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For Primary Care| View from the ground

Reducing Pain-Relief Drug Use Through Holistic Assessment

View From the Ground, by Ian McKenna

When I first joined the Hawthorn Drive Surgery 3 years ago, the practice manager asked me to review patients who had high usage of opiates and other medications. I recognised that this was going to be a challenging task—at the time, 60% of all patients registered at the practice were on high doses of pain-relief medications, such as opiates, or antidepressants, and the local area we cover is socioeconomically deprived, with 10,000 patients.

Firstly, through audit, we focused on patients aged 21–60 years. We invited them in for an informal chat to find out more about their medication needs. Our aim was to empower them to work with us to improve their health and wellbeing and, ultimately, reduce their medication usage as appropriate.

In the meantime, a mental health practitioner and a pharmacist joined our surgery. This was a really good opportunity for us to work together to tackle the issue of high medication usage. With support from the practice manager, we established the Holistic Assessment Team (HAT).

Patients who had high medication usage were invited to the surgery on a Wednesday morning. We spent an hour with each patient explaining about who we are, what we could do for them, and how we could support them in taking ownership of their health and recovery. An individual healthcare plan was used as a template to determine why patients were taking large amounts of medications such as opiates.

We tried to ensure that patients were relaxed, so that they could have a smooth journey through the process. The mental health practitioner focused on mood and mental health issues. The medical practitioner examined lifestyle, including food and drink intake and sleeping habits, and ordered blood tests and X-rays if required. The pharmacist discussed medication regimens, including the use of both prescribed and street drugs, and looked at alternatives that could reduce the amount of medications taken.

About 6 months ago, social prescribers were integrated into the HAT, and they are now an integral part of the work that we do. Although the work of the HAT continued throughout the pandemic, we have had to adapt to COVID-19—hence, although our clinicians would have preferred to see people face to face, this did not occur in the majority of cases. Instead, during lockdown, telephone triage was carried out prior to HAT assessments, and patients were offered consultations via video link. This meant that we were still able to ‘see’ people in their own homes, and 50% of our patients stated that they actually preferred this mode of consultation.

The team has progressed from simply talking about what to do with patients with high medication usage to being able to see and support these people on a monthly basis. And, it has expanded from one clinician to four healthcare professionals.

We are very pleased to have an average success rate of 40% in reducing high opiate usage among our patients. We are still learning, but we are in a good place to further address the issue of high medication use.

We have had a number of success stories that have led to people turning their lives around. For example, we spent 6 weeks working with a 30-year-old man who was taking two opiates and an antidepressant. He was referred to outside agencies for help with alcohol and drug addiction, and to mental health and social services for help with his living conditions, debt concerns, and employment situation. Within 12 months of engaging with our team, he had reduced his intake to just one prescription medication; he was no longer addicted to street drugs, had a job, and had repaired his relationship with his family. This is just one person among many whose situation has improved with our help.

The work of the HAT has assisted many people—this is an achievement of which I am very proud. 

Ian McKenna

Emergency Care Practitioner, Hawthorn Drive Surgery, Ipswich