PCN pharmacy: reviewing inappropriate medications

In our primary care network, Sunderland Central, we often review inappropriate medications alongside our GPs and one of the main focuses is opioid and gabapentinoid prescribing.

Patients may have started on these medications several years ago when guidelines and indications were different. Guidelines and evidence have changed a lot over the past few years and now these medications are no longer recommended for long-term use in non-cancer pain. Now, these medications may no longer be considered appropriate or safe.

Identifying patients

We identify these patients through structured medication reviews or targeted cohort reviews. Additionally, GPs may also highlight patients who require support with their medications from pharmacists.

This issue needs to be addressed as these medications can cause potential harm to patients such as dependence, tolerance, hypersensitivity to pain and cognitive impairment.

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By reviewing patients, it allows them to be safety optimised, reduces adverse effects and ensures medications are prescribed according to evidence and guidelines.

Working with GPs

I work closely alongside GPs to optimise patient care and safety. We regularly seek advice from each other regarding medication management to ensure the best patient care.

It is important to work collaboratively, especially when it involves reviewing complex medications as it supports deprescribing and ensures inappropriate medications are reviewed correctly.

Challenging perceptions

One of the biggest challenges is that patients have often been prescribed these medications for several years and were often initially informed that they would be required for long-term management.

It can be challenging to change this idea, especially when these medications were commenced in secondary care by consultants and often patients are less willing to change following advice from primary care. It is extremely important to build a rapport with patients and understand their background and pain history.

I focus initial consultations on building a trusted relationship and explaining to patients the updates to guidance and evidence, rather than enforcing a sudden change in medication - unless there were more of an immediate safety concern.

Where appropriate, we agree to follow up in a month or so, which allows patients time to digest the information. It is also important to maintain shared decision-making throughout consultations to ensure that the patient is involved in their care/medications.

Collaboration in practice

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It is beneficial to have pharmacists and GPs working collaboratively as I feel we complement each other.

I have found it works particularly well when GPs have held initial conversations with patients regarding medication reductions and they then ask the pharmacist to follow up/develop a tapering plan.

Pharmacists are quite good in managing the reductions and organising regular follow ups to review progress and side effects, this ensures shared decision making is maintained throughout.

Although this sometimes can be time consuming, it can be very beneficial for both patients and collaborative working.

Prior to GPs having pharmacist support, GPs had limited capacity for regular follow up to manage medication reductions and often resulted in medications being reduced more quickly than is ideal which potentially led to patient non-adherence. By having pharmacists and GPs working collaboratively it allows for improved safety, patient centred care and better patient outcomes.

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At present there are no future plans to develop the ways we work but we always look to improve. It is important to also listen to the patient for feedback which allows processes to be improved to enhance patient care and outcomes.