1. 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!

2. 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).

3. 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 mg top whack in primary care
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).

4. NHS England / PrescQIPP Audit
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

5. 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

6. 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

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