Indication: Pain
RAG rating: n/a
Document type: Position statement
Place: Hertfordshire and West Essex ICB
Output type: Pharmacy / Prescribing
Referral form: ENH-pain-referral.pptx SWH-pain-referral.pptx WE-pain-referral.pptx

Opioid Prescribing Position Statement

Herts and West Essex ICS Position Statement on Opioid Prescribing

Opioids are very good analgesics for acute pain and pain at the end of life but there is little evidence that they are helpful for long-term pain. Long-term use in non-cancer pain (longer than 3 months) carries an increased risk of dependence and addiction.

A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation). Patient expectations must be managed when starting opioid analgesia and a duration of treatment and review date should be agreed at the outset.

Herts and West Essex ICS DO NOT support the long-term prescribing (greater than 3 months) of opioids or the use of high dose opioids (>120mg daily oral morphine equivalent) for non-cancer, chronic pain in adults

The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit.

Rates of high dose opioid prescribing as a percentage of all opioids are high in Herts and West Essex and are well above national average

The Faculty of Pain Medicine (Royal College of Anaesthetists), in partnership with Public Health England advises that if a patient has pain that remains severe despite opioid treatment, it is not working and should be stopped, even if no other treatment is available.

Tapering or stoppinghigh dose opioids requires careful planning and collaboration with the patient and all members of their healthcare team. Tapering from a high dose may take weeks or months.

Prescribers should be mindful of the risk of diversion of opioids and other dependence forming medication and should consider the safeguarding implications of prescribing.

NICE guideline [NG215] (Medicines associated with dependence or withdrawal symptoms ) includes information on how to withdraw dependence forming medicines including benzodiazepines, Z‑drugs (such as zopiclone and zolpidem), opioids, gabapentin and pregabalin, and a reminder to ensure prescribing is within its licensed indications.

Urgent and Emergency care and Out-Of-Hours

Every attempt must be made to check the shared clinical record for appropriateness of prescription before prescribing.

The amount issued will be communicated to the GP who can then review ongoing pain management needs if appropriate.

Patients can use various self-management techniques to help with their pain.

Referral options within Herts and West Essex – see download forms attached

• Driving and Pain information leaflet, Faculty of Pain Medicine

• Taking Opioids for Pain leaflet, Faculty of Pain Medicine

• Ten Footsteps programme - Live Well with Pain

• Medicines and their risk of addiction leaflet, MHRA

• Flippin’ Pain on-line resources

• The Pain Toolkit – online resource with guidance on managing pain. NB some content requires payment

Further information and useful resources to support opioid withdrawal:

· Managed Opioid Reduction Tool step wise approach Herts and West Essex

· Dependence forming medicine Q&A HWE ICB

Discussing opioid reduction and signposting (Non-GP practice settings) – Making Every Contact Count

1. IDENTIFY: Is patient on high dose prescription opioids (≥ 120mg oral morphine equivalent over 24 hours) for longer than 3months? (Exclude palliative care, cancer)

2. NOTE: Note high dose unlikely to be beneficial and may cause harm

3. INFORM: Inform patient of risks and adverse effects with long term opioids

4. DISCUSS: Discuss with patient around willingness for gradual dose reduction

5. SIGNPOST: If willing, ask them to contact their GP Practice for reduction support &

Signpost to useful info: flippinpain.co.uk, livewellwithpain.co.uk

6. COMMUNICATE: Let GP Practice know the patient is open to reducing their opioid doses over time

Who is this pathway for: health care professionals working in non-GP practice settings. For example, secondary care, A&E, community pharmacy, community services.

If the service outside of GP practice has the resource/expertise to reduce opioids with patients over time, then they should instead follow the Herts and West Essex ICB Managed Opioid Reduction Tool step wise approach document.

https://hertsandwestessex.icb.nhs.uk/downloads/download/21/central-nervous-system

Version number: 1.0
Developed by: Stacey Golding, Lead Pharmacist, HWE ICB; Daniel Carlton Conway, GP Prescribing Lead
Approved by: Medicines Optimisation Delivery and Implementation Group
Date approved / updated: July 2023
Review date: This HWE APC document is based upon the evidence available at the time of publication. This document will be reviewed upon request in light of new evidence becoming available
Superseded version: n/a

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