Produced by the NHS Rotherham Medicines Management Team Tel (01709) 302639 if further information is required. The trouble with Tramadol The national statistics office has released the 2012 report on deaths related to drug poisoning in England and Wales. Some of the key findings are; There were 1,706 male drug poisoning deaths (involving both legal and illegal drugs) registered in 2012, a 4% decrease since 2011. Female drug poisoning deaths have increased every year since 2009, reaching 891 in 2012. The number of male drug misuse deaths (involving illegal drugs) decreased by 9% from 1,192 in 2011 to 1,086 in 2012; female deaths decreased by 1% from 413 in 2011 to 410 in 2012. The key finding of most relevance to Rotherham is The number of deaths involving tramadol have continued to rise, with 175 deaths in 2012 – more than double the number seen in 2008 (83 deaths). Tramadol A notable trend that has emerged in recent years is the steady increase in the number of deaths mentioning tramadol .The first recorded death was in 1996, and deaths have risen to an all-time high of 175 deaths in 2012. This increase in deaths may be partly explained by a 35% increase in tramadol prescriptions over the last five years In addition, the latest ‘Street Drug Trends Survey’ Clinical Commissioning Group carried out among police forces, drug agencies, frontline treatment services and drug user groups highlighted the continued rise in the recreational use of tramadol and other synthetic opioids. Unlike most other opioid analgesics, tramadol is not a controlled drug. Tramadol Prescribring Items/ASTROPU 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Rotherham England Rotherham has consistently had a prescribing rate for tramadol above the national average and there is considerable practice variation (see below) Action Commence no new patients on tramadol The CCG has requested RFT remove tramadol from the hospital formulary Do not routinely continue tramadol if the patient is discharged on it. Instead across to to co-codamol or down to paracetamol (RFT surgeons insist that they use it for post operative pain only and it should not be continued) Be cautious if patients request the drug by name Tramadol Items\ASTROPU 12 months to July 2013 Practices vs National Average 12 months to July 2013 45 40 35 30 25 20 15 10 5 0 Sharing good practice Reducing Hypnotic prescribing The thought of getting patients off long term hypnotics and anxiolytics has always filled Medicine Management Teams and prescribers with apprehension. We all know the rational and the benefits, but we also know the difficulty of convincing patients of these, when the withdrawal side-effects of insomnia and anxiety just reinforce to the patient that they need this medication. However, Treeton Medical Centre was up for the challenge. After years of trying gentle strategies and only making minor changes, they focused their full attention and confronted the problem head-on. A year later, the results are fully visible in the prescribing data, and the practices prescribing rate is moving towards the CCG average. 350 Total ADQ per ASTROPU for hypnotics & Anxiolytics 300 250 1st Quarter 2012/2013 200 1st Quarter 2013/2014 150 100 VILLAGE THORPE HESLEY HIGH STREET BROOM VALLEY ROAD WICKERSLEY KIVETON PARK MARKET SURGERY CROWN STREET BROOM LANE SHAKESPEARE ROAD SHRIVASTAVA'S DINNINGTON MORTHEN ROAD CLIFTON RAWMARSH STAG KILNHURST GREENSIDE ST ANN'S PARKGATE BRINSWORTH SWALLOWNEST GREASBROUGH WOODSTOCK BOWER THRYBERGH SURGERY OF LIGHT DALTON MANOR FIELD CANKLOW ROAD TREETON YORK ROAD ROSEHILL THE GATE BLYTH ROAD 0 QUEEN'S 50 How was this done? No easy answers unfortunately, but this is the strategy that Treeton used. Searches run to ascertain patients on hypnotics All staff were made aware of the need to reduce hypnotics All hypnotic repeat prescriptions were changed to acute When Patients requested medication they were given two weeks supply and an appointment made to see the GP for a review Clinicians discussed the use of hypnotics with patients Clinicians introduced a gradual reduction of the hypnotics where appropriate All hypnotics to remain on acute prescription unless the clinician had specifically indicated otherwise If patients needed a course of hypnotic medication, they were informed it was ONLY for short term use and given less than 2 weeks supply If a patient requested another supply then an appointment for a review by a clinician was made Patient’s took a while to get used to the new system, and patients that DNA’d appointments or came up with excuses why they couldn’t attend for a review had the prescriptions reduced to weekly until a review had been undertaken. There was also resistance to the medication being stepped down or stopped. However, clinicians were prepared with the knowledge of the side-effects such as increased risk of falls and car-crashes etc. Could you do this too? There is a prescribing KPI measuring the percentage of patients aged over 55 years prescribed a benzodiazepine. Also, for 13/14 we have a PBC LIS target to reduce the use of Z-drugs to below the national average. Please contact the Medicine Management Team if you would like support for this or any other prescribing area.