Reducing strong opiate prescribing

Introduction

The GPs at our practice attended a local GP education event and heard a presentation from the local consultant in substance misuse. She presented compelling and disturbing data about the rise in prescribing of opiate medication and the challenge facing her service of helping people to come off these addictive prescription painkillers. We had been aware of a general rise in prescribing within our own practice, and had also recognised we were sometime reaching for the prescription pad when a multi-modality approach to chronic pain management may be more appropriate. We made a plan to see if we could reduce our prescribing.

Aims

It was hard to set a clear aim, as we couldn’t predict what would be an appropriate level of prescribing for our patients; but we hoped to reverse the upwards trend in prescribing. We chose our aim as a reduction in the number of prescriptions for strong opiate medication (drugs of the equivalent strength of codeine 30mg or above) issued per month.

Actions

We had 2 ideas for testing. The first was to write to all patients who receive a repeat prescription for these medications, excluding those coded as ‘palliative’ or ‘end of life’ care. One of the GPs designed the letter and shared the draft with the practice team, as well as 2 patients who were on a repeat prescription to test out the wording. The letter would explain the long-term problems that can be caused by the medication and the possible benefits to reducing or stopping the drugs, as well as the issue of withdrawal symptoms.

The second idea (actually implemented at the same time) was to reduce the quantity of medication issued the first time a prescription for a strong opiate for pain was prescribed to 50 tablets with an attached leaflet explaining both the value of the drug for acute pain, and also the addictive potential and the issue of withdrawal symptoms following prolonged use. Again this leaflet was shared with the practice team and some patients for comment in order to ‘fine tune’ the wording.

We created a run chart showing the number of prescriptions of strong opiates issued per month as our measure. It was easy to gather retrospective data for the 10 months prior to the project so that we would have a baseline for comparison.

Results

We were delighted to see positive results. Having discussed them at our practice meeting it was felt the initial letter to patients with a repeat prescription made the most difference, as most of us were forgetting the decision we hade made about small quantities and attaching the leaflet to the first prescription. Following on from this initial work we are going to re-implement the second plan to see if it generates a further reduction. We also need to decide whether to try making the ‘would you like to reduce your opiates?’ letter an annual event. We had decided to use ‘patient grumbles’ about the project as our balance measure (which checks for negative impact of a project) and were surprised to find there were none, possibly because of patient involvement in the design of the letter.

We continue to run the search for the number of strong opiates issued per month and plot it on the run chart. This will allow us to track if our change has been sustained. The chart is displayed on our practice ‘Performance board’ (a visual display in our meeting room, where we all eat lunch) which helps to keep the issue in everyone’s mind. We try to spread the ideas by sharing our project with medical students and visitors to the practice.

Impact of intervention

Practice team roles involved/affected: