Wider effects In any event, the incident itself is often quite small (and completely avoidable if you follow sops and concentrate (your reported learning) and while it is not often that the consequences are catastrophic, it is often just the start of a change in the patient’s care. Many incidents are like an unravelling ball of wall, or the hem of your trousers, I pick and pick at it gets messier and messier!

Side effects Constipation Nausea Dizziness Drowsiness Respiratory depression Dry mouth Itching Rash Hypogonadism and adrenal insufficiency Amenorrhoea Reduced libido Erectile dysfunction depression Hyperalgesia Side effects are very common (50 – 80% of patients) and up to a quarter of patients taking opioids long term have developed a dependence on them.   Of all deaths related to drug poisoning in 2015, 54% involved an opioid drug. (ONS, 2016).

Chronic pain >120mg OME Gabapentinoids Benzodiazepines Hypnotics TCA SSRI Antipsychotics Magic number! We now have guidance about the threshold for prescribing opioids where harm starts to out weigh benefit. 120mg. Australia are now suggesting 80-100mg top whack in primary care https://www.racgp.org.au/your-practice/guidelines/drugs-of-dependence-a/appendix-d-example-practice-policies/D9-Practice-policy-%E2%80%93-Opioid-dosing-thresholds/ But we’re also going back to basics to say if the starting dose isn’t working – don’t increase, stop. Because…….it’s not working. Analysis local coroners’ reports suggests links between premature death and combinations of different drug classes. (Opioids, gabapentinoids, benzodiazepines or hypnotics, tricyclics, SSRIs, some antipsychotics). http://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware

NHS England / PrescQIPP Audit https://www.prescqipp.info/resources/category/428-community- pharmacy-opiate-searches NHS England developed a multidisciplinary audit. General practice have been provided with some searches – but inevitably these won’t capture everyone we need to be concerned about – because e.g. more than one drug. So the CDAO team would also like community pharmacy to highlight potentially inappropriate prescriptions to the GP and engage patients – e.g. MUR To reiterate, we are looking at chronic pain (or acute pain that is becoming chronic) rather than acute pain or palliative care (although keeping checking suitability of CSCI scripts – NPSA, dose increases & conversions etc) Third document is a letter to GP requesting action “How to clinical audit” is instructions for using the data collection form 4th document is details and dose equivalence

Audit Criteria 1. Pharmacy to contact their GP in all instances where: a) Patient is taking >120mg oral morphine equivalent as a result multiple opioids b) Patient is regularly ordering/collecting prescriptions early that suggests they are taking more than the prescribed dose of opioids or pregabalin c) Patient is prescribed more than one immediate release ‘top up’ opioid

2. Is there a record on the PMR made in the last 15 months that at the point of supply: a) Patient is advised about safe storage of controlled drugs in their home with respect to risk of accidental overdose of family members. Is there a record on PMR of this being done in the last 15 months? b) Patient is advised about impaired driving ability

Don’t forget Benzodiazepines Hypnotics With all the attention opioids are getting, we mustn’t forget the over prescribing of benzos and z-hypnotics