Co-prescription of gabapentinoid and opioid analgesia in a general practice: evaluation of a brief quality improvement exercise.
Problem
Chronic pain is common in the UK, affecting one-third to one-half of the population. Patients with chronic pain present to their general practitioner around five times as often as those without. Primary care pain management needs to be of a high-quality to address this population burden. Given contact frequency, primary healthcare professionals are well-placed to deliver this. The National Institute for Health and Care Excellence (NICE) are producing a clinical guideline on chronic pain; presently there are some recommendations listed in the NICE Clinical Knowledge Summaries (CKS).
We aimed to assess current practice of prescription of gabapentinoids with opioids in a single general practice against the NICE CKS recommendations and the impact of a brief practice-level quality improvement intervention.
Approach
We reviewed co-prescription of opioid analgesia and gabapentinoids in patients without active cancer (defined as a consultation including a Read code for cancer in the previous 15 months, or inclusion on the palliative care register).
We determined the number of patients at 01.01.2019 who had been prescribed both opioids and gabapentinoids within the previous three months and then stratified by strong opioids [(dia)morphine, oxycodone, (al)fentanyl, hydromorphone], or tramadol, or weak opioids (including compound analgesics).
The data were presented at a practice quality improvement meeting. It was agreed to try to stop initiating patients on opioid plus gabapentinoid repeat therapy without review and demonstration of clear functional benefit. Tools for non-pharmacological management were highlighted. Data were collected on 01.01.2020 for new patients (those not included in the 2019 cycle) only to assess whether practice had been modified between the time points.
Findings
On 01.01.2019, 127 patients were eligible for inclusion (without active cancer and recorded as having been prescribed both opioids and gabapentinoids in the previous three months). Of these, 18 (14%) had been prescribed a strong opioid, 34 (27%) tramadol (but not a strong opioid) and 75 (59%) other opioids.
On 01.01.2020, 111 patients in total were potentially eligible for inclusion, 14 (11%) of the original group having left the practice and 72 (56%) no longer receiving opioids plus gabapentinoids within the three months to 01.01.2020. 41 were newly eligible patients. Of these, five (12%) had been prescribed strong opioids, three (7%) tramadol, and 33 (80%) other opioids.
Consequences
Through a brief intervention, highlighting the problems associated with co-prescription of opioids and gabapentinoids and practice-based discussion of potential solutions, improvements in prescribing have been attained. Further work is needed to determine if these improvements can be maintained and are generalisable.