Leads: Dr Clare Jinks, Prof Christian Mallen (Long-term Conditions), Dr Elaine Nicholls (Meths)

The team are working with public contributors, with lived experience, throughout the project.

Dates: March 2019 - March 2024

Background:

Chronic pain is believed to affect up to half of the adult UK population, and causes moderate to severe interference in the lives of around 10-14%. Prescriptions for opioids have risen dramatically in England and Wales, from around 14 million in 2008, to 23 million in 2018. However, while opioids can be effective for short-term pain, the effectiveness diminishes over the long-term and continued use exposes patients to risks such as side-effects and dependency. Best practice guidelines recommend patients prescribed regular opiods once a stable regimen is reached, that opioids should be reviewed face to face at least 6 monthly, and more often if there are concerns. Structured review is recommended, taking into account evidence of effectiveness, including functional improvement / progress towards treatment goals, side-effects and evidence of problematic use. Supporting patients to taper and stop opioids is recommended if treatment goals are not met. Evidence suggests this review process does not happen as often as it should.

Policy and Practice Partners:

Primary healthcare organisations and Public Health England.

Co-Funding Partners:

Staffordshire and Stoke on Trent Clinical Commissioning Group.

Aims and Objectives:

In a five-year programme we are developing and testing a clinical pharmacist-led primary care intervention (PROMPPT - Proactive clinical Review of patients taking Opioid Medicines long-term for persistent Pain led by clinical Pharmacists in primary care Teams) and an associated clinical pharmacist training package which aim to reduce opioid use for people with persistent pain (where appropriate) and support self-management for those with persistent pain. The programme of work has three work packages: (1) intervention development; (2) feasibility study; and (3) a cluster randomised controlled trial. This abstract reports activity to date in work stream 1.

Methods:

A combined approach to developing the PROMPPT intervention and training included a synthesis of best practice guidance, theoretically informed qualitative studies, and engagement with stakeholders. Semi-structured interviews were conducted with n=15 patients prescribed opioids ≥ 6 months for PCNP, n=13 clinical pharmacists and n=9 GPs. An online qualitative study (netnography), which was co-developed with public contributors, and captured additional views of 31 people with persistent non cancer pain using a dedicated discussion forum over ten weeks. A prototype PROMPPT intervention, co-designed with patients and stakeholders was tested with patients and clinical pharmacists in 3 GP practices over three cycles of observed consultations incorporating cognitive interviews. Two focus groups of clinical pharmacists (n =7 and n=9) further investigated clinical pharmacists’ training needs. A framework approach to data analysis was used.

Main Results:

The findings from the interviews and netnography identified patients’ limited knowledge of clinical pharmacists working in GP practices. Once informed of their role, patients expressed confidence in their knowledge of medicines, often referring to them as the ’experts’ and as someone who would be able to listen to them and provide a different perspective. GPs supported this, valued the knowledge and skills of clinical pharmacists and believed that with the correct training they would be able to successfully deliver PROMPPT. All participants hoped that the additional time allowance clinical pharmacists have for appointments would allow a more holistic pain management review.

Clinical pharmacists perceived discussions about changing opiod prescription difficult conversations to have, and there was a lack of knowledge about how to do tapering for these patients, or how to assess patient’s readiness to change. Variable consultation styles existed and understanding of self management approaches for persistent pain varied. There were differences among clinical pharmacists about what would counted as a successful outcome from a new pain review and some felt the relevance of the review for different “types” of patients varied. Clinical pharmacists also talked about the wider impact of PROMPPT on the practice and how this impacted on what actions they would recommend to the patients. Finally there were different practice systems in place, meaning that referral and follow-up options varied.

Findings from the in-practice testing highlighted that PROMPPT pain management reviews were well received by both the patients and the clinical pharmacists, with the pharmacists valuing a framework to follow to manage consultations with this patient population. A key finding was that clinical pharmacists felt they had 'failed' if they had not initiated a dose reduction during the review. The test reviews also highlighted an issue with time management with time for writing up medical notes by the clinical pharmacist being limited following the consultation.

The above results were used to co-design an intervention for testing in the PROMPPT feasibility study. The intervention to be tested consists of a pre-consultation questionnaire to identify patients’ concerns, a 30-minute initial consultation and follow-up according to clinical need. The initial consultation includes holistic assessment of the patient’s persistent pain, personalised discussion to explore the patient’s own experience of the effects (wanted/unwanted, useful/bothersome) of opioids motivational interviewing techniques to explore patient’s reasons for considering changing their opioid medicines, their readiness to change and any ambivalence, before agreeing an individualised management plan.

Conclusion:

In light of COVID-19, the PROMPPT review has been adapted for remote consultations and training for clinical pharmacists developed in an online learning platform. Phase two of the programme is underway and comprises a single arm, non-randomised feasibility study (n=80 patients) with mixed methods process evaluation. Four GP practices have been recruited and pain reviews have commenced.

Implications for Implementation:

This programme is informing the continuing professional development for clinical pharmacists, and for general practitioners.

Project Website:

www.promppt.co.uk