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The pharmacist who tackled a patient’s ‘staggering’ fentanyl intake

“It’s becoming more difficult to monitor patients on opioids and benzodiazepines”

Danny Bartlett helped a patient who had been taking a heavy daily dosage of fentanyl with a five-point action plan

Further to my previous article on how my primary Care Network (PCN) is giving more comprehensive drug reviews – structured medication reviews (SMRs) – to patients in target groups, we have started to look at one group in particular. This is patients who are taking one or more than one of the following medications:

  • Opioids such as codeine and morphine
  • Benzodiazepines such as diazepam and temazepam
  • ‘Z-drugs’ such as zopiclone and zolpidem

We set out to target this group of patients, after we had completed our work reviewing the patients in our care home population, because they are generally an under reviewed and overlooked population.

With increasing pressure on GP practices and more prescription requests, it is becoming more and more difficult to safely monitor the frequency of requests from patients for the above groups of drugs while also trying to establish whether they are sticking to their prescribed dosages.

As a starting point, I decided with my pharmacy technician on an action plan – to split the total number of patients that meet the criteria into the following risk categories, with 1 being the highest risk.

1.              Patients taking more than one opioid regularly.

2.              Patients taking an opioid and a benzodiazepine regularly.

3.              Patients taking an opioid and a z-drug regularly.

4.              Patients taking a benzodiazepine and a z-drug regularly.

5.              Patients who take a single opioid regularly.

The categories allowed us to split up the very large group into more manageable chunks based on risk. The patients taking more than one opioid regularly were the most at risk of adverse events and overdosing due to, for the most part, a higher total oral morphine intake over differing formulations.

We now have those splits in front of us. Through the development of a specific data entry template, we can start to review the patients’ total daily oral morphine dose from all their different formulations, whether the patient is aware of the adverse effects and risks of dependence, and, most importantly, if the patient is willing to try to reduce their daily dosage.

These conversations can sometimes be difficult. However, as pharmacists we are best placed to look objectively at a patient’s medications and try and optimise their intake of these drugs in terms of formulation and timings with the aim of getting them on the most effective but safe dosage regime.

A key initial success story to come out of this project within my PCN was to reduce a patient taking a staggering 3mg of fentanyl daily, in the form of instant release lozenges for abdominal adhesion pain, down to 1.5mg daily.

This was achieved by changing to a more suitable and cost-effective dosage of sublingual tablets and by having regular phone calls to try to prevent her from relapsing. The patient’s pain levels remained in control. It became clear that the extra fentanyl dosage she was on gave no additional benefit to her pain levels.

There is still a very large amount of work to be done for this challenging patient population. Through a combined effort of data gathering and strategic medicines optimisation, we hope to benefit the patients being prescribed these medications.

Danny Bartlett is a senior clinical pharmacist for the Coastal & South Downs Care Partnership PCN

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