Medico-legal: Advice on prescribing opioids

The MDU's Dr Ellie Mein advises on how to avoid the medico-legal risks associated with opioid prescribing.

Figures for England and Wales show a 10-year increase of more than 60% in opioid prescriptions – from 14.8m in 2008 to 23.4m in 2018, figures from NHS Digital show. A number of initiatives have been announced recently to try to tackle inappropriate use of opioids, due to growing recognition of the problems caused by overprescribing and dependency.

The University of East Anglia has produced a toolkit for tackling chronic opioid use in non-cancer pain. Meanwhile, this week SIGN published updated guidance for the management of chronic pain, which included new recommendations around opioid use.

NICE has also announced that it intends to develop guidelines on opioid prescribing and how to help patients withdraw from the drugs, although these are not due to be published until 2021.

Last month, CQC’s annual update for 2018 also included a report on ‘The safer management of controlled drugs’. It highlighted the varied problems that can occur including overprescribing and dependency upon opioid medications.

Medico-legal risks

GPs commonly ask the MDU for support with medico-legal investigations arising from prescribing opiate and benzodiazepine medication. Complaints and claims commonly allege that the GP did not adequately warn the patient about the risk of dependency or other side effects, should have tried an alternative treatment, or that not enough was done to help the patient with their addiction.

A previous analysis of MDU cases relating to opiate or benzodiazepine medication also highlighted the potential for more serious adverse outcomes relating to opiate prescribing with most cases relating to coroner’s inquiries.

One of the organisations reviewing how to improve opioid prescribing is the Faculty of Pain Medicine in partnership with Public Health England who have produced the opioids aware resource. This site provides information to allow a safe and effective decisions to be made in relation to opiate medication prescriptions.

Advice for GPs

When considering prescribing opioids, the recommendations below should be considered to help protect both patients and the prescriber.

1. Be aware that you are responsible for any prescriptions you sign. The GMC’s ‘Good practice in prescribing and managing medicines and devices’ makes this clear. It also states: 'You should prescribe medicines only if you have adequate knowledge of the patient’s health and you are satisfied that they serve the patient’s needs. As such, it is important that doctors ensure that when prescribing medications that they understand the benefits, risks (including any known allergies or co-morbidities), along with any potential drug interactions or side effects.'

2. Ensure patients are aware of the benefits, risks and alternatives of any medication prescribed when seeking their consent to prescribe. This can help to better inform patients about pain control, side effects, potential for addiction and how this can be avoided.

3. Document these discussions clearly in the medical records including clear documentation about the clinical indication to prescribe and the risks discussed. 

4. Document any further discussions about doses or formulations being altered. Patients should also be warned if they are being prescribed a new medication that could potentially interact with opioids.

5. If possible, patients should receive their prescriptions from the same doctor and be supplied by the same pharmacist. If this is not possible, clear records can help to avoid misunderstandings or errors.

6. Review prescriptions regularly to determine if the medications have been effective or have caused any difficulties. The advice from the opioids aware site is that the patient should be first reviewed within four weeks of treatment starting. Once the regime is established, longer term follow up should be at minimum six monthly intervals but this depends on whether the patient continues to have a good response with minimal side effects. Reviews may need to be more frequent in patients who require other interventions or display evidence to suggest misuse of their opioids.

7. Be aware that it is illegal for patients to drive with more than certain specified limits of controlled drugs in the bloodstream. Guidance is available for healthcare professionals to help them explain the relevant law to patients taking these medicines. 

  • Dr Ellie Mein is an MDU medico-legal adviser

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