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Prescribing Matters Newsletter Article - Medication errors and opiate prescribing

Prescribing Matters Newsletter Article

Medication errors and opiate prescribing

The LMC is regularly involved in representing and supporting doctors who have been identified as having “performance” issues. The LMC has identified a number of themes which recur and this feature will highlight these, so that our members can avoid these pitfalls.

A recent article presented in the BMJ details a case of an elderly man with dementia who died following Tramadol overdose (BMJ, 2020). The patient had amassed a large quantity of unused prescription drugs at home after receiving 100 capsules of Tramadol every month over an extended period. The coroner in this case highlighted the importance of monitoring repeat prescriptions adequately, checking compliance and adherence. This is particularly important in high risk patient groups such as the elderly and those with a history of dependence or mental health problems.

The most common type of prescription error found in the 2012 PRACtICe study was “incomplete information” where no strength or route was specified on the prescription and where an “unnecessary drug” was prescribed. Failure to request drug monitoring has also been highlighted as a patient safety risk.

Medication and prescribing errors in general practice are common, around 1 in 20 GP prescriptions will have an error (NHS, 2012) (Avery T, 2012). Medication errors are an obvious patient safety concern and they create more work for GPs and practice managers. There continue to be instances where inaccurate or inappropriate prescriptions have led to harm to patients and distress for the prescriber involved. To avoid these occurrences, this “prescribing matters” will give advice on how to avoid these errors.

Opioid prescribing

When considering commencing an opioid take into account any mental health co-morbidities and history of addiction to drugs or alcohol. For those patients who are frail, elderly or with a history with mental health problems there should be a robust system in place to regularly review the opioid prescribing regime, compliance and associated risks.

Careful consideration should be given to prescribing to opioid-naïve patients, the elderly and those with renal failure. Opioids are not indicated for headache, back pain or fibromyalgia/chronic widespread pain. The reason for starting an opioid for non-malignant pain needs to be documented clearly, along with specific goal setting and if necessary, consider an opioid contract.

GPs should not prescribe opioids to patients with chronic pain because of the risks of causing harm (NICE, 2020). Repeated administration of opiates may cause dependence, tolerance or opioid-induced hyperalgesia. Long term use of opioids (beyond 6 months) is associated with increased risk of dependence and there is little evidence that opioids are helpful in chronic pain. Instead GPs should consider alternatives such as antidepressants, exercise, CBT, acupuncture and referral to a pain management programme (NICE, 2020).

Do not prescribe more than one type of opioid unless under specialist advice. Strong opioids at high doses do not necessarily provide complete pain relief and the patient should be counselled regarding this. Opioids should be prescribed in controlled-release formulations with a quick release formulation for breakthrough pain co-prescribed. Avoid large doses for breakthrough pain. Morphine sulphate oral solution 10mg/5ml should never be prescribed ‘as required’ instead a prescribed dose, route and dose interval should be specified.

In general opioids should not be added to repeat prescriptions. However if there is a documented positive benefit from the opioid then short-term repeat prescriptions could be considered and reviewed regularly e.g. twice a year (CCG, n.d.). It is recommended that a short term treatment regime should be agreed with the patient prior to starting the drug, and this clearly documented e.g. with an opioid contract. This can be accessed via Ardens.

Z-drugs such as Zopiclone should only be used for a maximum of two weeks so early discussion with the patient and goal setting is also advised or these drugs should be avoided.

Other prescribing considerations

Prescription mistakes can also be made during medicines reconciliation in hospital and when prescriptions are made in outpatient clinics. It is important to remember that you are responsible for any prescription you sign even if it is on the recommendation of a hospital specialist. The GMC advises that you must “satisfy yourself that the prescription is needed, appropriate for the patient and within the limits of your competence”.

For any drug, the prescriber should specify the drug dosage along with the frequency including if the drug should be taken morning or evening. It is unsatisfactory to write ‘as required’ or ‘once daily’ on a prescription as this does not give enough information to the patient about the route of administration or when to take the drug. For example alpha blockers e.g. tamsulosin should be taken at night to avoid postural hypotension and reduce the risk of falls.

Methotrexate should be given once weekly and this should be specified on the prescription to reduce the risk of fatal overdose by inadvertent daily dosing. The BNF states, where possible the day of the week for dosing should be written in full in the space provided on the outer packaging. Patients and carers should be made aware of this and of the potentially fatal risk of accidental overdose if taken daily.

Bisphosphanates such as alendronic acid are strictly for once-weekly administration and the prescription should detail the following instructions “the dose should be taken with plenty of water while sitting or standing, on an empty stomach at least 30 minutes before breakfast. Patient should stand or sit upright for at least 30 minutes after administration (BNF, n.d.). Other bisphosphonates such as Zolendronic Acid are injectable therefore the route needs to be specified on any bisphosphanate prescription.

Avoiding the pitfalls

The LMC suggests prescribers should take the opportunity during consultations to review repeat medications, check adherence and consider de-prescribing to avoid drug interactions and reduce polypharmacy.

If a new repeat medication is to be commenced you should specify a review date and the duration of treatment. Avoid prescribing opiates except in acute, malignant and end of life care. Be open and honest with patients about their prescription, discuss risks, side effects and recommend a pharmacist “new drug review”.

Be particularly cautious about repeat prescriptions for opiates.

When electronically prescribing a new medication, prescribers should review the prepopulated instructions that automatically enter onto the prescription to ensure accuracy. Practices should consider adopting computer-based formularies of commonly used prescription directions so they do not need to be manually typed into systems each time.


Works Cited

Avery T, B. N. e. a., 2012. Investigating the prevalence and causes of prescribing The PRACtICe Study, s.l.: GMC.

BMJ, 2020. Coroner warns about poor drug reviews after patient dies from tramadol overdose. BMJ, 370(m3101).

BNF, n.d. Alendronic Acid. [Online]
Available at: https://bnf.nice.org.uk/drug/alendronic-acid.html
[Accessed 19th January 2021].

CCG, D., n.d. South West Devon Formulary & Referral: Management of Opioids. [Online]
Available at: https://southwest.devonformularyguidance.nhs.uk/formulary/chapters/4.-central-nervous-system/management-of-opioids
[Accessed 19th January 2021].

NHS, 2012. prescriptions 1 in 20 has an error. [Online]
Available at: https://www.nhs.uk/news/medication/prescriptions-1-in-20-has-an-error/
[Accessed 12/01/2021 January 2021].

NICE, 2020. Chronic pain in over 16s: assessment and management. [Online]
Available at: https://www.nice.org.uk/guidance/GID-NG10069/documents/draft-guideline
[Accessed 19/01/21 January 2021].