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The benefits of this project
Benefits for Your Patients
- Improved quality of life for patients living with chronic pain.
- Reduced iatrogenic harms associated with overprescribing.
Benefits for Your Practice
- Enhanced care and supported self-management can lead to fewer GP appointments.
- Reduced prescription administration.
- Financial savings from reduced medication use.
Benefits for The Planet
- Fewer prescriptions leads to a reduced carbon footprint and reduced contaminant effects of pain medications in aquatic environments.
Opportunity for improvement
- Recent advancements in chronic pain research support a transition away from the prescription of opioids and gabapentinoids; there is a lack of evidence for a significant long-term benefit and there is a substantial body of evidence that illustrates both short-term and long-term harms.
- Whilst gabapentinoids remain in the NICE guidelines for neuropathic pain, they are not recommended for chronic (primary) pain, nor lower back pain with sciatica. Opiates are not recommended for chronic non-cancer pain. There is a consensus that patients can be better supported through a holistic approach using non-pharmacological interventions such as supported self-management.
- Opiate and gabapentinoid medications for chronic pain are a key area of overprescribing in primary care which leads to unnecessary medication burden for the patient, financial costs to the NHS and environmental costs. NHS England has included reducing opiate use in chronic non-cancer pain as one of its national medicines optimisation opportunities.
- This quality improvement project focuses on enhancing care for patients experiencing chronic pain (see disclaimers). It aims to evaluate the effectiveness of deprescribing pain medications through targeted review appointments with a GP and educational sessions for prescribers. Patients are offered supported self-management strategies through the Ten Footsteps Programme and ongoing support with monthly pain cafes.
- You might like to create a SMART goal for this project e.g. to reduce the number of patients prescribed tramadol and/or gabapentinoid by >2% over the next 3 months.
- Greener Practice would like to thank Dr Georgina Kirby and Frome Medical Practice who created and piloted this project.
How to carry out this project
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Discuss
Chat to the practice lead team, social prescribers and the wider practice team about chronic pain and how the practice approaches it. Some staff e.g. social prescribers or health coaches might be interested in running a monthly ‘Pain Café’, a peer support group for anyone living persistent pain.
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Ten footsteps for chronic pain programme
The online Ten Footsteps to Live Well with Chronic Pain Program is a resource to help patients with chronic pain.
Patients can work through it on their own or the practice might like to set up a rolling programme face to face programme facilitated by trained practice staff for patients to attend.
If such a programme is initiated think about measures to track impact e.g. numbers of patients attending, Quality of life measures (ONS scores) for patients attending.
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Identify patients
Run an IT search for patients prescribed repeat opiates / gabapentinoids and exclude those with a diagnosis of cancer or on the palliative care register. You might like to target different drugs in each QIP cycle e.g. tramadol in cycle 1, gabapentinoids in cycle 2 etc.
We hope to provide downloadable IT searches for EMIS & System 1 soon. In the meantime, you could use our EMIS and SystmOne search guides to create your own.
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Review the records
Review the records of the patients identified to assess suitability for an invitation for a GP / Pharmacist review to discuss their chronic pain management. Exclude patients if the indication for gabapentinoids is epilepsy, postherpetic neuralgia, a mental health condition, or diabetic neuropathy.
Too many patients? Use an online random number generator to randomly select a smaller group of patients.
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Contact patients
Invite suitable patients for a GP/Pharmacist review of their chronic pain via SMS/letter. The clinician(s) running the project might like to have a specific clinic which these patients can be booked into. Adjust this message to suit whichever drug you are targeting:
Resource: Chronic pain
We’d like to invite you for a GP review with [Name] to discuss your pain management. You're currently prescribed tramadol / another opiate / gabapentin / pregabalin. Research suggests these may not be the most effective long-term option and could have risks over time. We’d like to explore the possibility of reducing this medication and look at other ways to manage your pain. Please book an appointment with [Name]. You might find this helpful to read before your appointment: https://livewellwithpain.co.uk/wp-content/uploads/2022/09/medicines-decision-guide-2023.pdf More info here: https://livewellwithpain.co.uk/wp-content/uploads/2022/09/opioid-lottery-v03.pdf https://livewellwithpain.co.uk/wp-content/uploads/2022/09/ask-yourself-leaflet.pdf
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Pain reviews
Listening
- Enable patients to share their pain stories and express their priorities.
- Review the medicines decision guide if they have filled it in.
Explaining
- Assess patient grasp of chronic pain and share a clear explanation of chronic pain using metaphors (e.g. a faulty car alarm).
- Address misconceptions about opioids and gabapentinoids that led to past prescribing.
- Discuss how a holistic approach with supported self-management can lead to better outcomes and improved quality of life.
Plan
- Invite all patients to take part in the online Ten Footsteps to Live Well with Chronic Pain Program and also to the Pain Café if one exists.
For patients wanting to reduce or stop medications, give them a tapering plan (printed or via SMS messaging). Take the medication off repeat and issue acute scripts for tapering. Record the number and type of medications stopped:
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Follow up
Ask patients to book a follow-up telephone consultation with the GP in 1 month (or face-to-face if preferred). If they don’t, contact them asking how they were getting on with tapering and allowing them to respond via SMS:
Resource: Chronic pain follow up
We spoke on ‘x day’ & discussed reducing …. How are you getting on? Do you need another prescription?”
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Study
Review the results, summarise learning, share with practice team + decide if any changes are needed to improve the process. Decide when to repeat the next cycle e.g. 2-3 months and use the Project Monitoring form to keep track. Many practices run automatic searches at regular intervals – speak to your practice team about including this project in those searches.
Top tip
A whole practice approach to chronic pain involves buy-in from patients, practice leads, prescribing practitioners, pharmacists, social prescribers/health coaches, and the support staff to arrange patient appointments.
How to scale this project up or down
| Please note - Use of this project requires NetworkPLUS membership. If you would like to share this project with others, please invite them to purchase their own membership—access must not be shared with non-members. |
Share this project and your experience with your wider organisation e.g. PCN / Cluster / ICB so other practices can follow your process. You might like to work with your ICB / Healthboard to promote the online Ten Footsteps Programme to patients and consider setting up ‘Pain Cafes’ to promote supported self-management across the wider area.
Have you completed this QIP?
Tell us a little about your project and enter your data in order to generate a certificate showing the probable cost and carbon savings and other benefits. This project may help with CQC evidence submission (see disclaimers).
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