Title : Local audit of use of opioids in patients with headaches in secondary care
Abstract:
This study examines the concerning trend of opioid prescribing for headache management in Acute Medicine Units (AMU), Same Day Emergency Care (SDEC), and Emergency Departments (ED), practices that contradict the recommendations outlined in NICE guideline CG150. Opioid use for headaches has significant adverse implications, including the development of medication overuse headaches (MOH), longer hospital stays, reduced quality of life, increased re-admissions, and greater healthcare costs. Addressing these issues is critical to ensuring adherence to clinical guidelines and improving patient care. The audit aimed to evaluate whether the prescribing practices for patients presenting with headaches align with NICE guidelines and the local headache pathway, specifically avoiding opioids. It also sought to determine whether patients prescribed opioids had a clear discontinuation plan communicated to their GP. Compliance was measured against standards derived from NICE guideline CG150, which include avoiding opioid prescriptions during hospital stays, excluding opioids from discharge medications, and ensuring a documented discontinuation plan for any patient discharged on opioids.
Over six months, data was collected on 38 patients (14 males and 24 females) admitted to the Eastbourne site with headaches or migraines. The audit was conducted by a pharmacist, focusing on retrospective and prospective data analysis. The review included opioid prescriptions at admission, during hospital stays, and at discharge. Re-admissions and MOH diagnoses were also analyzed. However, a lack of documentation on over-the-counter (OTC) medication use limited the ability to fully assess the contribution of OTC drugs to MOH. The findings highlighted significant deviations from the standards. Only 16% of headache patients avoided opioid prescriptions during their hospital stay, while 79% were prescribed opioids as inpatients, and 21% were discharged with opioid medications. Alarmingly, 84% of patients prescribed opioids were re-admitted or diagnosed with MOH. Documentation of OTC medication use was inconsistent, and only 12% of patients discharged on opioids had a GP-recommended plan to discontinue them. The results reveal substantial gaps in compliance with NICE guidelines, with extensive opioid use for headaches and poor communication regarding discontinuation plans. These practices contribute to an increased burden on secondary care, longer wait times for headache clinics, and greater healthcare costs, all while compromising patient health and productivity. To address these challenges, several recommendations were made. These included eliminating opioid prescriptions for headaches, ensuring that discharge letters for opioid users include GP-directed discontinuation plans, mandating comprehensive documentation of OTC medication use, and enhancing awareness of NICE guidelines through Grand Rounds and pharmacist-led education. A re-audit revealed improvements, with opioid prescriptions decreasing from 84.2% to 26% and a slight increase in documented discontinuation plans from 12% to 14%.
This study underscores the need for consistent adherence to NICE guideline CG150 in headache management. By implementing the recommended actions, healthcare teams can improve patient outcomes, reduce the prevalence of MOH, and alleviate the financial and operational pressures associated with poor headache management.
