Shared learning database

Velindre NHS Trust
Published date:
January 2013

Opioids are offered frequently in palliative care to help reduce pain and breathlessness. The initiation and titration happens in clinics and outpatient settings, can sometimes be part of a much wider consultation on disease status and information between prescriber and patient tends to be verbal and not always backed up by written guidance. Yet these are complicated medicines to take, with varying regimens and they carry a lot of stigma, with patients (and carers) left frightened about possible side-effects and addiction potential.

Here, we present a written Patient Manual to taking opioids in palliative care settings, which includes a diary, and represents a useful take-home supplement to consultations where opioids have been discussed and considered.

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

NICE Guideline CG140, issued in May 2012, set out to bring clarity to the complex area of prescribing opioids in palliative care. Recommendations included topic areas to cover when considering opioids for the first time, discussion of side-effects and how they might impact on day-to-day life, including tasks such as driving. Also, the guideline suggested supplementing verbal information (in a clinic, for instance) with good quality written information.

Our aim was to produce such a document, in particular to keep it close to what was suggested by the NICE Guideline, and to make it available to healthcare professionals dealing with palliative care patients at the specific point in time when opioids are first being considered.

Reasons for implementing your project

Patients in Velindre NHS Trust, a tertiary cancer centre in Wales, who were being treated with palliative intent, would frequently receive information on opioids in clinic or in the inpatient unit. The initial consultations when first prescribing these medicines are extremely important, and can make a difference to adherence and compliance. Unfortunately, there are a lot of topics to cover, and sometimes, opioids are prescribed and discussed in clinic when many significant conversations (for example breaking of bad news due to disease progression, etc) have taken place simultaneously, and hence verbal information may not be readily retained by patients and their carers.

How did you implement the project

Four palliative care consultants reviewed NICE Guideline CG140 and incorporated recommendations into a written Opioid Patient Manual. After this, information was sought from patients, carers, allied healthcare professionals, patient information officers, pharmacists, junior doctors and nurses. The document subsequently went through clinical governance review in two NHS Trusts (Velindre NHS Trust and Cardiff and Vale NHS Trust) and was passed and is currently going through a similar process within Marie Curie Cancer Care's national governance process, for consideration in their operations throughout the United Kingdom.

Key findings

The opioid patient manual is at present being used in outpatient and inpatient settings within Velindre NHS Trust and also Cardiff and Vale NHS Trust. It is also available online and in the new Velindre Cancer Centre Patient Information area.

To view our Patient Info Centre, click here

Patients (and their carers), are asked to read the manual and write down any further questions they may have. Frequently asked questions, such as addiction potential of opioids are discussed in the manual, as recommended by NICE CG140, and patients are encouraged to ask further questions. Some examples of opioid dose regimens (with NICE recommended first-line agent Morphine) are presented. Patient feedback is continually sought, monitored and documented, and will be brought up at the next review of this document.

Both NHS Trusts have now reviewed their Opioid prescribing and have decided to switch from MST Continus to Morphgesic SR, as the preferred sustained-release opioid. The authors of the manual have therefore produced two parallel leaflets, one using the previously used, and one using the future drug, as examples. This complexity and change in medicine management, mainly for cost-cutting purposes, has potentially added a further complexity into opioid prescribing, which we hope will be improved by wide-spread use of our 'tailored' manual. Feedback from both professionals and patients, as well as carers, has been overwhelmingly positive. The manual is currently being translated into Welsh.

Key learning points

- Seek consensus on how opioids are first prescribed in your individual organization
- Find out what information is given and how and by whom.
- If only verbal information is given, consider a written leaflet or manual, using examples and encouraging user involvement
- 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 patients have 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 example documents, to improve adherence and identify opioid side-effects more efficiently.

Contact details

Mark Taubert
Consultant in Palliative Medicine
Velindre NHS Trust

Tertiary care
Is the example industry-sponsored in any way?