Oxycodone for non-cancer pain

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Background

Oxycodone is a strong opioid that milligram for milligram is approximately twice as potent as morphine. It is indicated for the treatment of moderate to severe pain, when morphine is not tolerated, and all other options have been considered. Although the majority of people dispensed oxycodone in New Zealand are initiated on this medicine outside of general practice, i.e. by a doctor in secondary care, general practitioners currently initiate almost one-third of prescriptions and continue oxycodone in 17% of people initiated in secondary care. Clinicians are urged to assess whether the initiation or continuation of oxycodone is appropriate for each specific clinical situation, before writing a prescription.

Morphine is the preferred first-line option for the treatment of acute and chronic moderate to severe pain, when a strong opioid is indicated. When compared to morphine, oxycodone:

  • Has no better analgesic efficacy
  • Has a similar adverse effect profile
  • May have more addictive potential
  • Is significantly more expensive

Fentanyl or methadone are safer options in patients with renal impairment, who require a strong opioid, because they have no clinically significant active metabolites (unlike morphine and, to a lesser extent, oxycodone). Discussion with a renal physician is recommended in patients with a creatinine clearance < 30 mL/min.

For further information, see “Update on oxycodone: what can primary care do about the problem”, BPJ 44 (May, 2012).

Recommendations

Oxycodone should only be prescribed for the treatment of moderate to severe pain in patients who are intolerant to morphine and when a strong opioid is the best option. When considering initiation of oxycodone, always ask yourself if you would use morphine for this patient. If the answer is no then do not prescribe oxycodone. Oxycodone should not be prescribed when a weaker opioid, e.g. codeine, dihydrocodeine or tramadol, would be more appropriate.

Remember that: 5 mg oxycodone is approximately equivalent to 10 mg morphine, 50 – 100 mg tramadol, 100 mg dihydrocodeine or 100 mg codeine.

Plan

This audit aims to help you identify patients who have been dispensed oxycodone and then to consider whether or not this was the most appropriate analgesic medicine.

The recommended steps for completing the audit are:

  1. Identify all patients currently prescribed oxycodone
  2. Assess whether they meet the indications for oxycodone treatment (below)
  3. Where appropriate, switch the patient to another treatment or taper their dose

Indications

Although there are exceptions to every rule, in the majority of cases, oxycodone should only be prescribed if the patient:

  • Is intolerant or allergic to morphine and;
  • Has moderate to severe pain and;
  • There has been an adequate trial of other treatments which have failed to control the pain

In most cases, oxycodone should be a short-term treatment only and analgesia should be tapered as pain levels decrease. The dose of oxycodone can be stopped or slowly reduced and, where required, the patient can be switched to a weaker opioid and/or paracetamol.

N.B. Tapering or ceasing analgesia is unlikely to be appropriate for patients with cancer pain (or other palliative care conditions requiring ongoing pain relief), therefore this audit is restricted to patients using oxycodone for non-cancer /non-palliative care pain.

Criteria for a positive result

Any patient currently being treated with oxycodone should have the following recorded in their notes:

  • The indication for treatment with a strong opioid (exclude those being treated for cancer pain)
  • The reason why morphine was not an appropriate treatment
  • The recommended plan for reducing the dose, ceasing treatment and/or switching to another analgesic as required

And if the patient does not meet the required indications

  • A note to recall the patient, to assess pain, and to taper the dose or switch to another analgesic

Audit standards

By the second data cycle of this audit, 90% of the patients who have been prescribed oxycodone in the previous 12 months will meet the required indications (i.e. moderate to severe pain requiring a strong opioid and intolerance or allergy to morphine).

Data

Eligible people

All patients who have received a prescription for oxycodone for non-cancer pain in the previous 12 months are eligible for this audit.

Identifying patients

You will need to have a system in place that allows you to identify eligible patients. Many practices will be able to identify patients by running a ‘query’ through their practice management software.

Once a patient has been identified, assess whether the indication for analgesia warrants treatment with a strong opioid and if there is a record of an intolerance or allergy to morphine. Check whether there has been a recent assessment of the severity of the patient’s pain and a plan for tapering analgesia. Also consider whether the patient has had an adequate trial of other treatments.

Sample size

The number of eligible patients will vary according to your practice demographic. If you identify a large number of patients, take a random sample of 30 patients whose notes you will audit.

Data analysis

Use the data sheet to record your data and calculate percentages.

Identifying opportunities for CQI

Taking action

The first step in taking action is to identify the criteria where gaps exist between expected and actual performance and decide on priorities for change.

Once priority areas for change have been decided on, an action plan should be developed to implement any changes.

The plan should assign responsibility for various tasks to specific members of the practice team and should include a timeline.

It is important to include the whole practice team in the decision-making and planning process.

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

Problem solving process

  • What is the problem or underlying problem(s).
  • Change it to an aim.
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers

  • Identifying barriers can provide a basis for change.
  • What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting.
  • Identify the barriers.
  • Develop a priority list.
  • Choose one or two achievable goals.

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change.
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behavior.
  • How can you overcome them?

Review

Monitoring change and progress

It is important to review the action plan against the timeline at regular intervals with the practice team. It may be helpful to discuss the following questions:

  • Is the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that practices complete the first part of the CQI activity summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended practices complete the remainder of the CQI activity summary sheet.

Claiming MOPS credits

This audit has been endorsed by the RNZCGP as an Audit of Medical Practice activity (previously known as Continuous Quality Improvement - CQI) for allocation of MOPS credits; 10 credits for a first cycle and 10 credits for a second cycle. General practitioners taking part in this audit can claim credits in accordance with the current MOPS programme.

To claim points go to the RNZCGP website: www.rnzcgp.org.nz

Record your completion of the audit on the MOPS Online credit summary, under the Audit of Medical Practice section. From the drop down menu, select the audit from the list or select “Approved practice/PHO audit” and record the audit name in “Notes”, the audit date and 10 credits.

General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.

As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).