Opioids

Errors in the use of opioids can occur at any stage of the medicines pathway. Choice of treatment, prescribing, dispensing and administration all provide opportunities for error. The biological effects of opioids make errors particularly hazardous.

The NPSA tells us that nine of the 12 reports of severe harm or death due to opioids were associated with overdose. It is imperative that every patient receives the appropriate dose of opioid and that patients receiving opioids are monitored regularly (Safety in Doses 2007).

When opioid medicines are prescribed, dispensed or administered, the healthcare practitioner concerned should ensure:

1. They are familiar with the following characteristics of that medicine and formulation: usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose and common side effects.
2. They have, whenever possible, taken full account of the patient's medication history.

Prescribing

Prior to prescribing opioid medicines, the prescriber should check the most recent dose, formulation and frequency of administration.

Ensure all Discharge Advice Notes with opioid oral solutions include the strength and check the dose intended if they do not.

Ensure the dose is safe for the patient. Dose increases should not normally be more than 50% higher than the previous dose.

Oral sustained-release opioids are a particular source of error and care should be taken to avoid any possible ambiguity when prescribing these drugs. Including the brand name on the prescription and dispensing label will aid in the identification of the correct formulation to be dispensed or administered.

All dose calculations of strong analgesics should be double-checked preferably by a second clinician.

Always follow the Analgesic Pain Ladder prior to initiating strong opioids.

Clinical Guidelines on the use of opioids are available on Leeds Health Pathways (NHSnet connection required)

Additional guidance on dose equivalents can be found here. (UKMI)

Leeds Palliative Care offers educational events for GPs.

An audit of prescribing of opioids in chronic pain can be found here.

 

Dispensing

Ensure the dose is safe for the patient. Dose increases should not normally be 50% higher than the previous dose.

All prescriptions dispensed for individual patients to take at home should be double-checked for accuracy.

Substance Misuse Dispensing Services

Dispensing to the wrong patient, dispensing without a valid prescription and dispensing after 3 days of abstinence were the three most commonly reported errors when dispensing methadone or buprenorphine against FP10MDAs. In the last year these errors accounted for 15 error reports received by NHS Leeds.

To avoid dispensing to the wrong patient:

• It is critical that the patient states their name and address/DoB and that this is checked against the physical prescription at every dispensing.
• Pharmacists must do this on every occasion regardless of how well known the patient.
• An obligation to provide this information could be placed in the client contract.

To avoid dispensing without a valid prescription:

• There must be a system for clearly highlighting when an FP10MDA is due to finish, or to record on the form if it has been stopped (or has had its final installment supplied).
• The prescription should be endorsed at the time of supply and removed from the batch of valid prescriptions at the time of endorsing.
• Completed and stopped prescriptions should be stored separately from current prescriptions.

To avoid dispensing after 3 days of abstinence:

• A telephone call to the Community Drugs Team is necessary if a patient has not collected 3 or more days supply of methadone or buprenorphine. This is to protect the patient from overdose as a 3 day abstinence is sufficient to reduce the patient’s tolerance. Confirmation that the prescription is safe to dispense must be sought before supply can be made.

Avoiding accidental overdose.

Appling the following warning to all take-home doses of methadone will help to avoid accidental overdose:

“This Methadone is for your use only. Small amounts of this can KILL somebody else. Store safely”

Stickers with this warning on can be ordered by pharmacies in West Yorkshire from the West Yorkshire Central Services Agency (WYCSA).

 

Patches 

Opioid patches have been the subject of numerous local incidents. A description of the incidents and suggestions on how to keep patients safe can be found here. 

Injections.

Managing the availability of high dose morphine and diamorphine is recommended by the NPSA to reduce accidental overdose at the point of administration. More information can be found here.

Local Incidents

The majority of opioid incidents reported locally relate to the dispensing of methadone and buprenorphine for substance misuse.

This includes:

¨      Dispensing the incorrect dose of methadone due to “wrong patient” or wrong prescription dispensed from.

Other reported incidents are:

¨      Prescribing and dispensing of oral morphine Concentrate 10mg/ml to opioid naïve patients leads to 2 deaths (nursing home patients)

¨      Prescribing and dispensing of Oxycodone Conc oral solution 10mg/ml to patient leads to toxicity and admission to hospice. Dose issued as 2.5-5ml when should have been 2.5-5mg.

¨      Prescription for oramorph 10mg/5ml with dose of 2.5-5mg when required labeled as 2.5-5ml when required

¨      Dispensing of MST 100mg against Prescriptions for 10mg.

¨      Death from overdose with methadone by opioid naïve patient (patient took partners dose)

¨      Dispensing wrong modified release formulation of morphine (once daily formulation against a prescription for twice daily formulation)

¨      Dispensing of modified release preparations of oxycodone against prescriptions for standard release. 

¨      Palliative care prescribing of fentanyl patch without being stable on oral strong opioid and without short acting opioid. (left patient in moderate pain for a short period)