This CPA will require review and updating as further evidence emerges to support new practices as more pharmacological treatments are trialled in this area.
Clinical Practice Algorithm: Managing opioid dependence in GP practice setting – flowchart
Clinical Practice Algorithm: Managing opioid dependence in GP practice setting- flowchart continued
[A,B,C, D] Patient group discussion
This Clinical Practice Algorithm is designed to support people who are dependent on opioid medication and to support their management in GP practice setting.
[A] Population included in this Clinical Practice Algorithm is registered with the GP Practice and can be recommended for consideration of opioid reduction by GP, pain clinic, prescription team, self-referral, search performed on practice clinical system. If the search is performed it is worth to quickly share a list of patients with assigned GPs so they can highlight any potential potentially important information about patients in question.
[B] Opioid dependence is defined as a state in which the drug is required to prevent physiological withdrawal. Physical dependence can develop with many other drug classes which do not cause addiction, following long-term use e.g. corticosteroids, beta-blockers. For the purpose of this CPA, we will look at opioid dependence syndrome as defined in the diagnosis section [J].
[C] Inclusion criteria:
Patients on long-term (over ninety days opioid use episode) opioid treatment for chronic pain, as reported by a search performed using practice clinical system and confirmed with the patient or referred by another service provider e.g. Pain Clinic, who developed physical dependence which could be measured and confirmed with COWS and SOWS, where:
* no need for pain relief is required or opioids are contraindicated as a class of medication e.g. resolved cancer, successful hip operation, use in Fibromyalgia (except Tramadol), headaches.
* Patients on high doses of opioids (above 120mg Morphine Equivalent Daily), as it is proven that risks outweigh benefits.
* pain persists regardless of optimal treatment, there is little evidence that opioids are helpful in long-term pain.
* unacceptable side effects are present.
[D] Exclusion criteria – this CPA does not extend to the following patient groups due to being outside my competencies:
1. Patients under age of 18 would be referred to GP or to the specialist clinic (if not already under specialist care)
2. Palliative care, active cancer patients would be excluded from this algorithm as most studies in this area excluded those population groups.
3. Patients who are not able to attend face to face consultation in surgery. Patients often communicate their concerns in indirect way and seeing them face to face would allow NMP to facilitate attendees to express their anxieties more openly. This happens not by direct questioning, but by allowing verbal and nonverbal communication to affect the patient.
3. Patients with safeguarding concerns, Alcohol dependent, Illicit drug users and patients with suicidal ideation/attempts would be outside of my competence zone and would need GP or specialist input.
4. A patient whose chronic pain is controlled in an appropriate way with intermittent supply of opioids, as well as patients under the care of Pain Clinic.
5. Patient pregnant or breastfeeding – lack of experience in this patient group.
6. Patients that are part of the Violent Patient Scheme (seen by GPs only)
7. Patients with severe renal and liver impairment (eGFR <30mls/min/1.73m2)
8. Patients not registered with the GP Practice.
9. Patients requiring schedule 1 controlled drugs.
(The British Pain Society, 2007)
(Von Korff, et al., 2008)
(Wesson D. R., 2003)
(Joint Formulary Committee, 2018)
(The Royal College of Anesthetics, 2018)
(Frank, et al., 2017)
(Bensing, et al., 2008)
[D] Review available blood results.
Some clinicians would not consider reviewing blood results essential at this stage, nevertheless recommend look into it, thus the full picture if being build. Also, there is a risk in renal failure that Morphine, Diamorphine and Oxycodone and their metabolites can accumulate and cause sedation, myoclonic jerks, hallucinations, and respiratory depression.
Consideration should be made for all patients who have a history of recreational drug use or those who report such use to have their urine or blood tested for commonly abused illicit substances.
All patients with current evidence of illicit drug use should be referred to the GP or to Drug and Alcohol Services.
On the other hand, if we suspect that the patient is not using prescribed opioid, evidence of absence in the blood would allow stopping prescribing the drug without additional time expenditure.
Patients who have met group criteria should have their blood results reviewed in an aim to avoid complications e.g. to exclude the possibility of withdrawal symptoms being confused with other condition. For example, anemia can cause fatigue, tachycardia and might be confused with withdrawal symptoms. A similar rationale applies to some viral infections – HIV and Hep B&C – which have a similar presentation to withdrawal symptoms: sweating, joint pain, appetite loss, nausea, vomiting. High LFTs with increased MCV might indicate alcohol use problem which would indicate further investigation and consideration of referral. Any abnormal results which have not been actioned should be discussed with a GP.
Any other relevant investigations regarding condition for which opioids were initially prescribed:
FBC, U&Es, CRP, Plasma Viscosity, TFTs, LFTs, Bone profile (Ca2+, Vit D3), Mg2+, HBA1C, CK,
(Joint Formulary Committee, 2018)
(Medicnes Optimisation Team Mid Essex CCG, 2017)
(NICE, 2015)
(The Royal College of Anesthetics, 2018)
(The Royal College of Anesthetics, 2018)
[E, F] History review without patient and the importance of yellow flags
[E] Preparation without a patient.
In an aim to support diagnosis, several factors and indicators have to be considered and a comprehensive history review performed. A necessary starting point is establishing an initial indication for opioid medication. It is also crucial to note duration the drug had been prescribed (months/years), the frequency of doses, morphine daily equivalent (MED) – especially if higher than 120mg, route of administration – oral, patches, injections, as well as recording other medication, especially with addictive potential being prescribed. Perform medication review.
Check increased risk indicators.
1. Is patient 120mg MED or over?
2. Records of physiological deterioration
3. Reliance on pharmacological treatment only.
4. Lost prescriptions/ dropped bottles/overordering
5. Continued use despite side effects
6. Possibility to pass medication?
7. Increasing pain with requests for increasing dose
8. Use clinical judgment
9. Significant comorbidities
10. [F] Identify yellow flags which might indicate an increased risk of poor outcomes. Attempt to support patients additional information and referral to other services if appropriate.
Social yellow flags
Low expectation to return to work, lack of confidence in performing work activities, heavier work, poor work relationships, medico-legal issues, social disfunction
Biomedical yellow flags
Severe pain or increased disability at presentation, multiple site pain, non-organic signs, iatrogenic factors
Psychological yellow flags
The belief that pain indicates harm, expectation that passive rather than active treatments are most helpful, fear avoidance behaviour, catastrophic thinking, high level of distress
(Medicnes Optimisation Team Mid Essex CCG, 2017)
(Scottish Intercollegiate Guidelines Network (SIGN), 2013)
[G] Structured face to face appointment.
Confirm all history as reviewed earlier.
The consultation is arranged either by letter or over the phone. The consultation should meet all criteria required by Prescriber competency framework issued by RPS and be structured e.g. Calgary Cambridge model.
• Introduction and explanation of role/qualification
• Confirmation of patient name, address, date of birth
• Ensure you have correct patient notes
• Confirm patient is aware of the problem that will be discussed
• Discuss details – opioid drug duration of use, dosing, frequency, withdrawal symptoms
• Take full medication history and review past symptoms / problems / illness/ surgery / referrals
• Confirm medication and concordance – prescription/ over the counter / herbal / recreational
• Family medical history
• Social History – available support, home circumstances, alcohol, and recreational drugs use, Tabaco consumption,
• Confirm non-pharmacological treatment involvement, physiotherapy, exercise/activity
• Confirm allergies/sensitivities; alcohol and smoking status; if the patient is pregnant or breastfeeding
• Consider red flags
• Confirm understanding with the patient
• Measure basal pain level ….
(Royal Pharmaceutical Society, 2016)
(Davies & Wilkinson, 2015)
[G] Structured face to face appointment.
Calgary Cambridge Model.
(Kurtz, et al., 2003)
[G] Structured face to face appointment.
The important steps at the stage of face to face consultation is Education. An NMP can provide effective education by:
1. Limiting instructions to 3 or 4 major points
2. Using simple everyday language
3. Providing written materials whenever possible
4. Involving family and friends
5. Reinforcing discussed matter
Explore positive and negative aspects of opioid use and their effect on day to day life. Explore patient experience of
tolerance development. Explain hyperalgesia phenomenon and discuss the possibility that pain is medication resistant and
may never fully resolve or might get worse if opioid medication is continued. If yellow flags are present, explore how they
are affected by opioid use. Explain the importance of reducing opioids (use online support as listed below).
Discuss side effects as patients best engage if they recognise opioid side effects that are personally relevant to
them: Nausea, daytime somnolence, poor concentration, memory loss, increased risk off falls, ventilatory
insufficiency, effects on hormones reduced testosterone, weakened the immune system, opioid-induced
hyperalgesia, addiction, increased mortality, the effect on driving if applicable.
Give examples of long-term benefits of stopping opioids: clear mind, better mood, motivated.
If chronic pain is still present discuss Non – Pharmacological active therapies (discussed below) and other available
resources:
A. Reconnect2life https://www.torbayandsouthdevon.nhs.uk/services/pain-service/
B. The Pain Toolkit available from www.paintoolkit.org
C. Useful websites and YouTube videos:
• Chronic pain www.youtube.com/watch?v=5KrUL8tOaQs
• “Brainman stops his opioids” https://www.youtube.com/watch?v=MI1myFQPdCE
• How mood affects pain https://www.tamethebeast.org/#home
Arrange follow up appointments – date, time, place – face to face or over the phone. Advise the patient to contact surgery if symptoms change at any time.
(Oxford Pain Management Centre, 2017)
(Atreja, et al., 2005)
(Oxford Pain Management Centre, 2017)
(Medicnes Optimisation Team Mid Essex CCG, 2017)
(Joint Formulary Committee, 2017)
[H] Differential diagnosis and red flags.
It is important to stipulate that diagnosis process consists of several steps in which NMP is involved, but the diagnosis is made by a GP or Consultant. It is essential that healthcare professionals involved in the care of the patient with pain understand the importance of differential diagnosis and action red flags appropriate
Red flags can be divided as relating to pain or relating to opioid use. All red flags require referral and further investigation.
[Hb] Red flags in relation to Opioid Dependence which would trigger additional tests or referral.
Aberrant behaviours: seeking drugs, selling prescribed medication, obtaining medication from no-medical sources,
injecting oral formulations, concurrent abuse of alcohol and illicit drugs, “prescription shopping”,
Psychiatric disorders: Depression and anxiety issues as measured by PHQ-9 and GAD-7 forms (Appendix 4), also self-
harm or risk of harm to others, suicidal ideation.
Safeguarding concerns e.g. possibility that somebody is stealing drugs
[Ha] Red flags connected to general health and possible condition:
Red flag Possible condition
An intense headache with a rapid onset meningitis, brain malignancies, haemorrhage
Bowel or bladder incontinence or retention, numbness in perianal/saddle area qauda equina
Inability to walk,
Fracture or tendon rapture
Excruciating pain in lower back
Disc protrusion or rapture, fracture
Chest pain
Myocardial infarction, unstable angina
Seizure Epilepsy, malignancy, infection
Loss of muscle control – especially one-sided, speech impairment, loss of consciousness
stroke
Fever, confusion, rapid breathing, tachycardia, non-blanching rash, no urine output in the past 18 hours
sepsis
[H] Differential diagnosis and red flags continued
[Ha] Red flags connected to general health and possible condition – continued.
Red flag Possible condition
Visual or neurological disturbance, blurred vision, loss of consciousness, confusion Stroke, malignancy, infection
Fever, weight loss, lymphadenopathy Malignancy, infection
Pain associated with a cancer diagnosis metastases
Abnormal blood or urine test
The differential diagnosis for Opioid dependence syndrome, symptoms, and recommended tests:
• Alcohol Dependence. Symptoms: Anxiety, drug-seeking behaviour, progressive neglect. Test – Severity of Alcohol Dependence questionnaire, Increased MCV, deranged LFTs
• Anaemia: Symptoms: fatigue, tachychardia. Test: FBC, Haematinics
• Menopause. Symptoms: hot flushes, mood disorders, musculoskeletal symptoms. Test: hormone levels
• Viral infections (flu, HIV, Hep B). Symptoms: muscle aches, fatigue, sweating. Test: blood tests, consider duration
• Hypo and Hyperthyroidism. Symptoms: Muscle aches, anxiety, fatigue, tremor in hands. Test: T3, T4, TSH
• Restless legs syndrome. Symptoms: paraesthesia and akathisia, refer
• Essential Tremor. Symptoms: tremor, refer
• Mood disorder. Symptoms: Bipolar, refer
• Insomnia. Symptoms: sleeping problems, refer
• ADHD, refer
(Cook, 2014)
[I] Confirmation with GP if required
As an NMP I will always look for assistance where I feel there is a ray of doubt or matter in question is outside of my competencies. Nor shall I issue a prescription in an inappropriate way, under influence of any other party or outside of the scope of competencies. Only this way patients safety can be served in an to the best
When following this CPA, an NMP is required me to work very closely with GPs involved in patient care. Above flowchart has stipulated main steps where seeking GP support is likely to be necessary, nevertheless, such need may arise at any episode of care.
An example of intervention where a patient would be referred to GP is a patient who has developed withdrawal symptoms of sufficient severity that would warrant pharmacological treatment. Such patient could be prescribed one of the below-listed items, provided all requirements for safe prescribing are met, as per BNF recommendations and items summary of product characteristics:
• Propranolol 40mg tablets, one to be taken every 8 hours for relief of somatic anxiety
• Loperamide 4mg capsules orally as a single dose then 2mg after each episode of diarrhoea [16mg per day maximum] for symptomatic treatment of diarrhoea
• Hyoscine butylbromide 10mg, 1-2 tablets to be taken every 6 hours for relief of stomach cramps
• Promethazine hydrochloride 25mg tablets, one to be taken orally every 12 hours for vomiting or insomnia
• Prochlorperazine 5mg, one or two to be taken three times a day when required for vomiting
• Metoclopramide 10mg one tablet three times a day when required to stop vomiting
• Paracetamol 1g orally every six hours for pain relief
• Ibuprofen 200-400mg three times a day after food for the relief of pain
• Ropinirole 250mcg one tablet at night for restless legs-a rare but extremely distressing symptom which also exacerbates insomnia
Other examples, of non-pharmacological actions, which could be ordered by a GP, in response to a red flag are: requesting blood tests or referral to secondary care (2WW).
(Royal Pharmaceutical Society, 2016)
(Joint Formulary Committee, 2017)
[J] Diagnosis and classification
It is important to stipulate that diagnosis process consists of several steps in which NMP is involved, but the diagnosis is made by a GP or Consultant.
There are two main classification systems DSM-V (Diagnostic Statistical Manual – fifth revision produced by the American Psychiatric Association) and ICD-10 (International Classification of Disease – tenth revision produced by the World Health Organisation) for the purpose of this algorithm ICD-10 was used. It does define opioid dependence as a syndrome:
“A cluster or behavioural, cognitive, and physiological phenomena that develop after repeated substance use and typically include a strong desire to take the drug, difficulties in controlling use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state”.
ICD – 10 stipulates that definitive diagnosis can only be made if three or more of below criteria are present:
• Opioid taken for the non-pain relieving effect
• A strong desire or compulsion to take opioids
• Aberrant behaviours with regards to onset, termination or levels of use
• Physiological withdrawal symptoms (COWS and SOWS)
• Evidence of tolerance (history of increasing doses in an aim to maintain the same level of pain control)
• Progressive neglect of alternative pleasures or interests
• Persisting opioid use disregarding evidence of detrimental physical or psychiatric consequences.
(WHO, 2016)
(Faculty of Pain Medicine, 2018)
(Wesson D. R., 2003)
[J] Diagnosis and classification
Gathering information about indicators of possible opioid dependence is an ongoing process and can occur at any point on the treatment pathway. From [A] to [U].
List of indicators of possible dependence:
a) Long-term opioid in non-cancer conditions
b) Reports of concerns received from patient, carers or family
c) The insistence that only opioid treatment will help with the pain
d) Missed appointments
e) Resisting referral for addiction assessment
f) Losing medication or prescriptions
g) Taking doses larger than prescribed
h) Attempting unscheduled visits in an aim to see different doctors or using out of hours services
i) Obtaining medication from internet or family members
j) Appearing sedated in clinic appointments
k) Resisting or refusing drug screening
l) Signs or symptoms of injecting or snorting oral formulations
m) New or worsening yellow flags (Faculty of Pain Medicine, 2018)
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