This document reviews the structured medication reviews (SMRs) conducted for patients on high-dose opioids at Living Well PCN, identifying 49 patients on more than 120 mg oral morphine equivalent, with 41 reviewed. Of these, 61% had their opioid doses reduced, with 49% now on lower doses, and some patients have stopped using opioids entirely. The review highlights the complexities of managing these patients and suggests a more staggered approach could improve the process.

1. Review of patients on high dose opioids at Living Well PCN
Background
SMR-01 recognises PCNs for delivering structured medication reviews (SMRs) to patients in priority cohorts. SMRs are a
comprehensive clinical review of a patient’s medicines and detailed aspects of their health. They are delivered by facilitating
shared decision-making conversations with patients aimed at ensuring that their medication is working well for them.
Cohort 2: Patients with a single prescription for an oral or transdermal opioid with > 120 mg oral morphine equivalent
Results/Data
• 49 patients were identified on searches to be on high dose opioids equivalent to 120mg morphine or more
• To date 41 patients have been reviewed
• From these 41 patients 25 patients (61%) have had their opioid doses reduced
• 20 of the 41 patients (49%) are now on an opioid dose equivalence of less than 120mg morphine
• 9 patients have completed their opioid reduction plan, 3 patients have stopped their opioids completely, 4 patients
have attempted to reduce/engage but haven’t been successful
• 24 patients are still engaged in current reductions
• 8 patients that have not engaged with the reduction process are currently still working through the different stages of
the process
Claire Sheikh, Vicki Rowell and Dr Chris Sanford, August 2022
Aim
To develop a process for Living Well PCN to enable all patients on high dose opioids to have a structured medication
review and a discussion about reducing opioid doses
Method/Strategy for Change
• To run a search to identify all patients with a single prescription for an oral or transdermal opioid with > 120 mg oral
morphine equivalent
• To develop a process to review and conduct SMRs for all these patients utilising the expertise of the CCG pain
medicines management pharmacist and PCN pharmacist with the support of the PCN clinical director.
Conclusions/Lessons Learned
Our process for opioid reductions has developed and evolved with time
Many of our patients on high dose opioids are very complex and it has taken a lot of clinician time to review these patients
In hindsight we probably shouldn’t have tackled so many patients at the same time. It would have been better to spread the
process over an even longer time period and have less patients reducing at the same time, due to the workload created in
continuously reviewing patients started on taper plans.
Overall we have successfully reduced opioid doses in 61% of the patients seen so far
3 patients have stopped opioids completely
Patients that haven’t successfully engaged in a taper have had very detailed education about the risks of high dose opioids
The project is still in progress so hopefully we will continue to see a reduction in opioid doses and the number of patients
receiving over 120mg morphine equivalence will continue to decrease.
Plan for managing deprescribing of opioid medication
Patient attends SMR initially with CCG pharmacist
- Shared decision making process to ascertain plan
Patient does not attend or declines appointment
Second invitation sent
Patient does not attend or declines
appointment
Patient does not engage with taper
Patient engages with taper
-Agree plan, clearly document
-Handover to PCN pcist to continue
reduction plan Provide patient with written information
Follow up phone call organised with CCG
pharmacist
Discussion at Living Well MDT – Dr Sanford, Vicki Rowell (VR), Claire Sheikh
Specialist opinion sought
OR
Referral to specilaist
Care Plan for safe continuation Invited for SMR joint appointment with VR and Dr Sanford
Enforced wean
Write to patient inviting them for SMR focussing on pain medication