Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project.

Abstract Background: Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations. Methods: Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4-6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p<0.05, 95% confidence intervals and/or Cohen’s d. Results: Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1,255 patients in the QI and 1,632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p=0.019) and prescribed ≥90mg/day MED (23.0% vs 15.5%, p=0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p=0.02), but not other outcomes (p³0.05). Conclusions: Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented.Trial Registration – Not applicable

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Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project

BMC Family Practice ◽

10.1186/s12875-020-01320-9 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Aleksandra E. Zgierska ◽

James M. Robinson ◽

Robert P. Lennon ◽

Paul D. Smith ◽

Kate Nisbet ◽

...

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Cancer Pain ◽

System Level ◽

Stepped Wedge ◽

Convenience Sample ◽

Clinic Staff ◽

Opioid Prescribing ◽

Urine Drug

Abstract Background Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations. Methods Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4–6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse risk screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90 mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p < 0.05, 95% confidence intervals and/or Cohen’s d. Results Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1255 patients in the QI and 1632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p = 0.019) and prescribed ≥90 mg/day MED (23.0% vs 15.5%, p = 0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90 mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p = 0.02), but not other outcomes (p ≥ 0.05). Conclusions Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented. Trial registration Not applicable.

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Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project.

10.21203/rs.2.19901/v1 ◽

2020 ◽

Author(s):

Aleksandra E Zgierska ◽

James M Robinson ◽

Robert P Lennon ◽

Paul D Smith ◽

Kate Nisbet ◽

...

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Cancer Pain ◽

System Level ◽

Stepped Wedge ◽

Convenience Sample ◽

Clinic Staff ◽

Opioid Prescribing ◽

Urine Drug

Abstract Background: Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations. Methods: Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4-6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The intervention subjects were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p<0.05, 95% confidence intervals and/or Cohen’s d. Results: Two-hundred-fifteen intervention subjects, a subset of clinical staff, received at least one intervention component; 1,255 patients in the intervention and 1,632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more intervention than comparison clinic patients were screened for depression (8.1% vs 1.1%, p=0.019) and prescribed ≥90mg/day MED (23.0% vs 15.5%, p=0.038). The stepped-wedge analysis did not show statistically significant change in outcomes in the intervention clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the intervention clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90mg/day MED in the intervention compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p=0.02), but not other outcomes (p³0.05). Conclusions: Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, under more rigorous implementation conditions.

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Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project.

10.21203/rs.2.19901/v4 ◽

2020 ◽

Author(s):

Aleksandra E Zgierska ◽

James M Robinson ◽

Robert P Lennon ◽

Paul D Smith ◽

Kate Nisbet ◽

...

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Cancer Pain ◽

System Level ◽

Stepped Wedge ◽

Convenience Sample ◽

Clinic Staff ◽

Opioid Prescribing ◽

Urine Drug

Abstract Background: Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations.Methods: Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4-6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p<0.05, 95% confidence intervals and/or Cohen’s d.Results: Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1,255 patients in the QI and 1,632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p=0.019) and prescribed ≥90mg/day MED (23.0% vs 15.5%, p=0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p=0.02), but not other outcomes (p³0.05).Conclusions: Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented.Trial Registration – Not applicable

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Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project.

10.21203/rs.2.19901/v2 ◽

2020 ◽

Author(s):

Aleksandra E Zgierska ◽

James M Robinson ◽

Robert P Lennon ◽

Paul D Smith ◽

Kate Nisbet ◽

...

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Cancer Pain ◽

System Level ◽

Stepped Wedge ◽

Convenience Sample ◽

Clinic Staff ◽

Opioid Prescribing ◽

Urine Drug

Abstract Background: Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations. Methods: Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4-6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p<0.05, 95% confidence intervals and/or Cohen’s d. Results: Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1,255 patients in the QI and 1,632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p=0.019) and prescribed ≥90mg/day MED (23.0% vs 15.5%, p=0.038). The stepped-wedge analysis did not show statistically significant change in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p=0.02), but not other outcomes (p³0.05). Conclusions: Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented.Trial Registration – Not applicable

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Enhancing system-wide implementation of opioid prescribing guidelines in primary care: protocol for a stepped-wedge quality improvement project

BMC Health Services Research ◽

10.1186/s12913-018-3227-2 ◽

2018 ◽

Vol 18 (1) ◽

Cited By ~ 6

Author(s):

Aleksandra E. Zgierska ◽

Regina M. Vidaver ◽

Paul Smith ◽

Mary W. Ales ◽

Kate Nisbet ◽

...

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Quality Improvement Project ◽

Stepped Wedge ◽

Improvement Project ◽

Opioid Prescribing ◽

Care Protocol

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Understanding long-term opioid prescribing for non-cancer pain in primary care: a qualitative study

BMC Family Practice ◽

10.1186/s12875-015-0335-5 ◽

2015 ◽

Vol 16 (1) ◽

Cited By ~ 26

Author(s):

Carolyn McCrorie ◽

S. José Closs ◽

Allan House ◽

Duncan Petty ◽

Lucy Ziegler ◽

...

Keyword(s):

Primary Care ◽

Qualitative Study ◽

Cancer Pain ◽

Opioid Prescribing

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Time trends and prescribing patterns of opioid drugs in UK primary care patients with non-cancer pain: a retrospective cohort study

10.1101/2020.04.07.20049015 ◽

2020 ◽

Cited By ~ 1

Author(s):

Meghna Jani ◽

Belay Birlie Yimer ◽

Therese Sheppard ◽

Mark Lunt ◽

William G Dixon

Keyword(s):

Primary Care ◽

Cancer Pain ◽

Case Mix ◽

High Dose ◽

Opioid Use ◽

Opioid Dose ◽

Opioid Prescribing ◽

Prescribing Behaviour ◽

Physician Prescribing

ABSTRACTBackgroundThe U.S. opioid epidemic has led to similar concerns about prescribed opioids in the U.K. In new users, escalation to more potent and high-dose opioids may contribute to long-term use as well as opioid-related morbidity/mortality. The scale of such escalation is unclear for non-cancer pain. Additionally, physician prescribing behaviour has been described as a key driver of rising opioid prescriptions and long-term opioid use. No studies have investigated the extent to which regions, practices, prescribers, vary in opioid prescribing, whilst accounting for case-mix.MethodsUsing a retrospective cohort study we used U.K. primary-care electronic health records from Clinical Practice Research Datalink to: (i)describe prescribing trends between 2006-17 (ii)evaluate the transition of opioid dose and potency in the first 2-years from initial prescription (iii)quantify and identify risk factors for long- term opioid use (iv)quantify the variation of long-term use attributed to region, practice and prescriber, accounting for case-mix and chance variation. Adult patients with a new prescription of an opioid without cancer were included.Findings1,968,742 new-users of opioids were identified. Rates of codeine use were highest, increasing five-fold from 2006-2017, reaching up to 2,456 prescriptions/10,000 people/year. Morphine, buprenorphine and oxycodone prescribing rates continued to rise steadily throughout the study period. Of those who started on high (100-200 Morphine Milligram Equivalents [MME]/day) or very high dose opioids (>200 MME/day), 4.9% and 10.3% remained in the same or higher MME/day category throughout 2-years, respectively. Following opioid initiation, 15% became long-term opioid users. In the fully adjusted model, MME at initiation, older- age, social deprivation, fibromyalgia, rheumatological conditions, substance abuse, suicide/self-harm and gabapentinoid use were associated with the highest odds of long-term use. After adjustment for case-mix, the North-West, Yorkshire, South- West; 103 practices (25.6%) and 540 prescribers (3.5%) were associated with a significantly higher risk of long-term use.InterpretationPatients commenced on high MMEs were more likely to stay in the same state for a subsequent 2-years and were at increased risk of long-term use. In the first UK study evaluating long-term opioid prescribing with adjustment for patient-level characteristics, variation in regions and especially practices and prescribers were observed. Our findings support greater calls for action for reduction in practice and prescriber variation by promoting safe practice in opioid prescribing.FundingVersus Arthritis and National Institute for Health ResearchResearch in ContextEvidence before this studyDrug dependence and deaths due to opioids have led to an opioid-overdose crisis in several countries globally including the US and Canada, and subsequent concerns about overprescribing in the UK. Physician prescribing behaviour has implicated as a key driver of rising opioid prescriptions and long-term opioid use however this needs to be assessed in the context of region, GP practice and individual patients. We searched Pubmed and Google Scholar between January 2005 and November 2019, with the terms “opioid” AND/OR “opiate”, “chronic pain” AND/OR “non-cancer pain”, and UK AND/OR England AND/OR “Great Britain” AND/OR “NHS”. We also reviewed relevant reports from Public Health England and other national bodies. The more recent trends for opioid prescribing have included all prescriptions including those for cancer pain, and those that include primary care UK prescription data for non-cancer indications are several years out of date. No studies evaluated how opioid dose and potency changes over time in individual patients after starting an opioid for the first time to assess escalation or tapering. National variation in opioid prescribing reported thus far has not accounted for patient case-mix. No studies have assessed the effect of the prescriber on opioid prescribing adjusting for regional, practice level variation and for individual characteristics.Added value of this studyThere has been a substantial overall increase in opioid-prescribing for non-cancer pain with clear drug-specific trends between 2006-17. To our knowledge, this is the first UK study that has evaluated the sequential transition on how dose/potency vary when a patient is first prescribed an opioid in primary care. Furthermore we report for the first time the effect of individual risk factors, UK regions, GP practice and prescriber (whilst considering these elements together) on long-term opioid use.Implications of all the available evidenceOur study highlights the key subpopulations in a UK primary care setting at risk of developing long-term opioid use and the need for closer monitoring of at risk patients. Marked variation between region, practice and prescribers still exists after adjusting for case-mix warranting evidence-based harmonised opioid prescribing guidelines with clearer MME/day thresholds. On a practice level, guidance on regular review and dose reduction, as well as using prescriber and practice variations as a proxy for quality of care through audit and feedback, to highlight unwarranted variation to prescribers, could help drive safer prescribing.

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Patterns of regional variation of opioid prescribing in primary care in England: a retrospective observational study

British Journal of General Practice ◽

10.3399/bjgp18x695057 ◽

2018 ◽

Vol 68 (668) ◽

pp. e225-e233 ◽

Cited By ~ 48

Author(s):

Luke Mordecai ◽

Carl Reynolds ◽

Liam J Donaldson ◽

Amanda C de C Williams

Keyword(s):

Primary Care ◽

Observational Study ◽

Cancer Pain ◽

Regional Variation ◽

Social Deprivation ◽

Retrospective Observational Study ◽

Opioid Prescribing ◽

The North ◽

Government Data

BackgroundOpioids are a widely prescribed class of drug with potentially harmful short-term and long-term side effects. There are concerns about the amounts of these drugs being prescribed in England given that they are increasingly considered ineffective in the context of long-term non-cancer pain, which is one of the major reasons for their prescription.AimTo assess the amount and type of opioids prescribed in primary care in England, and patterns of regional variation in prescribing.Design and settingRetrospective observational study using publicly available government data from various sources pertaining to opioids prescribed in primary practice in England and Indices of Social Deprivation.MethodOfficial government data were analysed for opioid prescriptions from August 2010 to February 2014. The total amount of opioid prescribed was calculated and standardised to allow for geographical comparisons.ResultsThe total amount of opioid prescribed, in equivalent milligrams of morphine, increased (r = 0.48) over the study period. More opioids were prescribed in the north than in the south of England (r = 0.66, P<0.0001), and more opioids were prescribed in areas of greater social deprivation (r = 0.56, P<0.0001).ConclusionLong-term opioid prescribing is increasing despite poor efficacy for non-cancer pain, potential harm, and incompatibility with best practice. Questions of equality of care arise from higher prescription rates in the north of England and in areas of greater social deprivation. A national registry of patients with high opioid use would improve patient safety for this high-risk demographic, as well as provide more focused epidemiological data regarding patterns of prescribing.

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Evaluation of an Educational Outreach Campaign (IMPACT) on Pain Management Delivered to General Practices in Walsall

International Journal of Pharmacy Practice ◽

10.1093/ijpp/riab015.059 ◽

2021 ◽

Vol 29 (Supplement_1) ◽

pp. i48-i49

Author(s):

S Visram ◽

J Saini ◽

R Mandvia

Keyword(s):

Data Analysis ◽

Pain Management ◽

Cancer Pain ◽

Educational Intervention ◽

Opioid Analgesics ◽

Educational Outreach ◽

Opioid Prescribing ◽

Prescribing Trends ◽

The Impact

Abstract Introduction Opioid class drugs are a commonly prescribed form of analgesic widely used in the treatment of acute, cancer and chronic non-cancer pain. Up to 90% of individuals presenting to pain centres receive opioids, with doctors in the UK prescribing more and stronger opioids (1). Concern is increasing that patients with chronic pain are inappropriately being moved up the WHO ‘analgesic ladder’, originally developed for cancer pain, without considering alternatives to medications, (2). UK guidelines on chronic non-cancer pain management recommend weak opioids as a second-line treatment, when the first-line non-steroidal anti-inflammatory drugs / paracetamol) ineffective, and for short-term use only. A UK educational outreach programme by the name IMPACT (Improving Medicines and Polypharmacy Appropriateness Clinical Tool) was conducted on pain management. This research evaluated the IMPACT campaign, analysing the educational impact on the prescribing of morphine, tramadol and other high-cost opioids, in the Walsall CCG. Methods Standardised training material was delivered to 50 practices between December 2018 and June 2019 by IMPACT pharmacists. The training included a presentation on pain control, including dissemination of local and national guidelines, management of neuropathic, low back pain and sciatica as well as advice for prescribers on prescribing opioids in long-term pain, with the evidence-base. Prescribing trends in primary care were also covered in the training, and clinicians were provided with resources to use in their practice. Data analysis included reviewing prescribing data and evaluating the educational intervention using feedback from participants gathered via anonymous questionnaires administered at the end of the training. Prescribing data analysis was conducted by Keele University’s Medicines Management team via the ePACT 2 system covering October 2018 to September 2019 (two months before and three months after the intervention) were presented onto graphs to form comparisons in prescribing trends of the Midland CCG compared to England. Results Questionnaires completed at the end of sessions showed high levels of satisfaction, with feedback indicating that participants found the session well presented, successful at highlighting key messages, and effective in using evidence-based practice. 88% of participants agreed the IMPACT campaign increased their understanding of the management and assessment of pain, and prescribing of opioids and other resources available to prescribers. The majority (85%) wished to see this form of education being repeated regularly in the future for other therapeutic areas. Analysis of the prescribing data demonstrated that the total volume of opioid analgesics decreased by 1.7% post-intervention in the Midlands CCG in response to the pharmacist-led educational intervention. As supported by literature, the use of educational strategies, including material dissemination and reminders as well as group educational outreach was effective in engaging clinicians, as demonstrated by the reduction in opioid prescribing and high GP satisfaction in this campaign. Conclusion The IMPACT campaign was effective at disseminating pain-specific guidelines for opioid prescribing to clinicians, leading to a decrease in overall prescribing of opioid analgesics. Educational outreach as an approach is practical and a valuable means to improve prescribing by continuing medical education. References 1. Els, C., Jackson, T., Kunyk, D., Lappi, V., Sonnenberg, B., Hagtvedt, R., Sharma, S., Kolahdooz, F. and Straube, S. (2017). Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. This provided the statistic of percentage receiving opioids that present to pain centres. 2. Heit, H. (2010). Tackling the Difficult Problem of Prescription Opioid Misuse. Annals of Internal Medicine, 152(11), p.747. Issues with prescriptions and inappropriate moving up the WHO ladder.

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