Quality prescribing for chronic pain 2026-2029: consultation

17. Appendix D: Example GP practice policy for opioid deprescribing in chronic pain

Example of a GP practice opioid prescribing policy

Starting patients on prescription opioid medication

Step 1: Biopsychosocial assessment of diagnosis, pain and function

• Avoid opioids in chronic primary pain, low back pain, headache and fibromyalgia, and in cases where there is no specific diagnosis
• Assess baseline pain and function using, for example, the Brief Pain Inventory Brief-Pain-Inventory.pdf (scot.nhs.uk) or the health check tool Live Well with Pain Health and Wellbeing Check tool - Live Well with Pain
• This includes screening for major medical co-morbidities and psychosocial factors
• See attached suggested GP consultation model for chronic pain.

Step 2: Consider Non-Opioid Therapies

• Non opioid medication including topical therapies, graded exercise, and psychological support strategies
• If neuropathic pain is present, consider neuropathic pain treatment or refer to local neuropathic pain guidelines
• Please see attached blog on biopsychosocial approach to chronic pain management and links to useful resources. GGC Medicines: Realistic Medicine - Chronic Non-Malignant Pain Management

Step 3: Assess Risk of Harm of Misuse from Using Opioids

• Individuals at increased risk of substance use BEFORE starting opioids are those who:
  • Have a history of recreational substance use or alcohol dependence.
  • Have a history of, or are currently experiencing, mental health problems.
  • Have a history of preadolescent sexual abuse.
• Consider risk factors for substance use and assess using a validated scoring tool such as The Opioid Risk Tool opioidrisktool.pdf (nih.gov) or DIRE score for opioid treatment DIRE Score for Opioid Treatment (mdcalc.com)

Step 4: Talk to Patient About Treatment Plan

• Set realistic goals for pain reduction typically aim for approximately 30% pain reduction with functional improvement, or pain intensity rating to justify ongoing opioid use
• Discuss benefits, side effects and risks of prescription opioids and provide information.
• Describe the opioid trial including upper limit of dosing
• Set criteria for stopping opioid such as failure to meet goals, no clear evidence of a dose response, or rapid development of tolerance requiring higher doses of opioids
• Plan review appointments, initial assessment should be 2-4 weeks from starting opioid, thereafter at appropriate regular intervals
• Document details of discussion with patient, including acceptable behaviour in relation to medication use as well as driving
• Check patient understands treatment plan

During Opioid Trial

• Encourage the patient to keep a diary during the opioid trial
• Assess within one to two weeks of starting trial using, for example, using the PADT tool. PainAssessmentandDocumentationTool.pdf (krhamaine.com)
• Assess pain and function compared to baseline at two weeks
• Observe for signs of aberrant behaviour, substance use and addiction using the PADT tool. If suspicious, urine screen for relevant substances can be done.
• In our clinical experience, if no clinically meaningful improvement in pain and function at a dose of 40mg oral morphine equivalent in 24 hours then it is very unlikely that continuing opioid therapy will be helpful. It is also unlikely that an alternative opioid will be effective. Wean and discontinue the opioid medication.
• Do not continue prescribing opioids if the trial has failed even if there is no alternative analgesic
• If there is improvement in pain symptoms and/or function, patients could be considered for continuing opioid prescription, for a planned period of time.

Continuing Opioid Prescribing (After a Successful Trial)

• There is no promotion of strong opioids in current guidelines for chronic pain
• Weak opioids such as co-codamol on a when required basis to allow activity such as walking the dog should be considered.
• All opioid medication to be put on acute prescription initially with Pharmacy Text stating “this medication should not be continued past date (three months from when initiated) without review” to prompt a review with GP and discussion about chronic pain management.
• If a prescription for an opioid has to be continued it can be moved to repeat with a limited number of issues and a Pharmacy text stating “due a medication review on date”
• Use oral route; do not initiate subcutaneous, intravenous or any parenteral route of administration
• Use the lowest possible dose. Avoid doses >90mg/day morphine equivalent (specialist advice required if doses are escalated beyond this threshold)
• There are no high quality randomised controlled trials to suggest that one opioid is more effective than another. If there is NO clinical benefit with a full trial of one opioid, we would not encourage further opioid trials in primary care – seek expert advice.
• Arrange regular review e.g.3-6 monthly, ideally with a single prescriber. Consider using the PADT tool
• At each review, aim for use of the lowest possible dose and consider tapering if possible
• Agree a plan with the patient to manage flare ups.
• Be aware of side effects resulting from continuing use of opioids. These include tolerance, withdrawal, cognitive impairment, weight change, reduced fertility and irregular periods, erectile dysfunction, hyperalgesia, depression, dependence, addiction, reduced immunity, osteoporosis and constipation
• Consider prescription of naloxone.
• Remember that Oxycodone is double the strength of morphine and Fentanyl is 50 to 100 times more potent
• There is an opioid calculator on the pain data website for converting opioids to morphine equivalent. See resource 9. This website also includes NHS GG&C pain guidelines and a tapering tool

Practice policy for prescribing/documenting all opioids

• Indication for opioids will be documented
• Plan for stopping and withdrawing made clear from outset
• Patients will be advised on the potential problems of dependence, falls and driving impairment, and document in records.
• If opioid drugs are to be initiated then include a caution message on the label e.g. “Warning this drug may cause dependence on long-term use” Do not add opioids to repeat prescription
• All opioid medication to be put on acute prescription initially with Pharmacy Text stating “this medication should not be continued past date (three months from when initiated) without review” to prompt a review with GP and discussion about chronic pain management.
• If a prescription for an opioid has to be continued it can be moved to repeat with a limited number of issues and a Pharmacy text stating “due a medication review on date”
• Lost prescriptions will not be replaced except in exceptional circumstances as agreed by GP
• If a patient takes higher doses than prescribed, and runs out of medication before the next prescription is due, they will not be prescribed extra tablets unless in exceptional circumstances as agreed by GP
• Display a poster to inform patients of the practice policy in the waiting area
• Encourage practice staff to make patients aware of the new policy when requests are made for opioids

Existing patients in the practice on an opioid

• Should be informed of policy as outlined above. Letters will be sent out to patients, posters will be displayed in waiting area, reception staff to inform patients when ordering opioid drugs, text message sent to patients informing of policy, notes attached to prescriptions

Opioid tapering

• Agree dispensing intervals
• Where possible, consolidate all strong opioids into one single modified release preparation without breakthrough doses
• Can use the following tool to work out the morphine equivalent dose of all of the opioids combined
• Do not prescribe two opioids e.g co-codamol and morphine
• Do not prescribe PRN doses
• Optimise non-opioid and self-management elements of pain management
• Provide written information on opioid tapering. The more harm than good leaflets are useful 2024_Codeine-MHTG.pdf (SECURED) (paindata.org), 2024_Dihydrocodeine-MHTG.pdf (SECURED) (paindata.org), 2024_Tramadol - MHTG.pdf (SECURED) (paindata.org), 2024_Co-Dydramol - MHTG.pdf (SECURED) (paindata.org), 2024_Co-Codamol - MHTG.pdf (SECURED) (paindata.org)
• Document decision to taper/stop and agree taper schedule
• Move the opioid to acute when on a tapering schedule. Put a Pharmacy Text on the prescription stating “On a reducing dose” to highlight that this patient is actively trying to reduce their opioid dose.
• For information on what to discuss with patient when tapering medication see Tapering and stopping | Faculty of Pain Medicine (fpm.ac.uk)
• Usually reasonable to reduce by 10% of original dose every 1-2 weeks as tolerated (higher risk patients may require smaller decrements or longer intervals between dose reductions). Use taper tool from pain Data.
• Plan for short term pain flares and for opioid withdrawal Managing setbacks - Live Well with Pain
• Patients will be regularly reviewed by Practice Pharmacist/GP Frequency of review depends on rate of taper and degree of support required e.g. if reducing every 1-2 weeks, monthly review may be appropriate
• Ideally, same clinician will review patient each time prior to next reduction
• Ask about improvement in function and reduction of side effects as well as pain and withdrawal symptoms
• Ask about mental health symptoms

Newly registered patient already taking opioids

• Should be informed of policy as outlined above
• Should be reviewed by one of the GPs (and/or PSP) to discuss implementing a plan to step down/stop the drug(s) in a structured and supported manner.