Pharmacists and safe opioid prescribing

Key Points
  • Pharmacists can advise patients about their medicines and can help improve safety, efficacy and adherence in medicines use.
  • Pharmacists should ensure that analgesics available ‘over the counter’ (OTC) containing codeine or dihydrocodeine are only used for acute pain of short duration (less than three days).
  • Pharmacists must ensure that the prescribed dose of medication is appropriate for an individual patient and that dose increases are proportionate to the current dose
  • Pharmacists are able to support monitoring of effectiveness and tolerability of opioids by carrying out Medicine Use Reviews (MURs)
  • By taking a proactive approach, pharmacists may highlight excessive/unusual doses and potential drug interactions and can request a review by the primary prescriber.

 

Pharmacists and safe opioid prescribing

Pharmacists are experts in medicines and are the most accessible community healthcare professional for many individuals. Pharmacists already offer (in addition to their core dispensing role) competencies and services relevant to the needs of people living with and receiving treatments for pain. Around 80% of the public already say that acute pain is a symptom/condition they would consult their pharmacist about.

Over the counter (OTC) analgesics containing codeine or dihydrocodeine in combination with other analgesics, such as paracetamol or ibuprofen, are intended for short-term use (no longer than three days) to minimise dependence and addiction. Concerns that codeine or dihydrocodeine containing analgesics are being taken regularly should be discussed with the patient and the patient should be encouraged to seek medical advice and access appropriate services.

A Medicine Use Review (MUR) is an advanced service offered by pharmacies in the United Kingdom and it is part of the current contract pharmacies hold with the National Health Service (NHS). An MUR is an opportunity for patients to discuss their medicines with a qualified pharmacist and provides:

  • A review of all medicines to see if there is any overlapping prescribing or drug interactions
  • Ability to give extra information on what medicines are for
  • Opportunity to discuss side effects of medicines
  • Identification of problems associated with medicines

Conducting well focused Medicine Use Reviews can allow pharmacists to help people use prescribed opioid and other analgesics effectively and safely (Youssef, 2010).
 

Other interventions that community pharmacists can provide for patients with pain include:

  • Lifestyle advice, including diet and exercise, and supported self management of pain.
  • Improving protection against potentially harmful over-use of common analgesics such as paracetamol and NSAIDs available over the counter
  • Informing public understanding of what types of pain should be either accepted and ‘worked through’, or referred to GPs and/or specialists;
  • Opening the way to an extended use of assessment instruments to identify persistent pain risks, and cases; and
  • Signposting psychological and other care providers, or facilitating patient use of relevant computer based services. 
     

Community and other pharmacists should in addition work in collaboration with local GP surgeries to provide better pain management. Specialised independent pharmacist prescribers, who can issue prescriptions, can run regular pain clinics and in some instances assume a direct case management role. This reduces GP workload and extends patient choice in ways that should also reduce pressures in hospital based services, especially if good working links with the other community based teams are developed.

In Scotland, the Royal Pharmaceutical Society has been working with the Scottish Government and the charity Pain Association Scotland to produce a booklet helping healthcare professionals to enable patients to self-manage chronic pain.

 

TOP TIPS: Questions for patients taking pain killers
Do you obtain adequate pain relief to allow you to function 'normally'?
Do you experience any side effects?
Have you taken more doses than prescribed?
During the past month have you often felt subdued, depressed, or hopeless?

 

Screen for risk factors for running into problems with prescription opioids

Patient factors

  • Depression, anxiety and other common mental health diagnoses
  • Previous history of alcohol or substance misuse
  • Previous history of opioid misuse

Drug factors

  • High doses (doses greater than oral morphine equivalent 120 mg/day)
  • Multiple opioids
  • Multiple formulations of opioids
  • More potent opioids
  • Concurrent benzodiazepines/sedative drugs

 

Further Reading

  • General Medical Council. Good practice in prescribing and managing medicines and devices (2013). 
  • General Pharmaceutical Council. Standards for pharmacy professionals. 2017 
  • Gill J, Davies J, Taylor D, Knaggs R. LESS PAIN. The results of a community pharmacy pilot pain service evaluation. UCL School of Pharmacy and UKCPA.  2013
  • Gill J, Taylor D, Knaggs R. Relieving Persistent Pain, Improving Health Outcomes. UCL School of Pharmacy and UKCPA. 2012
  • National Patient Safety Agency. Rapid Response Report RRR05 Reducing dosing errors with opioid medicines. 2008 
  • Royal Pharmaceutical Society.Professional Standards. 
  • Youssef S. Better MURs for Patients with Chronic Pain. The Pharmaceutical Journal 2010; 284: 587-589.
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