Opioids: the important gatekeeping role of UK pharmacists in supporting safe prescription
In our report in September 2017 we examined the steep increase in the use of prescription and non-prescription opioids in the United States and Canada, and fears that Europe may face a similar epidemic.
We now take a closer look at the extent of opioid use in the UK, the steps being taken to address this, and the potential impact on insurers.
In March 2017, a British Medical Association publication, Chronic Pain: supporting safer prescribing of analgesics, reported that:
- There has been a sharp and sustained increase in the prescription of opioid painkillers in recent years. The latest figures from 2014 show that 22.75 million prescriptions were written in England with a total cost of nearly £305 million to the NHS.
- The number of opioid analgesics prescribed in general practice in England increased by 1.5 million between 2008 and 2013.
- Between 2010 and 2014 the use of morphine rose by 66% from 2.44 million prescribed items to 4.05 million.
In January 2018, Public Health Minister, Steve Brine, commissioned Public Health England to undertake an independent review into the increased prescription of and dependence on “addictive medicines” in the UK, with prescriptions of such medication having risen by 3% over the past five years. Included within the scope of the review are antidepressants, benzodiazepines and Z-drugs (sometimes used to treat anxiety, sleeping problems and other disorders), and opioid pain medicines. The findings of the review are awaited.
In addition, on 12 February 2019, a government Expert Working Group (EWG) met at the Medicines and Healthcare Products Regulatory Agency, to begin a review of the benefits and risks of opioid medicines. Drawing on best practice internationally, the aim is to ensure that information for patients and health professionals “helps curb the over-prescription and misuse of these medicines”. As part of the review, the EWG will also “consider the current data on the utilisation of opioid-containing medicines in the UK, both prescribed and over the counter”.
Opioids Aware and the role of the pharmacist
A resource for patients and healthcare professionals to support safe and effective prescription decisions in relation to opioids, known as “Opioids Aware”, was developed (and launched at the end of 2015) by UK healthcare professionals and other stakeholders including the Royal Pharmaceutical Society, the British Pain Society, Public Health England, NHS England, NICE, and the Care Quality Commission.
The role of those prescribing opioids is clearly central to the safe prescription of opioids, but the guidelines set out in this resource also place significant obligations on pharmacists, within this process, notably as follows:
- Pharmacists should ensure that analgesics available ‘over the counter’ containing codeine or dihydrocodeine are only used for acute pain of short duration (less than three days).
- Pharmacists must ensure the prescribed dose is appropriate and dose increases are proportionate.
- Pharmacists are able to support monitoring of effectiveness and tolerability of opioids by carrying out Medicine Use Reviews.
- By taking a proactive approach, pharmacists may highlight excessive or unusual doses and can request a review by the primary prescriber.
Potential claims and the impact on insurers
Several high-profile court cases in the US including those involving pharmacists, who dispensed opioids that were allegedly misused by individuals that subsequently overdosed and died, have already been reported and highlight the importance of the role of the pharmacist.
Government efforts to ensure safer prescription and use of opioids are clearly welcome and will hopefully lead to the intended outcomes. Alongside this, greater public awareness and in particular, an apparent widening of the obligations on pharmacists, also raises the potential for a trend towards liability claims for over-prescribing (or in the case of a pharmacist for failing to sense-check the doctor’s prescription) and/or failing to adequately advise patients on those risks associated with using opioids.
Where the conduct of both the prescribing doctor and a pharmacist is held to be negligent, a significant question that arises is how liability will be apportioned and is a matter which is likely to be highly dependent on the circumstances of each individual case.
The Opioids Aware guidelines and the awaited outcome of the current Government reviews should greatly assist in regulating the prescribing and monitoring of the safe use of opioids. However, insurers of opioid prescribers and pharmacists should be aware that the risk of negligence claims against their insureds could also be on the rise, which may provide for some potentially complex litigation ahead.
Related item: The opioid epidemic: a painful threat to Europe?