(ID: 218) Evaluating the impact of a quality improvement bundle to reduce opiate over prescribing in urban general practice in Scotland

Introduction Chronic pain is a common complaint in primary care with the prevalence of chronic pain estimated to affect between 33–50% of the UK population [1]. Often chronic pain is treated with analgesics such as opiates. However, inappropriate opiate prescribing is associated with long term dependence, overdose risk and poor pain management outcomes [2]. NICE guidelines on chronic pain (NG193) advocates for reducing opiates for chronic pain due to lack of effectiveness and potential long-term adverse effects and focusing on a more holistic self-management approach to manage chronic pain [3]. Overprescribing of analgesics and lack of education and awareness of how to manage long-term chronic pain presents a significant challenge in primary care. Aim To evaluate the impact of a quality improvement (QI) bundle to reduce opiate prescribing and enhance chronic pain review process in a large GP practice. Methodology Using the Institute for Healthcare Improvement (IHI) Model for Improvement the practice identified key drivers influencing opiate overprescribing and suboptimal care of patients with chronic pain [4]. These were mapped using a driver diagram and a bundle of QI interventions were agreed upon. The “bundle” of interventions included a custom prescribing record template to improve documentation of the review itself, introduction of a pharmacist-led chronic pain clinic, MDT training and a directory of self-management resources for clinicians to provide to patients. A quality improvement strategy using iterative Plan-Do-Study-Act cycles was undertaken to assess the impact of these measures within the practice. Public Health Scotland prescribing data [5] was also reviewed to measure Defined Daily Doses (DDD’s) of strong opiates per 1000 patient’s list size per day to assess opiate prescribing rates at baseline and then three-monthly intervals over a 9-month study period. Audit was also conducted on the number of patients coded as having a diagnosis of chronic pain, having documented chronic pain review and provision of self-management information. No ethical approval was required for this study as it pertained to service improvement work. Results Over the 9-month study period opiate prescribing decreased from 12.77 to 11.57 DDDs per 1000 patients list size per day. Coding of chronic pain and chronic pain review improved from 0.88% to 7.6% and the provision of self-management advice increased from 0.44% to 3.84%. These results indicate improved identification and management of patients with chronic pain. Discussion The “bundle” of interventions contributed to improvements in opiate prescribing as well as improving the chronic pain process in relation to coding and provision of self-management information. The initial stages of the project proved most difficult as a culture change within the practice was needed. It required all members of the team to engage with patients and be willing to have some challenging conversations in relation to opiate use. Chronic pain reviews can be time consuming, and this work required significant input and time investment from the MDT team and consideration needs to be given to the impact of this on other practice work. The impact of the interventions was limited due to clinical capacity within the team.