Pain and pain prescribing in Gloucestershire: the Living Well with Pain Programme

Opioid prescribing for pain is the subject of international controversy. The marked increase in prescribing in North America over the past two decades has led to a parallel rise in prescription opioid related mortality and dependence related morbidity. By contrast, poor access to essential medicines for the relief of cancer related pain is a public health concern in many parts of the developing world. In the UK, prescribing data for opioids and other medicines for pain show a marked upward trend but this has not been matched by a proportionate increase in prescription rated mortality. Most recent UK data suggest that the rise in prescribing may be levelling off but opioid medicines are prescribed predominantly for chronic pain, a condition for which there is little evidence of efficacy and definite evidence of harm. The risk of opioid related harms is dose related and there is evidence for increase in adverse effects at doses greater than 120mg morphine equivalent daily with no evidence of increasing benefit at higher doses. Prescribing statistics suggest that the numbers of people remaining on high dose opioids is relatively static.

Guidelines for appropriate prescribing have been promoted in developed countries since the late 1990s but have had little impact on opioid prescribing trends. UK guidance was published in 2004 and revised in 2010 but has now been replaced with Opioids Aware, an online resource which contains all information about pain and about opioids to support responsible and safe prescribing.

Clinicians describe management of chronic/persistent pain as challenging and also report that despite knowledge that opioid prescribing may be unwise or even unsafe, the challenges posed in clinical encounters around pain can result in inappropriate prescribing.

The Gloucestershire Living Well with Pain Programme addresses challenges in managing pain generally and prescribing specifically. We use both ‘upstream’ and ‘downstream’ approaches. Upstream interventions promote a shared understanding of the complexity of persistent pain including emotional antecedents and sequelae and importance of empathy and seeing pain in the context of the patients’ lives. Being up to date with the evidence for use of medicines for pain helps set appropriate expectations for clinicians and patients. Downstream initiatives focus on support and management for patients who remain on high dose opioids, often in combination with other psychoactive drugs, many of whom have failed to make progress with specialist support.

We have addressed understanding of pain and pain prescribing in many ways including development of a joint formulary and promotion of the key concept of “first do no harm:” prescribing medicines that do not relieve pain and that cause adverse effects is worse than not prescribing at all. We have offered multidisciplinary assessment for complex patients and followed these patients up with their GP. We have run training sessions for primary care staff in the community and masterclasses for healthcare professionals, exploring conversations in pain management and using themes from transactional analysis to recognise prescribers’ own behaviours and feelings in consultations that often lead to poor prescribing decisions.

In 2018/19 we have implemented a risk mitigation programme to ensure that all patients taking high dose opioids and those taking multiple opioids or opioids in combination with other medicines, particularly gabapentinoids, antidepressants and benzodiazepines are identified and reviewed in primary care to optimise their prescriptions and reduce exposure to harm.

The cost and volume of opioid prescribing has reduced since launch of the Living Well with Pain Programme alongside other clinical programmes that focus on deprescribing.

A timeline of educational interventions which have been run in Gloucestershire around pain and pain prescribing can be found here.