How feasible is a proactive review of patients taking opioid medicines for persistent pain led by pharmacists in primary care?

Problem

Opioids are commonly prescribed for persistent non-cancer pain (‘persistent pain’) despite limited evidence of long-term effectiveness and important safety concerns. Clinical pharmacists working in general practices (‘practice pharmacists’) play an increasing role in managing patients on long-term medicines in UK primary care and seem ideally placed to review patients on opioids. This feasibility study is part of a National Institute for Health and Care Research funded research programme to develop and test a practice pharmacist-led intervention (PROMPPT) to support patients with persistent pain to safely reduce opioids, where appropriate, without increasing pain/pain-related interference, and aimed to investigate the acceptability, credibility, and feasibility of delivering PROMPPT in practice.

Approach

A single arm, non-randomised design, with nested mixed methods process evaluation. Eligible patients, prescribed opioids for ≥6months, identified from electronic records in four general (GP) practices were invited to participate in the Management of Opioids and Persistent Pain (MOPP) study by completing self-reported questionnaires at baseline and 3-month follow-up. A sample of MOPP participants were invited for a PROMPPT review with the pharmacist. Participants scheduling a PROMPPT review were invited to consent to audio-recording of the consultation and following the review, were sent an Acceptability Questionnaire and invited to an interview. Pharmacists delivering the reviews and one GP per practice were also interviewed. Qualitative analysis used a framework approach, drawing on the Theoretical Framework of Acceptability.

Findings

Between November 2020 and May 2021, n=1020 potentially eligible patients were mailed a consent-to-contact form and n=178 were returned. Of 178 potential participants invited, 148 (15%) consented to participate in the MOPP study. N=123 participants (83%) completed 3-month follow-up questionnaires. N=88 participants were invited for a PROMPPT pain review, n=80 (90.9%) attended, and n=8 reviews were audio-recorded. N=50 acceptability questionnaires were returned and 90% (n=45) rated the review completely acceptable or acceptable. Interviews were conducted with n=15 patients, n=4 pharmacists and n=4 GPs. Overall, patients interviewed perceived the pain review as a good idea and recommended it to others. Practice pharmacists were perceived as appropriate to conduct these reviews because they were knowledgeable about medicines and doing so redistributed workload away from overstretched GPs. Prior to the pain review, participants reported mixed feelings. These included feeling ‘pleased’ to be invited and ‘grateful’ someone was taking an interest alongside concerns about what would happen at the review, including opioids being stopped and changes being detrimental. Following the review, most participants who had agreed changes to opioids were happy with suggestions made.

Consequences

Practice pharmacist-led pain reviews were acceptable to patients, pharmacists and GPs. Uptake of PROMPPT reviews was high. Findings were used to refine the intervention (pain review and training) in readiness for a cluster randomised controlled trial evaluating the clinical and cost-effectiveness of PROMPPT, which is underway.