciplinary team working in primary care networks.
• To have an enhanced ability to provide holistic care to patients. prescribed high-dose opioids for persistent pain.

Key learning:

Participants were introduced to tools that can be used to understand the problem.

• Process Mapping – helps you to visually represent the sequence of steps and interactions involved in a process.
• 5 Whys – helps you identify the root cause of a problem or issue. It involves asking "why" repeatedly, typically five times, to uncover the underlying causes and contributing factors behind a particular problem.
• Emotional Mapping- helps you to understand and address the emotional experiences and reactions of stakeholders throughout their interaction with a product, service, or process. It aims to uncover the emotional highs and lows, challenges, and opportunities for enhancing patient and staff experience.

Key learning:

Participants were encouraged to identify project drivers and possible actions to take in response to the drivers.

Drivers:

Source: AHSN Network 2021

Key learning:

Participants were introduced to the Model for Improvement and Plan-Do-Study-Act (PDSA) cycle.

Plan:

Plan what data to collect and how long the test will run for and when you will regroup to reflect on what happened

• What is the objective of the test / cycle?
• What is the theory?
• What do you predict will happen?

Do:

Run the test on a small scale

• Carry out the test.
• Document problems and unexpected observations.
• Collect and begin to analyse the data.

Study: 

Analyse the results and compare them to your predictions

• Complete, as a team, if possible, your analysis of the data.
• Compare the data to your prediction.
• Summarise and reflect on what you learned.

Act: 

Based on what you learnt from the test, make a plan for your next step

• Adapt (make modifications and run another test), adopt (test the change on a larger scale), or abandon (don’t do another test on this change idea).
• Prepare a plan for the next PDSA.

Key learning:

Participants shared their reflections on completing their QI project in their general practices and primary care networks, which have been summarised using a weather map as follows:

Sunshine = What went well?

• Reducing our number of patients on opioids overall by 10%.
• Having a process and structure for reviewing patients prescribed long-term opioids.
• Working collaboratively within the primary care network (PCN) and patient-centred relevance to Impact and Investment Fund (IIF)/ Quality and Outcomes Framework (QOF).
• Getting lots of engagement and enthusiasm across the team from receptionists to GPs.

Rain = What didn’t go so well?

• Seeking agreement from patients to consider a dose reduction of high-dose opioid prescriptions for persistent pain.
• Initial commitment from the practices and support of the practice protocol for opioid medication review for patients living with persistent pain.
• Due to the inability to share management plans across sectors, in some cases, patients were put back on high-dose opioids after working for months to taper their regime when reviewed in hospital pain clinics.
• Misjudging the time involved and the complexity of the patient group within our practice.

Lightening – What took you by surprise?

• Some patients were willing to seek advice and seek support to taper high-dose opioid medication regimes for persistent pain.
• Most of the high-dose opioid prescriptions identified were not linked to an active problem and had not been reviewed at our GP practice.
• Patients’ appreciation and understanding of the need for opioid reviews for persistent pain.
• A lot of patients found that their pain was better controlled off the opioids, or that there was no difference because they adopted other techniques and alternatives to pain medicines.

Wind = What blew you off course?

• The business-as-usual (BAU) workload, staff sickness and annual leave slowed down progress.
• Insufficient time to review each patient.
• It took longer than anticipated to identify why the patients were taking high-dose opioids and why were they started.
• The complexity of some of the patients prescribed high-dose opioids for persistent pain.

Fog = What didn’t you understand?

• Unable to fully comprehend why there was such a lack of confidence across the team.
• Unable to understand why patients were not advised opioids in persistent pain were short term and expectations were not always appropriately managed.
• Unable to understand why so many patients had been started on these opioids but had not been offered physiotherapy and other alternatives to opioids.
• Unable to understand why there were so many patients on such high-dose opioids for persistent pain in the first instance.