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Right Decision Service newsletter: October 2024

Welcome to the Right Decision Service (RDS) newsletter for October 2024.

1.Contingency arrangements for RDS outages

Development of the contingency solutions to maximise RDS resilience and minimise risk of future outages is in progress, aiming for completion by Christmas. As a reminder, these contingency arrangements  are:

  • Optimising mobile app build process
  • Mobile app always to be downloadable.
  • Serialising builds to mobile app; separate mobile app build from other editorial and end-user processes
  • Load balancing – provides failover (also enables separation of editorial processes from other processes to improve performance.)

 

In the meantime, a gentle reminder to encourage users to download essential clinical toolkits to their mobile devices so that there is an offline version always available.

 

2. New deployment with improvements.

A new scheduled deployment with minor improvements drawn from support tickets, externally funded projects, information related to outages, and feature requests will take place in early December. Key improvements planned are:

  • Deep-linking to individual toolkits within the RDS mobile app. Each toolkit will now have its own direct URL and QR code, both accessible from the app. These can be used to download the toolkit directly where users already have the RDS app installed. If the user does not yet have the RDS app installed, they will be taken to the app store to install the app and immediately afterwards the toolkit will automatically open and download. Note that this will go live a few days later than the improvements below due to the need to link up the mobile front end to the changes in the content management system.
  • Introducing an Announcement Header field to replace the hardcoded "Announcements and latest updates" text. This will enable users to see at a glance the focus of new announcements.
  • Automated daily emptying of the recycling bin (with a 30 day rolling grace period)  in the content management system. A bug preventing complete emptying of the recycling bin contributed to one of the outages earlier this year.
  • Supporting multiple passcodes (ticket 6079)
  • Expanding accordion section to show location of a search result rather than requiring user coming from a search result to manually open all sections and search again for the term.
  • Displaying first accordion section Content text as a snippet on the search results page as a fallback if default/main content is not provided
  • Displaying the context of each search result in the form of a link to the relevant parent tool/section. This will help users to choose which search result is most likely to be appropriate for their needs.
  • As part of release of the new national benzodiazepine quality prescribing guidance toolkit sponsored by Scottish Government Effective Prescribing and Therapeutics, a digital tool to support creation of benzodiazepine tapering/withdrawal schedules.

We are also seeking approval to use the NHS Scotland logo and title for the RDS app on the app stores to help with audience engagement and clarity around the provenance of RDS.

3. RDS Search, Browse and Archive/Version control enhancements

We are still hopeful that user acceptance testing for at least the Search and browse enhancements can take place before Christmas. Thank you for your patience and understanding in waiting for these improvements. Timescales have been pushed back by old app migration challenges, work to address outages, and most recently implementing the contingency arrangements.

4. Support tickets

We are aware that there continue to be some issues around a number of RDS support tickets, in part due to constraints around visibility for the RDS team of the tickets in the existing  support portal. We are investigating the potential to move to a new support ticket requesting system from early in the new year. We will organise the proposed webinar around support ticket processes once we have confirmed the way forward with the system.

Table formatting

There is a known issue with alterations in formatting of some RDS tables which seems to have arisen as a result of the 17 October deployment. Tactuum is working on a fix and on implementing additional regression testing to prevent this issue recurring.

5. New RDS toolkits

Recently launched toolkits include:

NHS Lothian Infectious Diseases

Scottish Health Technologies Group – Technology Assessment recommendations

NHS Tayside Anaesthetics and Critical Care projects – an innovative toolkit which uses PowerAutomate to manage review and response to proposals for improvement projects.

If you would like to promote one of your new toolkits through this newsletter, please contact ann.wales3@nhs.scot

A number of toolkits are expected to go live before Christmas, including:

  • Focus on dementia
  • Highland Council Getting it Right for Every Child
  • Dumfries and Galloway Adult Support and Protection procedures
  • National Waiting Well toolkit
  • Fertility Scotland National Network
  • NHS Lothian postural care for care homes

6.Sign up to RDS Editors Teams channel

We have had a good response to the recent invitation to sign up to the new Teams channel for RDS editors. This provides a forum for editors to share learning, ideas and questions and we hope to hold regular webinars on topics of interest.  The RDS team is in the process of joining participants to the channel and we’d encourage all editors to take part, using the registration form – available in Providers section of the RDS Learning and Support area.

 

7. Evaluation projects

The RDS team has worked with colleagues in NHS Grampian and the Digital Health & Care Innovation Centre to evaluate the impact of the Prevent the progress of diabetes web and mobile app in a small-scale pilot project. This app provides access to local and national resources and services targeted at people with prediabetes, a history of gestational diabetes, or candidates for remission. After just 8 weeks of using the app, 94% of patients reported increased their knowledge and understanding of diabetes, and 88% said it had increased their confidence and motivation to make lifestyle changes, highlighting specific behaviour changes. The learning from this project is informing development of a service model based on tailored support for patient groups with, high, medium and low digital self-efficacy.

Please contact ann.wales3@nhs.scot if you would like to know more about this project.

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 29th November 3-4 pm
  • Thursday 5 December 3.30 -4.30 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

The Right Decision Service:  the national decision support platform for Scotland’s health and care

Website: https://rightdecisions.scot.nhs.uk    Mobile app download:  Apple  Android

 

 

Red – For medicines normally initiated and used under specialist guidance

Introduction

Description

Description: Potent synthetic opioid analgesic – partial agonist/antagonist - in a topical patch lasting 72 hours (3 days), 96 hours (4 days) or 168 hours (7 days).

Safety Alert: IT IS BEST PRACTICE TO REMOVE ALL TRANSDERMAL PATCHES FOR MRI SCANS. THIS IS OF PARTICULAR IMPORTANCE FOR FENTANYL AND BUPRENOPRHINE PATCHES WHICH CAN CAUSE SERIOUS OVERDOSE IF NOT REMOVED PRIOR TO SCAN

Preparations

Tables are best viewed in landscape mode on mobile devices

Strength of patch Licensed indication Frequency of patch application
5 microgram, 10 microgram, 15 microgram and 20
microgram per hour		 Treatment of non-malignant pain of moderate intensity when an opioid is necessary for obtaining adequate analgesia

Replace patch(es) every 7 days.

Butec® patches have been accepted by SMC for restricted use in patients over 65 years of age for the treatment of chronic non-malignant pain of moderate intensity when an opioid is necessary for obtaining adequate analgesia.
35 microgram, 52.5 microgram and 70 microgram per hour Treatment of moderate to severe cancer pain and severe pain which does not respond to non-opioid analgesics

Either: Apply a new patch every 72 hours (3 days)

Or

Apply a new patch after up to 96 hours (4 days).
SPC suggests bi-weekly dosing, for example Tuesday and Friday.

It is recommended that patients should ideally stay on the same formulation and should not switch between patches. Consult local guidance for preferred brand.

Indications

  • Strong opioid for moderate to severe opioid responsive pain.
  • Pain that is stable.
  • Oral and subcutaneous routes are not suitable.
  • Patient unable to tolerate morphine/diamorphine due to persistent side effects.
  • Compliance is poor, but supervised patch application is possible.
  • Intolerant of codeine.
  • Highly sensitive to strong opioids even at low dose and experiencing opioid toxicity/side effects.
  • Known to have compromised renal function.

Patients who require the topical route of administration and where opioid requirements are lower than the lowest initiating strength of fentanyl patch (refer to Choosing and changing opioids guideline).

 

Cautions

  • Buprenorphine is a potent opioid analgesic; check the dose carefully.
  • 5 microgram/hour buprenorphine patch is equivalent to about 12mg of oral morphine in 24 hours.
  • Frail or elderly patients may need lower doses and slower titration.
  • Heat/pyrexia increases the absorption of buprenorphine and can cause toxicity. Avoid direct contact with heat (for example hot water bottle, heat pad). Showering is possible as the patches are waterproof, but patients should avoid soaking in a hot bath, sauna or sunbathing. If the patient has a persistent temperature of 39◦C or above, the patch dose may need reviewed - use anti-pyretic measures.
  • Liver impairment: dose reduction may be needed in severe liver disease.
  • Renal impairment: no dose reduction. Buprenorphine is not usually cleared by dialysis.
  • If the patient has unstable pain or pain likely to change following treatment, for example radiotherapy, do not start buprenorphine. Seek advice and consider alternative opioids.
  • Do not cut patches, cutting patches makes them 'off-label'
  • Remove patches before MRI

 

Drug interactions

  • Hepatic metabolism may be increased by CYP3A4 inducers such as carbamazepine, phenobarbital, phenytoin and rifampicin which will reduce the concentration and efficacy of buprenorphine. Check British National Formulary (BNF).
  • Alcohol and central nervous system depressants increase side effects.
  • Buprenorphine must not be used in patients receiving Monoamine oxidase inhibitors (MAOIs) or within 2 weeks of discontinuing their use.

Side effects

  • Similar to other opioids (dizziness, sedation, delirium), constipation and nausea.
  • If signs of opioid toxicity (for example sedation, delirium), remove the patch and seek advice. Buprenorphine will be released from the reservoir and be systemically available for up to 24 hours. Monitor the patient for 24 to 48 hours.
  • Titrated naloxone is only needed for life-threatening, opioid-induced respiratory depression (refer to Naloxone guideline).

 

Note: Reversal of toxic effects by naloxone may require much higher doses than are usual, for example may require up to 2mg per stat dose. This impacts on providers of Out of Hours services and Scottish Ambulance Service and requires appropriate communication.

 

An allergic reaction to the patch adhesive can occur – consider switching brand of patch, change opioid or consider one to two doses of a 50 to 100 micrograms beclometasone dipropionate inhaler on to site prior to application of patch.

 

Dose and administration

Starting a buprenorphine patch

  • Choose a suitable patch - matrix patches allow titration in smaller increments.
  • Calculate the dose of buprenorphine from the conversion chart given here or seek advice.
  • Patch strengths can be combined to provide an appropriate dose provided they have the same frequency of application.
  • Make sure the patient takes another regular opioid for the first 12 hours after the patch is first applied to allow the buprenorphine to reach therapeutic levels:

Tables are best viewed in landscape mode on mobile devices

Immediate release (quick acting) oral morphine or oxycodone Apply patch; continue the immediate release opioid 4 hourly for the next 12 hours.
Modified release (long acting) oral 12 hourly morphine or oxycodone Apply patch when the last dose of a 12 hourly, modified release opioid is given.
Subcutaneous infusion of morphine, diamorphine, oxycodone or alfentanil Apply the patch and continue the infusion for the next 12 hours, then stop the infusion.
  • An immediate release opioid (for example oral morphine or subcutaneous morphine) must be available as required, for breakthrough pain or to treat any opioid withdrawal symptoms (diarrhoea, abdominal pain, nausea, sweating). These can occur during the buprenorphine initiation period due to the variable time to reach steady state. The correct 4 hourly equivalent dose should be used.

Note: DO NOT use short-acting buprenorphine products (for example Temgesic®) for breakthrough pain.

Adjusting the buprenorphine patch dose

  • Review the buprenorphine patch dose after 72 hours; drug levels should be at steady state.
  • If the patient shows signs of opioid toxicity (drowsiness, confusion), reduce the dose, reassess the pain and seek advice.
  • If the patient still has pain which is opioid responsive, titrate the buprenorphine dose in increments depending on the patch type in use. Remember to consider the breakthrough doses used. It will take 12 to 24 hours for the new dose to take effect so give breakthrough analgesia at the correct dose, as required. If there is a significant increase in the number of breakthrough doses required seek specialist advice.
  • Changing buprenorphine patches to another opioid: Seek specialist advice.
  • Buprenorphine is a partial opioid agonist. It is clinically possible to administer opioid agonists for breakthrough analgesia alongside buprenorphine.
  • Switching from buprenorphine patches to fentanyl patches is not routine practice, however 35 micrograms/hour buprenorphine patch is roughly equivalent to
    25 micrograms/hour of fentanyl patch and 70 micrograms/hour of buprenorphine patch is roughly equivalent to 50 micrograms/hour fentanyl patch. Seek specialist advice.
  • Consider switching a patient to a fentanyl patch when the maximum dose of
    140 micrograms/hour (two buprenorphine 70 microgram/hour patches) has been reached and an increase in dosage is indicated.

Buprenorphine patches in the last days of life

  • If a patient is semi-conscious or close to death, continue the buprenorphine patch, changing it according to schedule every 72, 96 or 168 hours.
  • If a new, opioid responsive pain develops, use subcutaneous morphine as required for breakthrough pain. Use the conversion chart to calculate the dose of morphine.
  • If the patient is known to be renally impaired (eGFR less than 30ml/min), alfentanil may be a more appropriate choice (refer to Renal Disease in the last days of life guideline).
  • After 24 hours, the breakthrough doses of morphine given in that period can be totalled and this dose of morphine administered as a subcutaneous infusion in a syringe pump syringe driver over the next 24 hours in addition to the buprenorphine patch.

Dose conversions

  • All opioid dose conversions are approximate.
  • Patients should be monitored closely so that the dose can be adjusted if necessary.
  • Manufacturers of the various formulations of buprenorphine have issued different recommendations for dose conversion, as have drug regulatory bodies.
  • Buprenorphine is approximately 100 times more potent than oral morphine; the table below provides a guide to dose conversions, but if in doubt seek advice (refer to Choosing and changing opioids guideline).
  • For doses beyond those stated in the table below, seek specialist advice.
  • The table below is based on the use of 1/6th of the 24-hour oral morphine dose for breakthrough dose.
  • The preparations for buprenorphine patches may not have an available strength equivalent available. Buprenorphine patches are licensed to be applied whole. In clinical practice where small (less than 5 micrograms/hour) dose titrations are required for safe opioid management and to overcome short term supply issues, patches that are matrix formulation may be cut diagonally however this procedure is unlicensed and specialist advice should be sought. Reservoir patch formulations must not be cut.

Dispose of the unused part of the patch safely as described in the buprenorphine patch care section.

Tables are best viewed in landscape mode on mobile devices

24-hour oral morphine dose Buprenorphine® patch dose (micrograms per hour)

Immediate release oral morphine

Suggested breakthrough dose (refer to guidance in dose and administration)

Immediate release oral oxycodone

Suggested breakthrough dose (refer to guidance in dose and administration)

 Fentanyl® patch dose (micrograms per hour)
12mg 5 2mg 1mg 6
24mg 10 5mg 2mg to 3mg 6 to 12
36mg 15 5mg 2mg to 3mg 12
48mg 20 10mg 5mg 12 to 18

 

Buprenorphine patch care

  • Apply to intact, non-hairy skin on the upper trunk or upper arm; avoid areas treated with radiotherapy, scar tissue or oedematous areas.
  • Apply each new patch to a different skin site; clean the skin with water only as soap products can alter absorption. Make sure skin is dry. Following removal of both parts of the protective liner, the patch should be pressed firmly in place with the palm of the hand for approximately 30 seconds, making sure the contact is complete, especially around the edges.
  • Record the date, time and site if the patch is changed by different people.
  • Change the patch according to brand schedule at about the same time of day.
  • Check the patch daily (or as per local guidance) to ensure it is still in place.
  • If patch adherence is poor, refer to local guidance for advice. Micropore tape may be recommended; buprenorphine is unsuitable for patients with marked sweating.
  • Used patches still contain active drug. When removed, fold the patch in half with the adhesive side inwards. Dispose of it safely (sharps bin for inpatients, domestic waste in the community). Wash your hands after patch changes.

 

Practice points

  • Buprenorphine patches are used for moderate to severe, stable pain.
  • Do not change buprenorphine patches to another opioid in a dying patient, continue the buprenorphine patch and use an additional opioid SC as required.
  • Do not initiate buprenorphine patches in the last days of life when the oral route is no longer available(refer to Care in the last days of life guideline).
  • Record the daily patch check and ensure this information is communicated in medicines documentation/reports if the patient transfers care setting
  • Do not use more than two patches of a single strength at one time.
  • Do not use short-acting buprenorphine products for breakthrough analgesia.
  • The same patch formulation should ideally be prescribed and dispensed consistently for each patient.
  • Ensure patients understand the safe use, storage and disposal of the patch, and the importance of not heating the skin under the patch.

 

References

Comer SD, Collins ED, Fischman MW. Buprenorphine sublingual tablets: effects on IV heroin self-administration by humans. Psychopharmacology (Berl). 2001;154(1):28-37.

Heit HA, Gourlay DL. Buprenorphine: new tricks with an old molecule for pain management. Clin J Pain. 2008;24(2):93-7.

Kornfeld H, Manfredi L. Effectiveness of full agonist opioids in patients stabilized on buprenorphine undergoing major surgery: a case series. Am J Ther. 2010;17(5):523-8.

Likar R. Transdermal buprenorphine in the management of persistent pain - safety aspects. Ther Clin Risk Manag. 2006;2(1):115-25.

Twycross R, Wilcock A, Howard P. Palliative Care Formulary PCF6. 6th ed. England: Pharmaceutical Press; 2017.

Electronic Medicines Compendium.  Summary of Product Characteristics. 2018. Available from: https://www.medicines.org.uk/emc/