Care Right Now

Transforming Healthcare Together

  • 
  • 
  • 
  • 
  • Home
  • Patient Led Clinical Education (TM)
  • Resources, Events & Consultancy Services
    • Turn Up The Volume!
    • Speak Up For Learning © – Consultancy

Managing long term pain. Summary of NICE Key Therapeutic Topic.

August 1, 2017 By Steve Turner

Medicines optimisation in long-term pain.

‘#jargonbuster ‘Medicines Optimisation’ means getting the medicines right for the individual. This may involve an alternative medicine, an alternative treatment or approach, and / or not taking medicines. The person’s experience, beliefs and what matters to them most should drive this decision, with clinicians providing guidance, advice and education on trusted sources of information, the evidence base and on safety’. (Steve Turner)

#MedLearn #medsopt #NICEguidance #pain #selfcare #opioids

This is a brief summary relating to a new topic for the 2017 update of Medicines optimisation: key therapeutic topics

 

NICE Key Therapeutic Topics  pages 27 -33.  To access a pdf copy of the document click here.

The section on medicines optimisation in long term pain contains a huge amount of information, including links to numerous other documents, on an areas critical to patient safety & wellbeing.

Key points:

Opioids

  • There is little evidence that opioids are helpful for long-term pain.
  • Patient safety incidents relating to the unsafe doses of opiates remain a major concern. People develop a ‘tolerance’ to opiate medicines, meaning that higher and higher doses may be needed to deliver the same effect. However this tolerance rapidly goes away when the opiates are stopped, so restarting at the old dose may be fatal.

You can read the patient safety alert here: http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59888&p=3

This image is taken from: ‘Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain.

Click on the image to enlarge it.

Link: http://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware

Here’s’ an extract from Key Therapeutic Topics  (p.31, my underlining):

‘A review of medicines-related safety incidents involving controlled drugs reported to the NRLS over 7 years found the risk of death with controlled drug incidents was significantly greater than with medication incidents generally (odds ratio 1.48, 95% CI 1.02 to 2.17). Incidents involving overdose of controlled drugs accounted for 89 (70%) of the 128 incidents reporting death or severe harm. Five controlled drugs (morphine, diamorphine, fentanyl, midazolam and oxycodone) were responsible for 113 (88%) of these 128 incidents.’

Non-opioid medicines in long-term pain

  • Patients can be prescribed gabapentin or pregabalin for certain types of pain. Both of these medicines can lead to dependence and may be misused or diverted.

#jargonbuster ‘diverted’ = passed on or sold one to someone else.

Finally, emotional influences are real:

  • When assessing pain with someone it’s vital that clinicians take all aspects of the person’s life into account, including lifestyle, nutrition, hydration, social and housing factors, safeguarding, sleep and rest, other illnesses, emotional influences and their mental health.

And take a full history of medicines being taken, or recently stopped, including over the counter medicines, internet bought medicines, borrowed medicines and illicit substances.


Overall key points to remember on pain management:

  • Adopt a  holistic patient-centered approach

  • Aim to prevent acute pain becoming chronic pain

  • There is little evidence that opioids are helpful for long-term pain


Related Guidance:

NICE Guidance NG5 Medicines Optimisation

NICE Guidance CG76 Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence

NICE Guidnace CG173 Neuropathic pain in adults: pharmacological management in non-specialist settings

NICE Guidance NG59 Low back pain and sciatica in over 16s: assessment and management

Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain

NICE Guideline NG46 Controlled drugs safe use and management

 

NICE Guidance CG140 Palliative care for adults: strong opioids for pain relief

Care during the last 2 to 3days of life is covered bythe NICE guideline NG31 on care of the dying adult

Author: Steve Turner

Date published / updated: 1/8/2017

Filed Under: Care Right Now, Medicines, Medicines Optimisation, NICE, Prescribing, Substance Misuse

Multi-morbidity & polypharmacy (taking 4 or more meds.)

May 15, 2017 By Steve Turner

Multi-morbidity and polypharmacy (that’s taking four or more medicines)

Taken from NICE Key Therapeutic Topics  pages 5-10.

Key points:

  • People with multiple illnesses are often prescribed multiple medicines, with new medicines being added to counter side-effects of others. The actual benefits of doing this are hard to ascertain.

Taking multiple medicines involves increased risks.

  • Everyone with multiple illnesses should receive a holistic person-centred review of their medicines and share in the decision making of what they take. (My view takes this further. I’d say ‘be given the option to lead on the decision making of what they take’).
  • Polypharmacy (taking four or more medicines) can be divided into two categories. Appropriate polypharmacy, where the benefits and disadvantages have been fully evaluated together. Problematic polypharmacy, where this hasn’t been done and the benefits of the medicines are not realised, sometimes to the extent that they are making the person worse.
  • There are some useful tools which can be used to help evaluate appropriateness of medicines in individuals (described in the document). Additionally I’d add that motivational interviewing techniques and time to build trust of the patients are also vital.
  • Intentional non-adherence can be overcome in a trusting clinician patient relationship, which usually happens over time.

#jargonbuster ‘intentional non-adherence’ = not telling clinical staff what you are actually taking and/or not taking.


More on the NICE Key Therapeutics Document here:


Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed; MIHM

Steve is a nurse prescriber and NICE Medicines and Prescribing Programme Associate.

You can follow Steve’s tweets @SteveMedGov

Steve is an Ambassador for @MedicineGov

Posting on #mentalhealth #MedsOpt #MedLearn #NICEGuidance #PatientEducation #substancemisuse #selfcare #prescribing 

Search under #MedLearn

LinkedIn profile here: https://www.linkedin.com/in/sjturner/

For more on Care Right Now’s Patient Led Clinical Education work-streams click here: http://www.carerightnow.co.uk/projects/

‘Phone 01872 248327

Or email steve@carerightnow.co.uk

 

For part one of this blog ‘Medicines are overused’ click on the image below:


 

Filed Under: Academic Detailing, Elderly care, Jargon Buster, Medicines, Medicines Optimisation, NHS, NICE, Prescribing

Psychotropic medicines in people with learning disabilities – Guidance

May 15, 2017 By Steve Turner

Psychotropic medicines in people with learning disabilities whose behaviour challenges

 

Key Therapeutic Topics  from NICE pages 11-19.

Plus this Document ‘Stopping overmedication of people with learning disabilities’

https://www.england.nhs.uk/wp-content/uploads/2016/06/stopping-over-medication.pdf

In part one of this two part blog I suggested that patients themselves need to take more responsibility for the medicines they are prescribed.

But what about vulnerable groups who may depend on decisions being made for them, and in their best interests?

Click on the image to enlarge it.

Key points:

Facts:

  • Most of the prescribing in this area is ‘off label’ ( #jargonbuster – that’s medicines prescribed for something that isn’t listed as an ‘indication’ for that medicine ).
  • This prescribing can include multiple psychotropic medicines, often medicines in the same class and without relevant indications. There is no evidence base for this type of prescribing.

( #jargonbuster – psychotropic medicines = The phrase “psychotropic drugs” is a technical term for psychiatric medicines that alter chemical levels in the brain which impact mood and behaviour.)

  • Psychotropic medicines in people with learning disabilities whose behaviour challenges are not always prescribed by a specialist in this area.

Actions to take:

  • A Holistic assessment.

Before prescribing it’s important to understand all triggers and environmental factors. Reasons for behaviour now and what has happened in the past.

  • Specialist initiation and review of prescribing.
  • Multi-Disciplinary team involvement.
  • Best interests decisions, regularly reviewed.
  • A tiered approach to prescribing – ‘start low, go slow’.
  • Involvement of Second Opinion Appointed Doctors (SOADs) to provide a statutory safeguard where consent is an issue.

‘SOADs visit the person and explore the current and proposed treatment, certifying what is considered to be appropriate and reasonable in circumstances where the person cannot or does not consent to it, discussing it with team members and the person before reaching their conclusions.’

  • Clear documentation:
    • Of the holistic assessment
    • Of patient involvement
    • Of carer and family involvement
    • Of multi-disciplinary team involvement
    • Of the rationale for prescribing / not prescribing
    • Review dates and evidence of reviews
    • Monitoring of the effect of the medicine(s) that includes as required ‘prn’ medicines (Charts can be useful)
    • Evidence of changes in response to the medicine(s) not being as expected, including if the medicines has no effect, and the actions taken on this.

NICE Pathway – ‘Challenging behaviour and learning disabilities overview’

https://pathways.nice.org.uk/pathways/challenging-behaviour-and-learning-disabilities

 

This important subject deserves a blog of its own. Feedback and views welcome, send them to info@carerightnow.co.uk


More on the NICE Key Therapeutics Document here:


Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed; MIHM

Steve is a nurse prescriber and NICE Medicines and Prescribing Programme Associate.

You can follow Steve’s tweets @SteveMedGov

Steve is an Ambassador for @MedicineGov

Posting on #mentalhealth #MedsOpt #MedLearn #NICEGuidance #PatientEducation #substancemisuse #selfcare #prescribing 

Search under #MedLearn

LinkedIn profile here: https://www.linkedin.com/in/sjturner/

For more on Care Right Now’s Patient Led Clinical Education work-streams click here: http://www.carerightnow.co.uk/projects/

‘Phone 01872 248327

Or email steve@carerightnow.co.uk

 

For part one of this blog ‘Medicines are overused’ click on the image below:


 

Filed Under: Academic Detailing, Care Right Now, Children Health, Jargon Buster, Medicines, Medicines Optimisation, NHS, NICE, Prescribing

Medicines are overused (part 2) – Muti-morbidity, long term pain, learning disability

April 19, 2017 By Steve Turner

Engagement at Care Right Now

In this blog Steve Turner, Head of Medicines & Prescribing @MedicineGov looks at three key areas related to the use of medicines, taken from the NICE Key Therapeutic Topics (2017).

 


Notes on three key areas:

In this blog I look at three of the NICE Key Therapeutic Topics  (2017). This is a 127 page document 127 page document packed with useful information on ‘medicines optimisation’, that’s making the best use of medicines, or ‘getting the medicines right’

 #jargonbuster – Here’s my definition of Medicines Optimisation:

‘Medicines Optimisation is all about giving people the option to take the lead in finding ways get the best from their medicines. This includes the option not take medicines and to use alternative approaches. It involves regularly evaluating the situation. Allowing individuals to balance the risks and benefits based on trusted information.’

This is my personal definition. I welcome your views on it.

In the next three sections I look at three of the fifteen key therapeutic topics, give the document and page numbers, and very briefly summarise my take on them.

Of course this is no substitute for reading the full document. This is just to whet your appetite.

 


 1. Multi-morbidity and polypharmacy (that’s taking four or more medicines)

Key Therapeutic Topics  pages 5-10.

Key points:

  • People with multiple illnesses are often prescribed multiple medicines, with new medicines being added to counter side-effects of others. The actual benefits of doing this are hard to ascertain.

Taking multiple medicines involves increased risks.

  • Everyone with multiple illnesses should receive a holistic person-centred review of their medicines and share in the decision making of what they take. (My view takes this further. I’d say ‘be given the option to lead on the decision making of what they take’).
  • Polypharmacy (taking four or more medicines) can be divided into two categories. Appropriate polypharmacy, where the benefits and disadvantages have been fully evaluated together. Problematic polypharmacy, where this hasn’t been done and the benefits of the medicines are not realised, sometimes to the extent that they are making the person worse.
  • There are some useful tools which can be used to help evaluate appropriateness of medicines in individuals (described in the document). Additionally I’d add that motivational interviewing techniques and time to build trust of the patients are also vital.
  • Intentional non-adherence can be overcome in a trusting clinician patient relationship, which usually happens over time.

#jargonbuster ‘intentional non-adherence’ = not telling clinical staff what you are actually taking and/or not taking.


2. Long term pain

Key Therapeutic Topics  pages 27 -33.  This section contains a huge amount of information, including links to numerous other documents, on an area critical to patient safety.

Key points:

Opioids

  • There is little evidence that opioids are helpful for long-term pain.
  • Patient safety incidents relating to the unsafe doses of opiates remain a major concern. People develop a ‘tolerance’ to opiate medicines, meaning that higher and higher doses may be needed to deliver the same effect. However this tolerance rapidly goes away when the opiates are stopped, so restarting at the old dose may be fatal.

You can read the patient safety alert here: http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59888&p=3

This image is taken from: ‘Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain.

Click on the image to enlarge it.

Link: http://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware

Here’s’ an extract from Key Therapeutic Topics  (p.31, my underlining):

‘A review of medicines-related safety incidents involving controlled drugs reported to the NRLS over 7 years found the risk of death with controlled drug incidents was significantly greater than with medication incidents generally (odds ratio 1.48, 95% CI 1.02 to 2.17). Incidents involving overdose of controlled drugs accounted for 89 (70%) of the 128 incidents reporting death or severe harm. Five controlled drugs (morphine, diamorphine, fentanyl, midazolam and oxycodone) were responsible for 113 (88%) of these 128 incidents.’

Non-opioid medicines in long-term pain

  • Patients can be prescribed gabapentin or pregabalin for certain types of pain. Both of these medicines can lead to dependence and may be misused or diverted.

 #jargonbuster ‘diverted’ = passed on or sold one to someone else.

Finally, emotional influences are real

  • When assessing pain with someone it’s vital that clinicians take all aspects of the person’s life into account, including lifestyle, nutrition, hydration, social and housing factors, safeguarding, sleep and rest, other illnesses, emotional influences and their mental health.

And take a full history of medicines being taken, or recently stopped, including over the counter medicines, internet bought medicines, borrowed medicines and illicit substances.


3. Psychotropic medicines in people with learning disabilities whose behaviour challenges

 

Key Therapeutic Topics  pages 11-19.

Plus this Document ‘Stopping overmedication of people with learning disabilities’

In part one of this two part blog I suggested that patients themselves need to take more responsibility for the medicines they are prescribed.

But what about vulnerable groups who may depend on decisions being made for them, and in their best interests?

Click on the image to enlarge it.

Key points:

Facts:

  • Most of the prescribing in this area is ‘off label’ ( #jargonbuster – that’s medicines prescribed for something that isn’t listed as an ‘indication’ for that medicine ).
  • This prescribing can include multiple psychotropic medicines, often medicines in the same class and without relevant indications. There is no evidence base for this type of prescribing.

 ( #jargonbuster – psychotropic medicines = The phrase “psychotropic drugs” is a technical term for psychiatric medicines that alter chemical levels in the brain which impact mood and behaviour.)

  • Psychotropic medicines in people with learning disabilities whose behaviour challenges are not always prescribed by a specialist in this area.

Actions to take:

  • A Holistic assessment.

Before prescribing it’s important to understand all triggers and environmental factors. Reasons for behaviour now and what has happened in the past.

  • Specialist initiation and review of prescribing.
  • Multi-Disciplinary team involvement.
  • Best interests decisions, regularly reviewed.
  • A tiered approach to prescribing – ‘start low, go slow’.
  • Involvement of Second Opinion Appointed Doctors (SOADs) to provide a statutory safeguard where consent is an issue.

‘SOADs visit the person and explore the current and proposed treatment, certifying what is considered to be appropriate and reasonable in circumstances where the person cannot or does not consent to it, discussing it with team members and the person before reaching their conclusions.’

  • Clear documentation:
    • Of the holistic assessment
    • Of patient involvement
    • Of carer and family involvement
    • Of multi-disciplinary team involvement
    • Of the rationale for prescribing / not prescribing
    • Review dates and evidence of reviews
    • Monitoring of the effect of the medicine(s) that includes as required ‘prn’ medicines (Charts can be useful)
    • Evidence of changes in response to the medicine(s) not being as expected, including if the medicines has no effect, and the actions taken on this.

NICE Pathway – ‘Challenging behaviour and learning disabilities overview’

https://pathways.nice.org.uk/pathways/challenging-behaviour-and-learning-disabilities

 

This important subject deserves a blog of its own. Feedback and views welcome, send them to info@carerightnow.co.uk


Click here for part one of the blog


Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicinegGov and NICE Medicines and Prescribing Programme Associate

 

You can follow Steve’s tweets @MedicineGovSte   hashtag #MedLearn

 

 

 

 


Version 2

Last updated: 8/12/2017

 

Filed Under: Care Right Now, Jargon Buster, Medicines, Medicines Optimisation, NICE, Prescribing, Substance Misuse

Medicines are overused – what can we do? (part 1 of 2)

April 10, 2017 By Steve Turner

In this blog Steve Turner, Head of Medicines & Prescribing @MedicineGov,  reflects on ways to reduce unnecessary use of medicines. Bringing together the need for more patient education with ways to negotiate the many rules and guidelines which can overwhelm us all.

 

My experiences and learning

I was speaking about the use of medicines at a conference recently when I mentioned that medicines are ‘over prescribed’. Although nobody questioned and challenged me on this I was troubled by my use of this expression. By saying medicines are prescribed too frequently it seems to me this can be interpreted as a bad reflection on the prescribers.

As I mentally mulled this over (I’m not a quick thinker) I came to the conclusion that the expression should be ‘medicines are overused’. After all it’s us (the patients) who go to our Doctors, Pharmacists and Nurses and us who accept their prescriptions. Therefore if we agree that people can rely too heavily on medicines, and there’s wealth of evidence for this, then we need to sort this out together.

My social enterprise company’s Patent Led Clinical Education work has shown us that a large section of the population is prescribed multiple medicines, with potential for interactions and increased side-effects. In addition it’s widely accepted that 50% of the population don’t take their medicines as prescribed. Add to this the sometimes forgotten fact that many people use alternatives (including street drugs), buy medicines over the internet and even borrow medicines from other people. It’s no wonder we have a problem.

The human and financial costs of over use of medicines are immense.  In our education sessions we have learned that many people don’t know what their individual medicines are for, and medicines prescribed purely to counteract the side-effect of another medicine can pile up.

In fact so far nobody who has attended one of our sessions (n=140) expressed a wish to take more medicines, and those who did express a view all said that they didn’t want to take medicines if they didn’t have to.

 

So what can we do together?

The next section looks at how to make sense of the vast amount of guidance available and describes why ‘trusted information’ is important in making decisions about medicines, including on when not to take them.

Overwhelmed by the information, policies & guidance?

There’s an overwhelming amount of information and guidance on medicines, coming out on a daily basis. Even clinicians struggle to keep up and need help.

Two things are important in trying to make sense of this information overload.

  1. Making sure that the information you are looking at is from a ‘trusted’ source
  2. The need to differentiate between different sources of information e.g. primary research, systematic reviews, evidence summaries and media reports.
  3. Relating information on the use of a single drug or treatment to the real world.

The first two points will be covered in future blogs. Here and in the second blog, I’m concentrating on guidelines and their use.

The National Centre for Heath and Care Education [NICE] in England produces guidance, standards, indicators and evidence services covering health and social care. It’s not just about medicines. There’s a massive amount of trusted information on their web site, which covers:

  • Conditions and diseases
  • Health protection
  • Lifestyle and wellbeing
  • Population groups
  • Service delivery, organisation and staffing

To get a feel for this one place to start is the NICE Pathways, where you can browse the topics, pick one and have the information presented in a diagram, where you can click on the headings for more information.

Recently there has been a move away from producing guidelines on a single illness or condition to a more holistic person based approach. This better reflects the complexities of real life, where it would often be a luxury to have just one illness with no complicating factors. NICE guidance on medicines optimisation, multi-morbidity clinical assessment and management, and patient experience in adult NHS services are good examples.

In addition NICE produces a document on Key Therapeutic Topics as part of the NICE Medicines and Prescribing Programme. This is a 128 page document covering 11 topics in all and is reviewed and refreshed annually.


Click here for part two

Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicineGov and NICE Medicines and Prescribing Programme Associate

 

You can follow Steve’s tweets @MedicineGovSte   hashtag #MedLearn

 

Or email steve@carerightnow.co.uk

Version 2

Last updated: 8/12/2017

 Care Right Now Logo

Filed Under: Care Homes, Care Right Now, Elderly care, Jargon Buster, Medicines, Medicines Optimisation, NHS, NICE, Prescribing

  • 1
  • 2
  • 3
  • Next Page »

Want to make your life easier? Join our community of practice:

Sign up here to share best practice tips, and receive short messages, key information and links to help prevent re-inventing the wheel.

Tweets

#harmreduction twitter.com/Release_…

About 6 hours ago from #MedLearn Medicines Prescribing Head Steve 🚑 🔬🌐's Twitter via Buffer

#medicines #pescribing #medicationsafety #medicinessafety twitter.com/Medicine…

Yesterday from #MedLearn Medicines Prescribing Head Steve 🚑 🔬🌐's Twitter via Buffer

Steve Turner talking about the new 'You're in Charge' sessions on mental wellness Find out more here: nice.org.uk/sharedle… #MedLearn #Sharedlearning #prescribing #MedEd #nursing #wemdt #PUNC14 youtu.be/R5Oqj5NsseU

Yesterday from #MedLearn Medicines Prescribing Head Steve 🚑 🔬🌐's Twitter via Twitter Web Client

I asked Sam what persuades people to go along with their clinician's suggested plan, and what put a them off. youtu.be/nZaiUtQEk9s #MedLearn #PUNC14 #wemdt

Yesterday from #MedLearn Medicines Prescribing Head Steve 🚑 🔬🌐's Twitter via Twitter Web Client

#MedLearn twitter.com/Medicine…

Yesterday from #MedLearn Medicines Prescribing Head Steve 🚑 🔬🌐's Twitter via Buffer

Follow @MedicineGovSte

Want to make your life easier?

Sign up here to receive best practice tips and receive short messages, key information and links to help prevent re-inventing the wheel.





Your Name (required)

Your Email (required)

Subject

Connect With Us

Care Right Now

Company number: 07587531

Registered Office,

Bennett Jones & Co.,

Unit 22, Callywith Gate Industrial Estate,

Launceston Road,

Bodmin, Cornwall,

England, PL31 2RQ

M:07931 919 330

E: info@carerightnow.co.uk

  • Privacy Notice

Copyright © 2019 — Care Right Now • All rights reserved. • Company Structure• Blog • Disclaimer

WordPress • Log in