Chapter 10: Pain Medicine 2026

Dr Sunil Dasari

Why do this quality improvement project

The use of opioids in non-cancer chronic pain has increased in recent times. There is limited high-quality evidence for the effectiveness of opioids for chronic non-cancer pain¹,². Despite this, many patients with chronic non-cancer pain are prescribed and remain on opioids, with little evidence of significant improvement in pain intensity, functionality, or overall quality of life. Prolonged ineffective use of opioids causes side effects and may cause harm to patients³. The aim of this QI project is to improve the quality of prescribing and managing opioids in outpatient settings, for instance from a chronic pain clinic, but equally can be applied to any outpatient setting initiating opioid prescriptions.

Background

Identification of patients who will and will not benefit from opioid prescriptions is challenging. Both at the point of initial prescribing, and if prescribed supporting weaning and cessation if there is no benefit, or even harm, identified. Chronic opioid use at higher doses for prolonged periods of time can cause tolerance, dependence, misuse, and addiction⁴. Risk of harm increases as dose increases. There is evidence of harm at doses more than 50 mg Morphine equivalent doses/day (MED/day), increasing further at more than 90 mg MED/day. At doses above 120 mg MED, the risk of harm substantially increases with no increase in benefit¹, ⁵, ⁶. 

Best Practice

There are useful national guidelines for prescribing opioids such as the multi-society-produced Opioid Aware,³ the Scottish Intercollegiate Guidelines Network opioid pathway on the use of opioids⁷ and the Welsh Pain Society guidance on opioids⁸ which are useful resources to help health care professionals in the management of opioids.

The evidence of opioids effectiveness in chronic pain is limited, putting the onus on the healthcare professional to thoroughly assess the patient on the usefulness before starting opioids. There should be agreed outcome goals which include decreased pain, improved function and quality of life. When prescribing opioids, caution should be exercised with patients on sedatives like benzodiazepines or gabapentinoids, patients with renal and liver impairment, patients aged over 65 years of age or living with frailty, and those with a history of alcohol, drug, or medication misuse. The key for success in opioid management is patient involvement at every stage: Initiation, maintenance and de-escalation. Patient education and shared decision making is vital along with effective communication and team working.

Initiation

•There should be a proper indication where there is a realistic chance of benefit. 

•There should be a biopsychosocial assessment which includes opioid risk assessment. 

•Non-opioid management options should be tried first. 

•There should be a discussion with the patient about indication, treatment goal, agreed outcome, type of opioid, route, dose, side effects, duration of trial, and time of next review. 

•Discussion about when and how to de-escalation should be initiated at the initiation stage to facilitate shared decision making for a smooth de-escalation at a later stage. 

•There should be a discussion on effects of opioids on driving. 

•Patients should be given all the relevant information or signposted to resources where the information is available. 

•There should be a clear plan for a 4-week review to decide continuation or weaning to cessation. There should be a clear plan for a 4-week review to decide continuation or weaning to cessation.

 Maintenance

•There should be annual reviews to assess whether the indication is still appropriate and whether there is any improvement in pain and/or functionality. 

•Review whether the side effects are within tolerable levels. Review for any role for non-opioid interventions. 

•If the dose reaches above 90 MED³ and there is no benefit review, for de-escalation. 

•Review if opioid switch will benefit.          

De-escalation:

•Review for de-escalation if there is no benefit or there is more harm than benefit. 

•There should be a discussion about a de-escalation plan with the patient. 

•There should be a patient support mechanism in place for de-escalation and management of withdrawal symptoms. 

•If there is resistance for de-escalation assess whether it is due to genuine apprehension⁹ or due to high-risk behaviour. 

•Specialist support should be offered for high-risk patients.

Non-pharmacological management strategies:

National exercise programme, education programmes for patients, pain management programme (PMP), referral to social prescribers or local area co-ordinators, psychological interventions and support, Pilates, mindfulness, acupuncture, swimming, listening to music, reading books of interest, painting or artwork.

Suggested data to collect

Consider undertaking a service evaluation of a specific time period to provide baseline data. Areas for improvement could then be collected as continuous or frequently sampled data to provide a review of interventions over time.

Outcome measures

• Total volume and associated cost of opioid prescribing per month
• Prevalence of patients on opioid prescriptions that are deemed to be lacking benefit
• Incidence of opioid related harm events in the population of clinic patients

Process measures

• Percentage of initiating prescriptions with appropriate indication
• Percentage of Initiations with biopsychosocial assessment, including opioid risk assessment
• Percentage of patients who had tried non-opioid and non-pharmacological strategies before initiation
• Percentage of patients with documented discussion of indications, side effects, outcome plan agreement, and plan for de-escalation before initiation.
• Percentage of patients on opioid prescriptions review after a four-week trial
• Percentage of patients on opioid prescriptions who had annual review
• Percentage of patients on more than 90 MED/Day referred to a specialist pain service if initiated in a non-specialist setting for patients .
• Percentage of patients supported to de-escalate when indicated
• Qualitative analysis of problems with de-escalating

Balancing measures

• Percentage of patients reporting inadequate pain control following opioid reduction or cessation
• Number of referrals to specialist pain services following opioid stewardship interventions

 

Quality improvement methodology

Define the Problem: Undertaking a baseline service evaluation to identify areas for improvement. Form a multidisciplinary team to help understand the system clearly.

Analyse the Current Process: Depending on the specific problem identified methods that could be used include process mapping and baseline data collection. 

Components of the process that could be reviewed as a team include:

Initiation:

Assessment for appropriate indications and opioid risk: Who does the assessment and how? 

Patient education: Who does this and what information needs to be discussed? What is the trial period, route, dose, and agreed outcomes?

If there is no benefit after the trial period, is the plan for de-escalation agreed and documented? 

Maintenance: 

Who reviews the patient after the trial period if continued on opioids and how often? Is it at primary care or at secondary care?  Is the indication still relevant? Is there still any sustained improvement in pain and functionality? Are the side effects within tolerable levels? Is initiation of de-escalation needed as there is no benefit or risk of harm more than benefit? 

De-escalation: 

How are the risk benefits assessed and by whom? Does the patient agree to de-escalation? 

Who develops the de-escalation plan? How fast are patients de-escalating? What kind of support is provided for de-escalation? Who monitors and manages withdrawal symptoms? If there is resistance to de-escalation what are the obstacles? Is it due to genuine apprehension or due to high-risk behaviour? What is the management plan for high-risk behaviour?                                                                                                                

Develop and Test Changes: 

Generate ideas for improvement as a multidisciplinary team. Driver diagrams can be useful in producing a wide array of potential changes.

Consider what data sampling would be useful to know if changes make a real improvement, and how to monitor for unexpected impacts. As a team undertake review sessions regularly, the Institute for Healthcare Improvements ‘Model for Improvement’ and subsequent Plan/Do/Study/Act cycles can be helpful to structure and guide these reviews.

Sustain Improvements: 

Consider how you can ensure that improvements are sustained over time through ongoing monitoring and process adjustments. How will your local governance processes enable this, does there need to be regular service evaluation or continuous data collection. 

References

1.Busse JW, Wang L, Kamaleldin M, et al. Opioids for Chronic Noncancer Pain: A Systematic Review and Metaanalysis. JAMA. 2018; 320(23): 2448–2460. doi:10.1001/jama.2018.18472. 
2.Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review.Annals of Internal Medicine (2015) 162: 276-286. 
3.Faculty of Pain Medicine, Opioid Aware (2025). https://www.fpm.ac.uk/opioids-aware
4.Moore RA, McQuay HJ: Prevalence of opioid adverse events in chronic non-malignant pain:Systematic review of randomised trials of oral opioids. Arthritis Research &Theory. 2005; 7: R1046–R1051.
5.Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, MMWR Recomm Rep 2022;71 (No. RR-3):1–95. DOI https://www.cdc.gov/mmwr/volumes/71/rr/pdfs/rr7103a1-H.pdf
6.Jason W. Busse DC etal, Canadian Guideline for opioid therapy and chronic noncancer pain, 2017 May 8;189 https://www.cmaj.ca/content/cmaj/189/18/E659.full.pdf.
7.https://www.sign.ac.uk/media/2102/sign136_opiod_pathway_2019.pdf
8.https://www.welshpainsociety.org.uk/_files/ugd/c792fe_5e1e6630a03b47149…
9.Jane Quinlan, Heather Willson and Katheryn Grange et al. Hopes and fears before opioid tapering: a quantitative and qualitative study of patients with chronic pain and long-term opioids. British journal of pain (2020). https://journals.sagepub.com/toc/bjpb/15/2.