Evidence collected by Public Health England (PHE) shows an increase in the use of over-the-counter codeine medicines (PHE, 2014a). It is also increasingly recognised by health professionals, that opioid medications used to treat pain become less effective over time. Doses can be increased to high levels and this usually does not work and can create a dependency on opioid medication in the long run, particularly codeine-based medications (PHE, 2014a; 2019; British Pain Society, 2020).
In the US, the prescribing and the illicit drugs trade in opioid painkillers has led to an increase in mortality figures (National Institute on Drug Abuse, 2021). The government has called the situation at present a national crisis as 130 people die every day from opioid-related drug overdoses. In the UK there is evidence that opioid analgesic prescribing has increased in the last decade, with a doubling of mortality figures (Office for National Statistics, 2019).
Codeine is a highly addictive opiate painkiller. As a user's tolerance to the drug builds up, they will need higher doses of codeine to feel its effects. After prolonged use, users can become physically and psychologically dependent on codeine (Gault, 2019).
A wide range of prescribed medications and over the counter medicines are being used by patients who have developed an addictive pattern. The main ones being opioids, sedative medications, and mood stabilising medications such as gabapentin and pregabalin (Royal College of General Practitioners (RCGP), 2021). In the period between 2004 and 2012, the rate of prescribed opioid medications increased to twice the rate it was before. There is now a growing recognition in general practice that there is a cohort of patients who are using prescribed medication dependently and problematically. There needs to be a focus from general practice to address this.
The government has looked at addressing this issue with PHE initiating services to try and treat this cohort of patients with the following guiding statement:
Good practice in prescribing opioid medicines for pain should reflect fundamental principles in prescribing generally. The decision to prescribe is underpinned by applying best professional practice; understanding the condition, the patient and their context as well as understanding the clinical use of the drug.
Clearly this does need to be addressed; however, there also needs to be a tailor-made individual plan for patients who have developed addictive behaviour patterns around opioid analgesics and benzodiazepines to ensure good practice (British Pain Society, 2021).
It is argued that experts in addiction can be best placed to develop a service to meet this increasing need: providing advice and plans for reductions, working with the patient, who while in pain has also developed addictive behavioural patterns that need to be recognised and worked with. The benzodiazepine and opiate withdrawal service (BOWS) was set up across two neighbouring London boroughs. It has its expertise in treating addictive behaviour patterns and hence logically transferred these skills to the field of treating opioid dependency and benzodiazepines. Often, services would use substitute medications used in the field of addictions, which proved effective in the field of benzodiazepine and opiate addiction using non-medical prescribers (NMPs). This article is an illustration of what can be achieved with this client group with nurses playing a very central part to service provision. The nurses in BOWS are also highly skilled in motivational interviewing and cognitive behavioural therapy (CBT) for insomnia called CBTi. These skills are used as well as prescribing, to meet the patient need for people presenting to the service.
The Benzodiazepine and Opiate Withdrawal Service: BOWS
BOWS is a recently developed service, with its expertise from the drug and alcohol mainstream service for addictions. It is set-up to treat patients for dependency on codeine-based drugs prescribed or used illicitly, benzodiazepines, and other prescribed medications such as gabapentin and pregablin that have led to patients suffering from dependent behaviours. The service often sees patients who have these dependencies, but they may also have other dependencies such as heroin, crack and alcohol.
The BOWS was started in October 2018 with its main setting being in general practice. It is now firmly established in twelve primary care (GP) surgeries in one inner London borough. To date it has seen, assessed and treated 240 patients, and the case studies included in this article are drawn from this patient population to illustrate what can be achieved in treating these patients in primary care. It also will showcase the usefulness of addressing this issue with experienced nurses who can also prescribe in this speciality.
Patients who have alcohol and other illicit drug problems, as well as having dependencies on opiate painkillers or benzodiazepines are referred to the BOWS service from GP and the hospital pain management teams.
This leads to an assessment and a decision will then be made by the BOWS team to see whether they can work with the patient in primary care.
Seeing an experienced NMP nurse from an addictions background is very valuable. It enables a patient to see only one clinician for their dependencies, which is seen as effective and streamlined care that is easy to access. It also enables them to get all their treatment in one place. The setting being general practice is also beneficial to engaging and then treating this cohort accordingly.
In summary, the case studies presented in this article illustrate a simple way of accessing treatment with positive outcomes.
Non-medical prescribing for drug and alcohol clinics
The number of NMPs working in drug and alcohol service provision in England and Wales is increasing (PHE, 2014b). NMPs can improve the quality of care and the management of patients overall in general practice (McIntosh et al, 2016). It has many advantages, as discussed below. This is the main framework which underpins the treatment and prescribing interventions of the NMPs in the BOWS service.
Specialist care can be delivered closer to home
A service delivered in primary care settings enables a high potential for the patient to engage as they have less distance to travel for treatment. This can provide a complex needs service in primary care and free up GPs to care for other patients in their practice (NHS Scotland, 2006).
Reducing unnecessary referral to specialist services
There are improved health outcomes for patients (unpublished data) who are misusing opioids, alcohol and other prescribed medications. The patients can be managed by experienced NMPs and not referred onto a specialist service. The experience of the NMPs enables BOWS to cope with some very complex patients in primary care.
Increasing access
The service encouraged those patients less engaged with GP services to access healthcare via the NMP where specialist advice and prescribing could be accessed, and this improved patient engagement and experience of health services positively (DH, 2006).
Choice
Patients were given the opportunity to access the NMP specialist service or see their usual GP/nurse. Uptake of the service was high, with low did not attend (DNA) rates, indicating that the additional service was well received.
Personalisation
The success of the service in addressing opioid management and dependencies on prescribed drugs has been built around the tailoring of therapy and lifestyle advice to meet the needs of the individual. This has proved successful as the case studies will illustrate.
The NMP role is an integral part of the model for BOWS and enables patients to receive holistic care. It enables patient's easy access to treatment and medication. It allows all care and treatment to be delivered by one clinical member of staff (in this case the NMP). It can also free up the GP to address the other needs of the practice and patients (Brodie et al, 2014). Having experienced NMPs in primary care has also led to increased retention of patients.
Analgesics
Before focussing on treating patients with problems on opioids, it is important to outline the medications that patients may have developed a dependency around. This is the next focus.
There are a range of opioid analgesics (British National Formulary, 2021). Weak opioids are analgesics such as codeine phosphate and codeine, usually prescribed at low doses of 60–180 mg daily. Dihydrocodeine can also be used to treat moderate to severe pain, in some cases at a higher dose. Strong opioids used for pain relief include morphine and buprenorphine, morphine sulphate and oxycodone hydrochloride. It has to be noted that repeated administration of these medications could cause dependence and tolerance.
This article looks at benzodiazepines and the increasing ineffectiveness of codeine long-term, and how switching from a weak to moderate analgesic to a stronger one at a low dose can be more effective in terms of managing both pain and dependency, with greater stability for patients.
As mentioned in the introduction, codeine can be addictive and often patients can overuse their prescribed medication. Frequent overuse is often a sign of addictive behaviour to codeine. While the BOWS service does treat patients who present with this pattern, the case studies show patients who have been on codeine long-term with growing ineffectiveness and who wanted to change. Changing to medication such as buprenorphine and methadone can be more effective and less problematic and, as the case studies show, can lead to greater long-term stability.
Case studies
Case studies are in-depth investigations of a single person, group, event or community. Typically, data is gathered from a variety of sources by using several different methods such as interviews and case notes.
The case study research method originated in clinical medicine (the case history, ie the patient's personal history). In psychology, case studies are often confined to the study of a particular individual (Bradby, 2009).
In this article, the case studies presented are developed from individual's case notes and informal interviews and look at the outcomes of treatment that the BOWS nurses provided and whether there was a positive benefit for the patient.
Client A
Client A was a middle-aged man who has had a long history in the drug and alcohol services to date. He had lived in London for the last 20 years. He came to London to look for work. He was working up until 6 months ago and is still actively looking for work. He was using heroin, alcohol and benzodiazepines when he presented for treatment. He was living on his own in a local authority flat and had no debts and no problems with his tenancy. This was a patient who presented with multiple addictions.
He was prescribed methadone for his substance misuse dependencies. However, his benzodiazepines were often prescribed by the GP and he always overused his prescription for these drugs. Often this was not known by the specialist treatment agency and the GP was not aware of the dose and frequency of client A's treatment for methadone, with only annual reports being completed and sent to the GP. For the GP this often led to fragmented care and the GPs wanted a service that could treat Client A for all of his presenting problems to increase the safety of prescribing for the clinician and the patient.
Client A had difficulty attending the specialist service and often missed his appointments, resulting in him being discharged from the service and he did not access treatment for his heroin dependency until he came to see his GP for a related problem. He presented with a chest infection and the GP referred him to the BOWS service, as he was not stable with his benzodiazepine use.
He presented to the BOWS service and outlined his problems of opiate (heroin) addiction and benzodiazepines. He was on 30 mg diazepam and at the times was on 15 mg zopiclone. He was using £20 worth of heroin (usually one-quarter of an ounce). He did want to stop using heroin and wanted a small dose of methadone, which he felt he could stabilize on, and then he would look to reduce his other prescribed medications. He wanted to be more stable on his medications and he acknowledged he had a problem with his prescribed medications.
His assessment and presenting problems were discussed with his GP and he was started on 30 mg of methadone and maintained on 30 mg of diazepam and 15 mg of zopiclone with pick-ups changed to a daily pick up for all of his medications. He was on no other analgesic prescribed medications.
He understood the rationale for his care plan, as this was to make it easier for him to manage his medications and to help in his overuse of his prescribed medications. The NMP working for BOWS would prescribe these for him and would see him every 2 weeks at the GP surgery and would review and plan treatment accordingly.
He engaged well and managed to become very stable on his prescribed medications. He started to reduce his methadone after two months of stabilising on 30 mg. After 12 months in treatment with the BOWS service he had detoxified off his methadone completely and is now opiate free. He has also reduced his other prescribed medication to 20 mg diazepam and 7.5 mg zopiclone. He wanted to stop using the zopiclone and this is the next thing he will try to reduce. His pick-ups for his prescribed medications are now every 14 days and no longer daily, and he is able to manage this well.
He feels the idea of seeing someone in his GP surgery is very convenient as it is near where he lives and therefore helped him keep to his appointments. Also, seeing a specialist nurse who can prescribe has also been very beneficial for him as it enables his treatment to be easily accessed and managed. He also receives some psychological interventions such as motivational interviewing (MI) that can improve insight and lead a service user to cope better with their health and dependencies around medications.
‘I feel the easiness of the treatment with one appointment every fortnight where my needs a re treated very well. Makes a change from having two and maybe three appointments that was the case in the past and this made it difficult to keep all these appointments.’
Client A
Therefore, the patient does feel the benefit of being treated in primary care as well as having all his needs met in one appointment. In this case in particular it has led to better engagement with treatment, and it has enabled a positive outcome as well.
Client B
Client B was a woman who had suffered from osteoarthritis for over 10 years. She had been working in a school, but her pain was so excessive she took early retirement. She had been living in a council flat in London and was being treated for her pain with codeine tablets: 8 tablets of 30 mg a day. She often overused and ran out of her medication early. Many GPs at the practice had prescribed for her and she was becoming dependent on codeine and she seemed unaware of her addiction.
She was also complaining that her pain was not being well managed. She was referred to the BOWS service for a pain management review.
Her overusing was discussed, and she did recognise this was a problem and therefore agreed to stabilise on a dose of codeine that was beneficial for her and the GP practice. She agreed to go on a shorter script then her usual 2-weekly prescriptions. She was changed to 3-day scripts and this was reviewed by the BOWS service weekly. She found it difficult at first to remember the days to pick up but over time she developed a regular routine to pick this up and never missed her doses.
She soon stabilised on 8 tablets daily but her pain was still an issue, which illustrated that over time codeine had become ineffective for her as a means of treatment and therefore needed to be reviewed. Buprenorphine was discussed and the benefits of switching to this medication were talked through with the patient. The patient agreed to switch to this medication and titrate to an effective dose.
The conversion from 240 mg of codeine to buprenorphine was approximately 40 mg of morphine and between 4-8 mg of buprenorphine (Opiate Conversion Doses, 2020). Client B was started on 4 mg and seen daily for the first 4 days and settled on 8 mg daily. Over the next 4 weeks she reduced her dose to 5.2 mg and is stable on this medication now. She is on weekly scripts for her buprenorphine and she is able to manage this well. This was all completed by the NMP for the BOWS service. Her dose of buprenorphine after six months has now settled on 2 mgs daily and she has been very comfortable on this dose. This lower than the conversion rate as she feels the buprenorphine is a more effective analgesic.
She feels her pain is better managed on buprenorphine, but she does have some breakthrough pain. However, she can manage this with a paracetomol. She feels much better on buprenorphine and has been able to mobilise better than before. She is now walking to her appointments at the GP surgery. She feels this has been a beneficial change and to do this in primary care has been important.
‘I was often treated like I was a number at the pain clinic and the doctors never really changed anything in my regime. In primary care and seeing someone from BOWS was responsive and effective. I have always found it easier to access treatment from the GP surgery, and BOWS, with prescribers, does sort of show that this is easy to access…’
Client B
Getting all needs meet in one service based in primary care was seen as important, provided easy access and also enabled better engagement.
As can be seen, the idea of having all treatment under one roof is important for patients as they find treatment easier to access as a result. It can also be easier to engage with as the GP surgery is usually closer to home for many patients. Having nurses and NMPs who are experienced and skilled in the field of addictions can also enable beneficial outcomes for patients. These nurses are able to understand the nature of addictive behaviour and consider substitute prescribing.
Discussion
The BOWS service is recently established, and this article shows it can offer an effective service for patients who have dependencies on opiates and prescribed drugs in Camden and Islington. A formal audit of the service will be taken and therefore the positive outcomes in this study can hopefully be verified through greater analysis of the data of the 240 patients.
However, this paper was written to illustrate what was possible in the BOWS, particularly delivering services with nurses developing and shaping the prescribing provision. This has proved valuable for patients and helped them achieve positive outcomes as the case studies show. This article hopefully showcases what can be achieved with nurses running the services as NMPs from the field of addictions.
Using nurses as NMPs can enhance service provision and patient health. It shows we can provide the service closer to home, ie in the GP setting; effectively engage treat and retain patients; and improve their health.
This article can give an insight into the NMPs' high degree of expertise in prescribing medication used to substitute opioid use, such as methadone and buprenorphine. It also further showcases that nurses can be seen a creative and innovative source to drive, shape and deliver new services in healthcare.
Key Points
- In the UK there is evidence that opioid analgesic prescribing has increased in the last decade, with a doubling of mortality figures
- A wide range of prescribed medications and over the counter medicines are being used by patients who have developed an addictive pattern
- The benzodiazepine and opiate withdrawal service (BOWS) was set up across two neighbouring London boroughs. It has its expertise in treating addictive behaviour patterns and hence logically transferred these skills to the field of treating opioid dependency and benzodiazepines
- A service delivered in primary care settings can have many benefits for patients and clinicians.
CPD reflective questions
- What are the benefits for patients being treated for addiction in primary care?
- Would a service like the Benzodiazepine and Opiate Withdrawal Service (BOWS) be useful to your patient population? Why or why not?
- Can you think of other nurse-led services that would be beneficial to patients?