Opioid and gabapentinoid abuse is a rising problem in the UK, reaching similar numbers to the opioid epidemic in the United States.
Ten percent of patients with acute post-operative pain will develop chronic pain in the months following surgery. Chronic pain and insufficient pain management have been recognised as contributing factors to the growing opioid epidemic.
The MHRA has produced prescribing alerts for co-prescribing opioids and gabapentinoids due to an increased risk of respiratory depression and neurological effects, including at-risk patient groups and considerations of dose reductions when prescribed more than one CNS depressant.
The continued prescribing of opioids and gabapentinoids in primary care for post-operative pain has been recognised as an area of concern for public health as it may contribute to opioid abuse and related harm in the UK. A review of opioid prescribing in primary care has shown that prescribers are issuing prescriptions for stronger opioid drugs to patients, more frequently. This is at its highest in more deprived regions, such as The North of England and East Midlands.
Despite a clear instruction from secondary care not to continue analgesia in primary care after the course was finished, 20 percent of patients were still requesting strong opioids or gabapentinoids from their GP
In secondary care opioids may be started as part of enhanced recovery programmes aimed at speeding recovery and discharge but a consequence of this is that patients may be discharged before analgesia can be reviewed, increasing the risk of patients not being stepped down to weak opioids such as codeine, or discontinued altogether before discharge. The persistent use in primary care may be linked to an increase in prescribing following initiation in hospital and a continuation in primary care, either due to patient requests or under instruction of the hospital discharge, although this is an area which may require further research.
In this article we share the results of an audit of the number of people discharged on strong opioids or gabapentinoids following surgery at Aintree University Hospital, and whether they continued in primary care.
Objectives
- To calculate the number of patients discharged on strong opioids or gabapentinoids from surgical wards
- To determine the number of patients who continue on strong opioids or gabapentinoids in primary care after discharge
- To investigate whether these patients request strong opioids or gabapentinoids six- and 12-weeks post-discharge
- To investigate whether prescribers leave discharge notes advising GP’s regarding opioid and gabapentinoid continuation
- To determine whether patients who request opioids and gabapentinoids after six weeks have any predisposing risk factors for addiction.
Methods
Discharge prescriptions dispensed in August 2022 from surgical wards at Aintree University Hospital were analysed. Data were collected from the electronic prescribing system to determine how opioids and gabapentinoids were prescribed on discharge; for example, which drug was prescribed, how many days supply was given, if GP to continue was selected, and the prescriber.
Patients admitted on a strong opioid or gabapentinoid were excluded, as well as patients who were not post-operative. From the remaining data set, primary care records were used to determine whether the patient was still requesting the medication from their GP, six and 12 weeks after discharge.
Results
Seven hundred and twenty-three patients were screened for suitability. From the remaining data set, 243 patients were prescribed a new strong opioid or gabapentinoid, or a combination of the two, on admission for post-operative pain. Of these 243 patients, 75 opioid discharge prescriptions and 10 gabapentinoid prescriptions were written, for a total of 64 patients. The data below displays the key findings from reviewing discharge prescriptions of newly started opioids and gabapentinoids.
| Opioid | Gabapentinoid | |
| Number of prescriptions written | 75 | 10 |
| Number of prescriptions written by a doctor (as GP to continue) | 39 (5) | 3 (3) |
| Number of prescriptions written by a prescribing pharmacist (as GP to continue) | 36 (2) | 7 (1) |
| Number of prescriptions requested after 6 weeks (originally prescribed as GP to continue) | 11(4) | 6 (3) |
| Number of prescriptions requested after 12 weeks (originally prescribed as GP to continue) | 9 (4) | 4 (1) |
The number of prescriptions relates to the drug prescribed, not the number of patients, as some patients were prescribed multiple formulations or a combination of opioids and gabapentinoids. The only newly started gabapentinoid prescribed on discharge was pregabalin and the most common opioid prescribed was morphine oral solution, with 26 prescriptions written. Forty percent of gabapentinoid prescriptions were prescribed inappropriately as GP to continue compared to 9.3 percent of opioid prescriptions.
In total, seven opioid prescriptions were written as GP to continue, 71 percent of these were selected by doctors and 29 percent by prescribing pharmacists. Only four gabapentinoid prescriptions were written as GP to continue: 75 percent by doctors and 25 percent by prescribing pharmacists, showing a similar trend in prescribing to opioids. The average duration of prescribed treatment was seven days, with 70 percent of prescriptions prescribed as seven days or less, meeting the Faculty of Pain Medicine Surgery and Opioids Best Practice Guidelines 2021.
In total 17 drugs were continued in GP after six weeks, for 12 patients. Four patients had suffered a major traumatic event, such as a road traffic collision (RTC), and eight of which had been diagnosed with or a received a diagnosis of cancer. Surgeries for this group of patients were broad, ranging from tumour resection to Radiologically Inserted Gastrostomy (RIG).
Risk factors for addiction include co-morbidities such as depression and anxiety, simultaneous use of benzodiazepines or antidepressants, and gender. For the 17 patients who requested prescriptions from their GP after six weeks the following risk factors were investigated.
| Risk Factor (number of patients) | ||
| Gender | Male | Female |
| 8 | 4 | |
| Documented medical history of depression | 5 | |
| Documented medical history of anxiety | 2 | |
| Current benzodiazepine use | 1 | |
| Current antidepressant use | 5 | |
Only two patients out of 17 who were still requesting prescriptions after six weeks had zero risk factors for potential abuse or addiction. However, one had suffered a major trauma and the other had received a cancer diagnosis, which may lead to future mental health problems, adding to the risk. One patient had a past medical history of alcohol and drug abuse but was still prescribed gabapentinoids on discharge.
For the 64 patients, we also investigated whether a discharge letter was written to the GP regarding the use and continuation of analgesia in primary care. Thirty-one (48 percent) had a discharge letter written to the GP to state that the analgesia provided was a short-term prescription, not to be continued in primary care. From these 31, only 12 drugs were continued after six weeks, for six patients, despite clear instructions from the pharmacist not to continue long term. From these 12 drugs, two were prescribed as GP to continue by the doctor, with a contradicting note from the pharmacist to not continue long term.
Discussion
The results show effective deprescribing of opioids and gabapentinoids in secondary care post-operatively, as 65 percent of inpatient prescriptions were not continued on discharge. This may be due to the high number of prescribing pharmacists working on surgical wards, as this audit highlights the disparity of safe opioid and gabapentinoid prescribing on discharge between doctors and prescribing pharmacists. Doctors prescribed more items as GP to continue, despite over half the prescriptions written by pharmacists. However, it is important to note that not all requests made by patients were discharged with a strong opioid or gabapentinoid prescribed as GP to continue. This may be due a lack of effective communication between primary and secondary care on discharge or patient pressure to prescribe in primary care.
This audit demonstrates that 20 percent of patients are still requesting strong opioids and gabapentinoids six weeks post-discharge. Primary and secondary care should be collaborating to ensure patients receive accessible and correct information before starting an opioid and that a step-down plan has been agreed. All areas should recognise that opioids are of limited use for chronic pain and in non-cancer pain; therefore, they should be considered as a course of treatment with a pre-determined end date.
Opioids and gabapentinoids were more likely to continue after a major traumatic event, such as a RTC or life changing diagnosis. Highlighting wards within Aintree Hospital that may benefit from reviews post-discharge to manage pain relief and psychological symptoms which may lead to an increased risk of addiction. However, opioids are recommended in the treatment of cancer pain and therefore may not need to be reviewed as regularly.
The results show that of the 17 patients still requesting opioids and gabapentinoids after six weeks, 88 percent had at least one risk factor prior to admission. These risk factors could be identified on admission and the analgesia and discharge planning could be reviewed more closely for these patients as a result.
NHS England has produced an action plan to reduce inappropriate prescribing and over-use of possibly addictive medicines, including but not limited to opioids and gabapentinoids. The framework is directed at Integrated Care Boards (ICB) and health and social care practitioners working in settings where the most potentially addictive drugs may be prescribed. The actions laid out are to help support and optimise care and support for patients at risk of dependence or withdrawal, as well as optimising prescribing and clinical decision making to reduce unnecessary prescribing.
Despite a clear instruction from secondary care not to continue analgesia in primary care after the course was finished, 20 percent of patients were still requesting strong opioids or gabapentinoids from their GP. This could be due to ineffective communication, such as GPs not reading the discharge letter in full, transcription errors, or patient pressures to prescribe. Structured Medication Reviews and medicines optimisation were introduced in the 2020/21 Network Contract Direct Enhanced Service for primary care networks and this included identifying and reviewing patients taking 120mg oral morphine equivalent or more for chronic pain.
The Opioids Aware project, in conjunction with NHS Cheshire and Merseyside ICB, reports that the number of patients prescribed high dose opioids (> 120mg Morphine or equivalent) within this area is above the national average. However, the number of high dose opioids prescribed as a percentage of regular opioids have reduced to meet the national median.
Looking locally, the total number of opioid prescribing in NHS Liverpool as oral morphine equivalence of 120mg daily per 1000 patients is above the nation median. For the last financial quarter up until October 2022 NHS Liverpool spent over £600,000.00 on opioids.
Additionally, NHS Discharge Medicines Service and NHS New Medicines Service were introduced in community pharmacies, where NHS Trusts can refer patients newly started on opioids for review and follow-up to minimise risk of inappropriate long-term use and addiction.
The new NHS England change model should be used to optimise patient care to achieve transformational change relating to opioid prescribing. Looking to the future, we recommend using the services already created by the NHS and also to put forward recommendations to local ICBs for potential implementation of post-operative clinics within secondary care to reduce prescribing pressures in primary care. These post-operative clinics can be run by prescribing pharmacists in secondary care, ensuring opioids and gabapentinoids are not continued and patients are reviewed regularly.
Virtual wards could also be implemented for review between pharmacists in hospital and GP practice. These clinics could be funded by the ICB and would allow patients to be reviewed by specialist teams, including prescribing pharmacists, to ensure opioids and gabapentinoids are not continued long term and step-down analgesia is prescribed and weaned appropriately.
Limitations
This audit focused on discharge prescriptions for the month of August within Aintree University Hospital. Therefore, the population size was small, limiting the population data and external validity. This audit does not highlight the number of patients discharged on opioids or gabapentinoids for post-operative analgesia across the Northwest or England as a whole. However, this method is something that can be repeated across sites within Liverpool University Hospital Foundation Trust (LUFHT), including our rehabilitation wards as well as other NHS trusts.
Further investigations should be completed within local Primary Care Networks (PCNs) to determine why so many opioids and gabapentinoids are continued on repeat prescriptions, as this study only focused on discharge prescription writing in secondary care. Audits of the number of DMS and NMS completed for opioid and gabapentinoid prescriptions in community pharmacies could enable a complete picture and identify areas for improvement across the ICB.
Conclusions
Opioid and gabapentinoid prescribing is becoming an increasing area of concern in the North West of England, especially Merseyside and Cheshire. Patients were requesting strong opioids or gabapentinoids from their GP even if there was specific documentation for analgesia not to be continued or to be reviewed after discharge. Numerous services are already in place to reduce inappropriate long-term prescribing of potentially addictive drugs; however, patients are still collecting repeat prescriptions.
This audit highlights areas of improvement within LUHFT as well as the Cheshire and Merseyside ICB. Post-operative clinics within secondary care, allowing patients to be reviewed and stepped down appropriately, would reduce the number of opioid and gabapentinoid prescriptions within primary care and therefore relieve pressures. In addition, education around opioid and gabapentinoid addiction and proper prescribing on discharge should be implemented in line with The Faculty of Pain Medicine Surgery and Opioids Best Practice Guidelines 2021 to reduce risks and development of chronic pain.
The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
