Shared learning database

Velindre Cancer Centre
Published date:
December 2013

In 2012, in response to NICE Guideline CG140 (Opioids in Palliative Care), our team created an Opioid Patient Information Manual, which received governance approval in two NHS Trusts and was also adopted by the Wales Medicines Strategy Group. NICE recommended that strong opioid prescribing in palliative care should be backed up with understandable written guidance. We decided to evaluate the effectiveness of our written opioid manual and conducted a NICE clinical audit (full audit cycle) at Velindre Cancer Centre in Cardiff. This example updates the previous version located here.

Authors: Dr Mark Taubert, Consultant in Palliative Medicine, Velindre Cancer Centre & James Holloway, Medical Student at Peninsula College of Medicine and Dentistry.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Opioids are offered frequently in palliative care to help reduce both pain and breathlessness. The initiation and titration happens in wards, clinics and in outpatient settings. As their prescription sometimes forms part of a much wider consultation on disease status and other important matters in the palliative care context, it can be difficult for a patient (and their carer) to take in all the relevant information with regard to taking these strong medicines. Information tends to be verbal and is not always backed up by written guidance. Yet these are complicated medicines to take with varying dosing regimens and they can carry a lot of stigma and even fear for some people. Patients (and carers) can be left concerned or frightened about possible side-effects, addiction potential, or even feel that taking these drugs implies they are reaching the end of their lives and this can adversely affect compliance. NICE have recommended that strong opioid prescribing in palliative care should be backed up with written guidance. See the recommendations.

Reasons for implementing your project

In response to the publication of NICE Guideline CG140, our team were approached asking for written guidance to offer patients who are started on strong opioids. A patient information manual was created, with feedback from patients, carers and healthcare professionals including doctors, nursing staff, pharmacists. The manual was written to cover the most frequently asked questions that patients have when they have started on these medicines. To evaluate the manual, we conducted a clinical audit based on a NICE clinical audit tool developed for the Opioids in Palliative Care guideline CG140. The National Institute For Health and Clinical Excellence (NICE) states that patients on strong opioids should be provided with written and verbal information about their pain relief and indicate which aspects of communication should be covered. NICE have set a list of key criteria that should be discussed when first prescribing opioids.

How did you implement the project

Using the audit tool provided by CG140 a survey of 40 inpatients in total at Velindre Cancer Centre was conducted. Patients were selected at random throughout. Patients were excluded from the audit if they lacked capacity or were in the terminal phase of life. In the first audit cycle, 20 patients who were on opioids but had not received any supplementary written information were asked to provide information on how much information they had been given on initial prescription of strong opioids. This was done following the template which can be found in the supporting material. Patients were asked to answer yes or no for each question. In the 2nd audit data collection, 20 further patients, who had received both verbal and written information on strong opioids were asked the same set of questions.

The opioid manual contains patient examples on how and when to take the prescribed opioid, has a useful opioid diary which can help the reader to learn about correct or incorrect use of medication, and answers some of the less commonly addressed queries, for example is it safe to drive whilst on opioids? The Opioid Patient Information Manual is available in the supporting material here, the All Wales Medicines Strategy Group, two NHS trust websites and is also available in Velindre Cancer Centre's Patient Information Area.

Key findings

- Amongst the 40 patients 58% had their oral opioid started in the Velindre Cancer Centre, 30% in the community, 5% in another hospital and in 7% it was unclear.
- 77% of patients were on MST and 33% of patients were on Oxycontin as their long acting oral opioid.
For further analysis of results, please see the supporting material.
The Opioid Patient Manual was translated into Welsh and Polish. One Polish patient who required interpreters for all consultations gave particularly good feedback, and it drastically improved his compliance, which he charted in the diary at the end of the Manual.

Key learning points

- The use of this Patient Opioid Manual improved patient knowledge and understanding when compared to verbal communication only (p<0.01).
- Patient knowledge regarding side effects improved (verbal and written info) when compared to verbal communication only (p=0.016).
- Hallucinations and fear of addiction were raised as areas of concern by 2 patients and 5 patients respectively in each audit data collection.
- These are areas that patients and carers want to talk about, when being prescribed opioids.
- Gain consensus and buy-in for such a leaflet or manual, which should be something all potential prescribers (including doctors, pharmacists and nurses) should feel comfortable with.
- Do not be put off by the length of such a document. Opioids are complex drugs and the patients we evaluated had a lot of different questions about them, ranging from addiction, to driving advice. Do not assume that leaflets or manuals have to be short at all cost.
- Use a question and answer style in your opioid patient manual. This means that patients can skip over areas they have less questions on, and can concentrate on their most pressing concerns.
- Encourage patients and their carers, to read through the document, and at subsequent review to bring up any questions.
- Encourage questions to be written down, for instance in the relevant section on the leaflet/manual.
- Encourage patients to use a simple opioid medication diary, such as the one presented in our manual, to improve adherence and identify opioid side-effects more efficiently.

Contact details

Dr Mark Taubert
Consultant in Palliative Medicine
Velindre Cancer Centre

Secondary care
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