Adult Opioid Prescribing Guidelines for Acute or Persistent Pain Author: Community Health Services Pharmacist Sponsor/Executive: Medical Director Responsible committee: Medicines Governance Group Approved Medicines Governance Group Consultation & Approval: 1st June 2020 (Committee/Groups which signed off the policy, including date) Quality, Safety & Governance Committee 24 June 2020 This document replaces: V3 Date approved: 24 June 2020 Date issued: 15 September 2020 May 2023 Review date: Version: V4 Policy Number: MM42 To provide a guide containing key points for safe prescribing and monitoring for Purpose of the Guidelines: adults who are prescribed opioid medication for acute or persistent pain. If developed in partnership with another agency, ratification details N/A of the relevant agency Signed on behalf of the Trust:………………………………………………….. Chief Executive Elizabeth House, Fulbourn Hospital, Fulbourn, Cambs CB21 5EF Version Control Page Version Date Author Comments 2.0 May 2013 Lucy Oakley Developed and ratified by Cambridgeshire Community Services NHS Trust 3.0 March 2016 Lucy Oakley Updated following new guidance from the ‘Faculty of pain medicine Dose equivalence of conversion from oral morphine to transdermal patch medication updated in line with the BNF, SPC and Faculty of Pain Medicine. Naloxone dosing changed in line with Patient Safety alert on naloxone. 4.0 January 2020 Lucy Oakley Updated. Includes advice on tapering opioids, accidental exposure to patches, referral to Cambridgeshire and Peterborough netformulary. [ Scope Medical / nursing staff who prescribe, administer or care for adults on opioid medication for acute or persistent pain. This does not include palliative care. Purpose of document To provide a guide containing key points for safe prescribing and monitoring for adults who are prescribed opioid medication for acute or persistent pain. To provide information on opioid medication to support the NPSA rapid response report ‘Reducing Dosing Errors with opioid medicines’. To provide a resource for medical / nursing staff caring for people on opioids for acute or persistent pain. Monitoring Incidents will be monitored via the Datix reporting system Review Review March 2018 or earlier is there is new national guidance, changes in treatment or legislation. References 1. BNF online; https://bnf.nice.org.uk/ 2. NPSA Rapid Response Report Reducing Dosing Errors with Opioid Medicines July 2008 https://webarchive.nationalarchives.gov.uk/20081008133250/http://www.npsa.nhs.uk/nrls/alerts-and- directives/rapidrr/reducing-dosing-errors-with-opioid-medicines/ 3. National Patient Safety Agency. Ensuring safer practice with high dose ampoules of diamorphine and morphine. Issued- 25th May 06. Available at: https://webarchive.nationalarchives.gov.uk/20100306052101/http://www.nrls.npsa.nhs.uk/resources/clinical- specialty/surgery/?entryid45=59803&cord=ASC 4. The electronic Medicines Compendium (eMC) http://www.medicines.org.uk/emc 5. The Faculty of pain medicine, Royal College of Anaesthetists; funded by Public Health England: ‘Opioids aware: a good practice resource to support opioid prescribing; a web-based resource available on the website since 30th December 2015; http://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware 6. Arthur Rank Hospice Charity Factsheets; http://www.arhc.org.uk/pro-information-resources.asp; 7. Patient Safety Alert – risk of distress and death from inappropriate doses of naloxone in patients on long-term opioid or opiate treatment; 20th November 2014; NHS England. https://www.england.nhs.uk/2015/10/psa-naloxone-2/ 8. What naloxone doses should be used in adults to urgently reverse the effects of opioids? December 2019 https://www.sps.nhs.uk/articles/what-naloxone-doses-should-be-used-in-adults-to-reverse-urgently-the-effects-of-opioids- or-opiates/ 9. Medicines optimisation in chronic pain; NICE guidance; January 2017, updated Sept 2019; https://www.nice.org.uk/advice/ktt21/chapter/Evidence-context 10. CPFT Pain guidelines 11. Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children; Drug Safety Update; 11 October 2018; https://www.gov.uk/drug-safety-update/transdermal-fentanyl- patches-life-threatening-and-fatal-opioid-toxicity-from-accidental-exposure-particularly-in-children Adult opioid prescribing guide for acute or persistent pain Review date: May 2023 Page 2 of 11 Contents Page 5. Decide What is the type of pain and is it appropriate to prescribe an opioid? Page 6. Route Which route is most appropriate? Page 6. Choice of opioid Which opioid is the most appropriate for the patient? Is the patient’s current opioid prescription appropriate? Page 7. Dose Which formulation? What frequency? PRN doses? Use the dose conversion tables to choose dose when switching between analgesics Page 9. Side Effects / monitoring What side effects are expected? How can we prevent and treat side effects? Page 10. Alarm Bells Opioid toxicity – what to look out for Page 10. Function of kidneys and liver Have the patient’s renal and hepatic function been considered when choosing the opioid and dose? Page 11. End of life Who to refer to Adult opioid prescribing guide for acute or persistent pain Review date: May 2023 Page 3 of 11 Adult Opioid Prescribing Guidelines for Acute or Persistent Pain (These guidelines are not for palliative or end of life care) Strong opioids in persistent non-malignant pain should really be avoided, except in a very small number of carefully selected patients. Before prescribing strong opioids, please consider the following points very carefully: ❖ Strong opioids are an extremely effective medication for use in ACUTE pain conditions and end of life care, but there is little evidence that they are helpful for long term pain. ❖ A small proportion of people may obtain effective and sustained pain relief with opioids in the longer term if the dose is kept low and especially if their use is intermittent, but it is difficult to identify these people at the start of treatment. Many long-term effects are dose related and it is recommended that maintenance doses are kept to the lowest effective dose. ❖ Persistent pain is very complex and difficult to treat, with most types of treatment helping less than a third of patients. The decision to prescribe strong opioids in persistent non-malignant pain should only be made after an appropriate risk-benefit analysis (including family and social factors) and with clearly defined treatment parameters as they are not very effective in this type of pain. ❖ Plan an opioid trial for persistent pain to establish whether the patient achieves reduction in pain. Short term response does not predict long term therapy, which may be limited by adverse effects or declining efficacy. ❖ Early escalation of the dose, lack of analgesic efficacy at low doses or the development of drug-seeking behaviour or adverse social behaviour should warrant consideration of drug discontinuation. ❖ The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit. ❖ Opioids should be discontinued if the person is still in pain despite using opioids, even if no other treatment is available. It is usually expected that a reduction in pain of at least 30%, or significant improvement in quality of life / ability to carry out activities of daily living should be demonstrable to justify longer term prescribing. ❖ Avoid the use of breakthrough doses in persistent pain patients, as regular use of short-term opioids may increase the risk of dependency. These may be prescribed for emergency treatment of flare-ups, or to aid rehabilitation/therapy sessions, but their use is discouraged otherwise. ❖ The risk of inadvertent abuse or overdose of the medicine by relatives This guidance is primarily for use by medical and nursing staff who prescribe, administer or care for adults on opioid medicines in inpatient settings, but can also be used as a resource for staff caring for people on opioid medicines in all settings. This guidance is not intended for use in palliative care – please refer to the end of life care pathway. Adult opioid prescribing guide for acute or persistent pain Review date: May 2023 Page 4 of 11 Decide 1. History taking A full history and examination should be performed to include a detailed assessment of pain, physical health including operations and illness, mental health, together with a full medicine history. (See CPFT pain guidelines) 2. Medicine History As part of the medicine history for all patients find out and document: • Whether the patient has been taking any medicine(s) for pain • Name of the medicine(s) • Formulation (e.g. liquid or solid-dose, immediate release or modified release) • Dose and frequency • When the last dose was taken • How long the patient has been prescribed the medicine(s), and what is the response to it • Dates of any recent increases or decreases in dose, and reasons for changes • Allergy history/sensitivities • Current or past history of addiction to drugs or alcohol (in patient or close family), depression or anxiety. These patients are more likely to develop problems with opioid use. Addiction is a risk particularly in long term use. https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware/clinical-use-of-opioids/dependence-and-addiction • History of problems with sex drive or infertility (see side effects section) Sources of information for a medicine history can include: - The patient or carer