Overview of project:

The South Gloucestershire OAD Pilot Project is currently being piloted in two GP practices in South Gloucestershire. It will be piloted for 24 months by the Drug & Alcohol Action Team (DAAT). Following the ‘shared care’ approach of the drug treatment system, the key element of this interdisciplinary model of care is partnership working among the Project Support Worker, GPs, patients, and consultants in pain management and addiction psychiatry, improving the interface between primary and secondary care.

The project also aims to reduce inappropriate opioid prescribing in chronic pain patients by the dissemination of information to GPs on good prescribing methods via training sessions, information leaflets, and other technology, for example e-modules. Therefore, the pilot service aims to benefit chronic pain patients with prescription opioid dependence while reducing the harm associated with inappropriate opioid prescribing for all chronic pain patients, irrespective of the presence or absence of opioid painkiller dependency.

How was the need for this project identified?

For most of the 20th century, concerns about the risk of addiction and dependence meant that opioid painkillers were rarely prescribed for the treatment of chronic non-cancer pain; their use was limited to the treatment of acute pain and pain in terminally ill cancer patients. However, from the 1990s onwards, newer opioid formulations were heavily marketed by pharmaceutical companies as safe and effective for the treatment of chronic non-cancer pain despite a lack of evidence about the effectiveness of these medicines (Noble et al., 2010).

Additionally, there has been a lack of awareness of the adverse consequences associated with opioid painkiller use, which include addiction and dependence, cognitive impairment, reduced wellbeing and poor quality of life, higher accident rates including falls, and hospitalisations due to overdose and deaths (Ballantyne et al., 2016).

While it is difficult to accurately estimate the scale of the problem in South Gloucestershire, data from the National Drug Treatment Monitoring System (NDTMS), which provides an overview of drug treatment provisions and access to local treatment services, show that the percentage of clients in treatment citing prescription or over the counter drug use (no illicit use declared by the patients) has increased since 2010; prescribed opioid and benzodiazepine use have increased yearly. In addition, the rate in South Gloucestershire is the highest among other local authorities in the South West region, and six times higher than the South West average.

Prescription opioid dependence may affect all age groups, with important negative physical, psychological, health, and social consequences for individuals, families, and the wider community (Royal College of General Practitioners). It may also act as a gateway to illegal drug use and other criminal activity (Mars et al., 2014). However, patients who are dependent on prescription opioid painkillers are less likely to access traditional specialist substance misuse treatment centres than those dependent on illicit opioids (National Treatment Agency for Substance Misuse, 2011). National guidance for commissioners recognises this and recommends that commissioners seek to engage opioid painkiller dependent patients by providing separate addiction to medicine sessions, premises, or services (Public Health England, 2013).

GPs support the national recommendation and recognise that they play an important role in identifying and treating patients who become dependent on prescribed opioid painkillers. However, although GPs agree that primary care provides an appropriate setting, many GPs are uncertain about how they should actually manage these patients. Additionally, there is evidence that GPs would welcome guidance on, and support with the management of chronic pain and opioid prescribing (McCrorie et al., 2015).

References:

  • Ballantyne JC, Kalso E, Stannard C. WHO analgesic ladder: a good concept gone astray. BMJ 2016; 352:i20 doi:10.1136/bmj.i20.
  • Mars SG, Bourgois P, Karandinos G, Monetro F, Ciccarone D. Every ‘never’ I ever said came true: transitions from opioid pills to heroin injecting. The International Journal on Drug Policy 2014; 25(2):257-266.
  • National Treatment Agency for Substance Misuse. Addiction to medicines: an investigation into the configuration and commissioning of treatment services to support those who develop problems with prescription-only or over-the-counter medicine. London, 2011.
  • Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C, Schoelles KM. Long-term opioid management for chronic non-cancer pain. Cochrane Database of Systematic Reviews 2010. Issue 1. Art. No.:CD006605.DOI:10.1002/14651858.CD006605.pub2.
  • Public Health England. Commissioning treatment for dependence on prescription and over-the-counter medicines: a guide for NHS and local authority commissioners, 2013.
  • Public Health England. Commissioning treatment for dependence on prescription and over-the-counter medicines: a guide for NHS and local authority commissioners, 2013.
  • Royal College of General Practitioners. Factsheet 1: Prescription and over-the-counter medicines misuse and dependence.

Please give an overview of the project’s benefits, and the aspects of public health it addresses.

Benefits of the OAD Pilot Project that could potentially be realised include:

  1. Improvement of health and wellbeing outcomes for opioid painkiller dependent patients with chronic pain due to successful treatment of their dependence.
  2. Reduction of harms associated with inappropriate opioid prescribing including accidents or falls, hospitalisations due to overdose, and deaths.
  3. Better management of patients with chronic non-cancer pain by the promotion of integrated clinical and psychosocial interventions, therefore reducing the need for over-reliance on prescribed medication.

Specific innovative aspects of the project will also deliver the following benefits:

  • Building links with a wide range of service providers and establishing referral pathways so that service users receive holistic support packages that are tailored to meet their physical and mental health needs (example services will include Bristol Advice Centre, South Gloucestershire Psychological Therapies, MIND, domestic violence support services, physical activity services, and complementary therapies such as mindfulness and yoga).
  • Encouraging family members and carers to engage with the Families Also Matter service to facilitate improvement in their own wellbeing and the support that they provide to their loved ones.
  • Working in partnership with GPs, community pharmacists, and pain consultants to devise a training package around appropriate opioid prescribing and opioid painkiller dependency to improve opioid prescribing.

Raising awareness of opioid analgesic dependence and alternative approaches to pain management among the general public by working with community groups, promotion of Opioid Painkiller Addiction Awareness Day, and use of online channels including social media (Facebook and Twitter) and online user-led communities (e.g. ‘Over-Count’ and ‘Codeine Free’).

What was the biggest challenge faced by your project? How was this overcome?

The biggest challenge faced by this project is to demonstrate achievable and realistic outcomes. Some patients require engagement from the start to recognise the health issues that they experience, while others may wish to reduce their opioid dosage. The outcomes will therefore need to be patient-centred and manageable during the period of the project.

What advice would you give to a team managing a similar project?

The following advice may be useful for those who manage a similar project:

  • Ensure that the project is grounded in the evidence of need for the local area
  • Identify the target population for this project
  • Check that robust local capacity exists to deliver the project in an efficient and cost-effective manner
  • Ensure that there is appropriate collaborative working
  • Ensure the delivery of outcomes which are achievable and relevant for patients

What’s next for this project?

NIHR CLAHRC West will provide support with the evaluation of the pilot. There is a lot of national interest in the project due to its novelty and therefore robust evaluation is required to demonstrate the effectiveness of the project. Should the pilot project prove to be successful, it will be mainstreamed into the main substance misuse services in South Gloucestershire. It will then seek to be a model of service for other areas that wish to replicate the service.

Have you had any feedback (e.g. from colleagues, third-sector partners, members of the public)?

Other areas, such as North Lincolnshire and Isle of Wight, have sought our expertise to set up a similar service in their area. We also presented our pilot project to the Advisory Panel on Substance Misuse (APoSM) of the Welsh Assembly Government in 2016, which received favourable feedback from the panel.

Which aspect of this project makes you most proud?

As far as we know, this pilot project is not being implemented elsewhere. It is the first pilot of its kind in the UK (which is based in a primary care setting) and has support from a range of local and national partners. There is definite scope for rollout in other areas if the pilot shows promise, as the increase in opioid analgesic prescribing for chronic non-cancer pain is a national and international issue.

How can your public health colleagues get more information about this project?

More information can be obtained from the following websites:

OAD Pilot Project Page, South Gloucestershire Council
NIHR CLAHRC West Evaluation Page

If you have any further questions, please contact Kyla Thomas via email or call 01454 864582.

Is there anything else about this project you would like to share with your colleagues across AGW?

As above. We are happy to be contacted for further questions regarding any aspects of the pilot project.