Pharmacists and safe opioid prescribing

Key Points
  • Pharmacists are medicines experts and advise patients about improving safety, efficacy and adherence in medicines use, including opioids.
  • Pharmacists provide training and education in the safe, evidence-based use of opioids and other analgesics to colleagues from different healthcare professions
  • Pharmacists and their teams work to safety-net prescribing undertaken by professional colleagues, which might include querying and adjusting doses, reviewing the necessity and rationale for additional medicines, and advising on potential interactions or safety concerns
  • Pharmacists and pharmacy technicians carry out medicines reviews which examine the effectiveness and tolerability of opioid analgesics., They also provide the opportunity to support people to adopt self-management strategies as part of a pain management plan
  • Pharmacists have an increasing role within or alongside pain management services in all sectors, and should lead on pharmacological management guideline development and safety initiatives to reduce the harm caused by opioids

 

Pharmacists and opioid stewardship

Pharmacists are experts in medicines and their use. They tend to have a particular focus on safe and rational prescribing, acting as a safety-net for people receiving prescriptions or medicines advice from other healthcare professionals. Pharmacists have a wide range of roles across primary care, community services, hospitals and in industry and can develop competencies at advanced and consultant level, working alongside other healthcare practitioners to provide multi-disciplinary care. Pharmacists can qualify as independent prescribers and so have potential to develop their own caseloads, clinics or services in any healthcare setting that could include acute or chronic pain support and prescribing.

In primary care, community pharmacists are the most accessible community healthcare professional for many individuals. In addition to a core dispensing role, pharmacists and their teams can advise on managing minor conditions including many common acute musculoskeletal conditions which present with pain. Working with other healthcare organisations such as Health Boards, Primary Care Networks (PCNs) and Integrated Care Boards (ICBs), community pharmacists provide services specific to people living with pain. This may be part of a locally enhanced or nationally developed services and whilst tending to have a focus on medicines use, will also encourage discussion of self-management and signposting to local services. Examples include the Medicines Care and Review service in Community Pharmacy Scotland. *

*https://www.cps.scot/core-2/medicines-care-and-review

 

General Practice (GP) Pharmacists work alongside General Practitioners and other healthcare professionals, providing medicines-focussed clinical care. Pharmacists also have roles across networks of GP practices and other community services, such as PCNs in England and Primary Care Clusters in Wales. Primary Care Pharmacists often have highly developed expertise in the management of long-term conditions and increasingly support people living with pain, particularly in relation to reducing the harm from analgesic medicines. Pharmacists are likely to be the professional group most involved in reviewing and advising on tapering analgesic medicines in Primary Care. The increasing focus on reviewing medicines associated with dependence and withdrawal is leading to larger numbers of Primary Care pharmacists and pharmacy technicians, developing skills and expertise support wider pain management, as part of a multi-disciplinary approach to supported pain management and harm reduction.

Hospital pharmacists will see people presenting or living with pain in all specialties and are likely to be asked for advice on analgesic medicines use. Pharmacists working in hospital will develop specialisms and it is not uncommon to have specialist surgical pharmacists working with acute pain teams and other anaesthetic colleagues. Similarly, to the changes in Primary Care and the focus on reducing analgesic-related harms, pharmacists are more frequently being employed as part of multi-disciplinary pain teams. In these roles, it would be expected for pharmacists to lead on medicines education, safety, and reviews in a clinical setting and for the rest of the team.

Medication reviews take different forms in different settings, however, as a general rule, the purpose of an analgesic review is to determine1-6:

  • the effectiveness of current treatment in terms of reducing pain intensity and how the medicine(s) allow the person to improve or maintain a satisfactory level of function
  • any adverse effects being experienced – these could be due to interactions with other medicines or conditions the person has or as a direct result of the analgesic medicine(s)
  • the risks and benefits of continuing the current analgesics at the same dose, adjusting the dose, or stopping it altogether and the person’s preference for the same
  • any signs the person is developing problematic use of the analgesic medicines including dependence
  • who can be contacted if they have any problems or concerns about their analgesic medicines

 

Other interventions that pharmacists 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 analgesics including those available to purchase from shops and pharmacies
  • Informing public understanding of different types of pain and the safe, evidence-based use of analgesic medicines
  • Signposting to other support which might include local pain services, third sector providers or facilitating the use of relevant online services

 

References:

  1. NHS England. Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for integrated care boards (ICBs) and Primary Care. https://www.england.nhs.uk/long-read/optimising-personalised-care-for-adults-prescribed-medicines-associated-with-dependence-or-withdrawal-symptoms/
  2. Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults (NG215). Published 20 April 2022. https://www.nice.org.uk/guidance/ng215
  3. Taylor S, Annand F, Burkinshaw P, Greaves F, Kelleher M, Knight J, Perkins C, Tran A, White M, Marsden J. Dependence and withdrawal associated with some prescribed medicines: an evidence review. Public Health England, London. 2019
  4. All Wales Medicines Strategy Group, All Wales Analgesic Stewardship Guidance. November 2022 (updated July 2023).
  5. NHS Scotland. Effective prescribing and therapeutics – Chronic Pain Prescribing Strategy. https://www.therapeutics.scot.nhs.uk/pain/
  6. Reviewing medicines associated with dependence or withdrawal symptoms

 

Further Reading

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