Strong opioid medicines are recommended at Step Three of the World Health Organisation pain ladder, and are typically reserved for the treatment of severe acute pain or moderate to severe chronic pain, depending on a patient’s response to other analgesics. There are few situations when a strong opioid would be initiated for acute pain in primary care. More common scenarios for General Practitioners are renewing a prescription of a strong opioid medicine for patients discharged from hospital, renewing prescriptions of strong opioids for patients with chronic pain managed in primary care or initiating or renewing prescriptions of weaker opioids such as tramadol or codeine.
Opioid medicines are potentially addictive. Dispensing data from New Zealand show that for each year, over the last five years, approximately one-fifth of the population received an opioid medicine.1 The focus of discussion regarding addiction to opioid medicines is often on strong opioids such as oxycodone, however, the same prescribing cautions should be applied to weaker opioids, such as tramadol, to minimise the risk of inappropriate use. Dispensing data from New Zealand show that tramadol use increased by 13% from 2013 to 2015.
Patients using opioid medicines should be encouraged to adopt and continue with non-pharmacological approaches to managing pain, such as exercise, physiotherapy and relaxation. Clinicians can consider the use of multimodal analgesia, such as using paracetamol in combination with an opioid medicine, in order to reduce the dose of opioid medicines required and therefore reduce a patient’s risk of adverse effects, as well as provide analgesia when the opioid medicine is withdrawn.
Clinical guidelines recommend that patients should be reviewed within one to four weeks of initiating an opioid medicine or increasing dose, as patients can become dependent as early as one month after initiating opioid medicines.2,3 For patients using these medicines long-term, review on a three-monthly basis is recommended, or more often if required.3 Reviewing patients using opioid medicines long-term can ensure that the medicines and doses they are prescribed are still appropriate for their underlying condition and degree of pain they experience, as well as allowing the opportunity to assess for the development of potential adverse effects.
Withdrawing patients who have become dependent on opioid medicines can be a difficult process, particularly if this is being managed in primary care without the patient having access to additional support from addiction services or a pain clinic in secondary care. The focus of this audit is on identifying patients who are using opioids long-term and ensuring they are reviewed. Withdrawing patients from opioid medicines is not included in the audit process.
For further information on withdrawing patients who are dependent on opioid medicines, see: www.bpac.org.nz/BPJ/2014/October/opioid-addiction.aspx
This audit identifies patients who have been prescribed an opioid medicine for three months or more in order to assess whether the choice of medicine(s) and doses remain appropriate.4
Recommended audit standards
Ideally, all patients who have been taking an opioid medicine for the management of non-cancer pain for three months or more should have a documented discussion in their notes about the intended duration of opioid medicine use and a plan for withdrawal. This could also include whether the addition of another analgesic medicine is appropriate in order to reduce the dose of opioid medicine(s) required or whether switching to another analgesic medicine is appropriate. If there is no documented evidence of a discussion, the patient should be flagged for review.
Identifying eligible patients
You will need to have a system in place that allows you to identify patients using opioid medicines for a period of three months or more. Many practices will be able to do this by running a “query” through their PMS. The notes of identified patients will need to be reviewed in order to ascertain the clinical indication for the prescription of opioids; patients using opioid medicines for the management of pain associated with cancer or another palliative care condition can be excluded from the audit.
A sample size of 30 patients is sufficient for the purpose of the audit. However, it is recommended that all eligible patients using opioid medicines long-term for the management of non-cancer pain are subsequently reviewed.
Criteria for a positive result
A positive result is if a patient who has been prescribed an opioid medicine for three months or more has a documented discussion in their notes regarding their pain management plan. This discussion could include the expected duration of use of opioid medicines, the use of other analgesics which could be used in combination with opioids to help patients manage their pain, non-pharmacological strategies for pain management and whether withdrawing from an opioid medicine is appropriate or has been attempted.
During the review, clinicians can consider factors such as:
- Has the patient’s underlying condition changed, e.g. is a greater or lesser extent of pain relief required?
- Are the prescribed opioid medicine(s) still the most appropriate choice?
- Should doses be adjusted or other non-opioid analgesics initiated?
- Should the patient be referred for additional support for non-pharmacological pain management, e.g. to a physiotherapist? Does the patient require assistance from addiction services?
- Pharmaceutical Claims Collection, Ministry of Health, 2018.
- Manchikanti L, Kaye AM, Knezevic NN, et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician 2017;20:S3–92
- Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain - United States, 2016. JAMA 2016;315:1624–45. doi:10.1001/jama.2016.1464
- If this audit is used to identify patients taking other analgesic medicines long-term, such as gabapentin, clinicians can choose a timeframe appropriate for the medicine in question
The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual
performance and then to decide how to change practice.
Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.
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 to promote change
- 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
- 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
Monitoring change and progress
It is important to review the action plan developed previously at regular intervals. It may be helpful
to review 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 the doctor completes the first part of the
of Medical Practice 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 that practices
complete the remainder of the Audit of Medical
Practice summary sheet.
Claiming credits for Continuing Professional Development (CPD)
This audit has been endorsed by the RNZCGP for CPD purposes for General Practitioners and can be claimed towards the Patient Outcomes (Measuring and Improving Outcomes) learning category of the Te Whanake CPD programme, on a credit per learning hour basis. General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
The RNZCGP encourages that evidence of participation in the audit be attached to your recorded activity. Evidence can include:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).