Prescribing controlled drugs

THE US has endured a long nightmare of opioid addiction, with a steadily rising number of overdose deaths that in March 2022 reached a staggering 110,000 deaths over a 12-month period – largely driven by the spread of illicit fentanyl.

A recent report for National Public Radio (NPR) expressed some cautious optimism, with the number of overdose deaths appearing to have crested and begun to fall. It cites a series of major reforms in 2022 to the way drug addiction is treated in the US and efforts to reduce stigma and improve access to care.

The “opioid crisis” is not restricted to North America. A Lancet Public Health editorial points out that almost half of all fatal drug poisonings in the UK involved opiates, such as heroin and morphine. Opioid prescriptions increased by 34 per cent in England between 1998 and 2016, and opioid-related hospitalisations rose by 48·9 per cent between 2008 and 2018, with an estimated healthcare cost of £137 million.

Substance abuse is obviously a multifactorial challenge involving both health and social care but clinicians remain at the sharp end. Appropriate practice in prescribing controlled drugs, including opioids, in the UK should always be based on current guidance from the General Medical Council (GMC) and other relevant authorities.

In Good medical practice, the GMC states (paragraph 16a):

In providing clinical care you must:

a. prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.

More explicit advice is provided in GMC guidance on Good practice in prescribing and managing medicines and devices. This makes clear that a doctor is responsible for the prescriptions they sign and for decisions and actions when they supply and administer medicines and devices, or authorise or instruct others to do so.

The doctor must also be prepared to explain and justify their decisions and actions when prescribing, administering and managing medicines.

Regular review

The GMC guidance (paragraph 95) states that reviewing all prescribed medicines is particularly important where:

a. patients may be at risk, for example, those who are frail or have multiple illnesses

b. medicines have potentially serious or common side effects

c. the patient is prescribed a controlled or other medicine that is commonly abused or misused

d. the BNF or other authoritative clinical guidance recommends blood tests or other monitoring at regular intervals.

Regular medication reviews for patients on controlled drugs are extremely important. Paragraph 59 of the GMC guidance states:

Some categories of medicine may pose particular risks of serious harm or may be associated with overuse, misuse or addiction. When prescribing, you should follow relevant clinical guidance, such as drug safety updates on the risk of dependence and addiction associated with opioids.

At each review, the clinician should confirm that the patient is taking their medicines as directed, and check that the medicines are still required, effective and tolerated.

This can be particularly important following a hospital admission, or changes to medicines following a home visit. Clinicians should also consider whether requests for repeat prescriptions received earlier or later than scheduled may indicate poor adherence, leading to inadequate therapeutic value or significant adverse effects.

Clinicians prescribing controlled drugs should also follow relevant clinical guidance, such as drug safety updates on the risk of dependence and addiction associated with opioids.

Emergency prescribing

It is important to have access to relevant information from the patient’s medical records before prescribing controlled drugs or medicines that are liable to abuse, overuse or misuse, or when there is a risk of addiction and monitoring is important. Exceptions to this are when no other person with access to that information is available to prescribe without unsafe delay and it is necessary to:

• avoid serious deterioration in health or avoid serious harm
• ensure continuity of treatment where a patient is unexpectedly without access to medication for a limited period.

In these circumstances, you should provide a limited quantity and dose – one that is sufficient to make sure the patient receives suitable care until a) they are able to see an appropriate health professional who has access to the relevant information from their medical records or b) you are able to verify that information yourself. In making this decision you should consider the possibility that the patient may be obtaining medicines from other sources.

Remote prescribing of controlled drugs

Remote prescribing has become much more common since the pandemic – either online, over video-link or by phone. There are potential patient safety risks, particularly when prescribing is not linked to a patient’s NHS GP or regular healthcare provider and there may be limited access to medical records.

GMC guidance on prescribing controlled drugs remotely highlights relevant safeguards including:

a. robust identity checks to make sure medicines are prescribed to the right person

b. if you are not the regular prescriber, check to make sure the patient has given consent for their regular prescriber to be contacted about their prescription (see paragraph 27)

c. making sure all relevant information about the prescription is shared with the patient’s GP or added to the primary care record (see paragraphs 56 to 57).

Patients should be given the names, roles and contact details of key people involved in their care, and advice on who to contact with any questions or concerns.

Supply, storage and disposal

Prescribers should keep a record log for the supply, administration, transfer and disposal of all controlled drugs and prescribe enough of a controlled drug to meet a patient’s clinical needs for up to but no more than 30 days (NICE NG46, para 1.5.5).

Should it be clinically necessary under exceptional circumstances to prescribe a larger quantity, the reasons for this should be clearly documented in the patient record.

Prescribers are also urged to provide advice and information to patients about how to store and dispose of controlled drugs safely. This could include providing advice on lockable storage boxes – to minimise the risk of a drug-related adverse incident.

Alternative interventions

Latest NHS data has shown that GPs and pharmacists working together have helped reduce opioid prescriptions in England by 450,000 in the last four years, and that in under three years the number of opioid painkillers prescribed has fallen by eight per cent, which is estimated to have saved nearly 350 lives and prevented more than 2,100 incidents of patient harm.

NHS England has unveiled a new action plan to further crack down on the overuse of potentially-addictive medicines, including action to assist patients who become dependent on addictive drugs and struggle with withdrawal.

Proposed alternative interventions to medicines should be considered and offered to patients when a prescription for a medicine associated with dependence and withdrawal symptoms is first considered, or when the prescription is being reviewed.

These can include alternative treatments and services such as self-management approaches – social prescribing, health coaching, psychosocial interventions, musculoskeletal clinics, mental health services such as NHS talking therapies, pain clinics and sleep services.

ACTION

• Keep up-to-date with guidance on prescribing controlled drugs.
• Check carefully to ensure the continued need for prescribing at current levels.
• Check that local storage protocols for controlled drugs are maintained and current.
• Monitor the efficacy of repeat prescribing policies in relation to controlled drugs.
• Provide clear advice to patients about the risks associated with opiate use.
• Access the MDDUS GP risk toolbox resource on prescribing.

Alan Frame is a risk adviser at MDDUS