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Right Decision Service newsletter: September 2024

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

1.Business case for permanent provision of the Right Decision Service from April 2025 onwards

This business case has now been endorsed by the HIS Board and will shortly be submitted to Scottish Government.

2. Management of RDS support tickets

To balance increasing demand with available capacity and financial resource, the RDS team and Tactuum are now working together to  implement closer management of support tickets. As a key part of this, we want to ensure clear, timely and consistent communication with yourselves as requesters.  

Editors will now start seeing new messages come through in response to support ticket requests which reflect this tightening up and improvement of our processes.

Key points to note are:

2.1 Issues confirmed by the RDS and Tactuum teams as meeting the critical/urgent and high priority criteria will continue to be prioritised and dealt with immediately.

Critical/urgent issues are defined as:

  1. The Service as a whole is not operational for multiple users. OR
  2. Multiple core functions of the Service are not operational for multiple users.

Example – RDS website outage.

Please remember to email ann.wales3@nhs.scot and his.decisionsupport@nhs.scot with any critical/urgent issues in addition to raising a support ticket.

High priority issues are defined as:

  1. A single core function of the Service is not operational for multiple users. OR:
  2. Multiple non-core functions of the Service are not operational for multiple users.

Example – Build to app not working.

2.2 Support requests that are outwith the warranty period of 12 weeks since the software was originally developed will not be automatically addressed by Tactuum. The RDS team will consider these requests for costed development work and will obtain estimate of effort and cost from Tactuum for priority issues.

2.3 Support tickets for technical issues that are not classified as bugs will not be automatically addressed by Tactuum. The definition of a bug is ‘a defect in the software that is at variance with documented user requirements.’  Issues that are not bugs will also be considered for costed development work.

The majority of issues currently in support tickets fall into category 2 or 3 above, or both.

2.4 Non-urgent requests that require a deployment (i.e a new release of RDS) will normally be factored into the next scheduled release (currently end of Nov 2024 and end of Feb 2025) unless by special agreement with the RDS team.

Please note that we plan to move in the new year to a new system whereby requests all come to an RDS support portal in the first instance and are triaged from there to Tactuum when appropriate.

We will be organising a webinar in a few weeks’ time to take you through the details of the current support processes and criteria.

3. Next scheduled deployment.

The next scheduled RDS deployment will take place at the end of November 2024.  We are reviewing all outstanding support tickets and feature requests along with estimates of effort and cost to determine which items will be included in this deployment.

We will update you on this in the next newsletter and in the planned webinar about support ticket processes.

4. Contingency arrangements for RDS

Many thanks to those of you who attended our recent webinar on the contingency arrangements being put in place to prevent future RDS outages as far as possible and minimise impact if they do occur.  Please contact ann.wales3@nhs.scot if you would like a copy of the slides from this session.

5. Transfer of CKP pathways to RDS

The NES clinical knowledge pathway (CKP) publisher is now retired and the majority of pathways supported by this tool have been transferred to the RDS. Examples include:

NHS Lothian musculoskeletal pathways

NHS Fife rehabilitation musculoskeletal pathways

NHS Tayside paediatric pathways

6. Other new RDS toolkits

Include:

Focus on frailty (from HIS Frailty improvement programme)

NHS GGC Money advice and support

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

To go live imminently:

  • Focus on dementia
  • NHS Lothian infectious diseases toolkit
  • Dumfries and Galloway Adult Support and Protection procedures
  • SIGN guideline – Prevention and remission of type 2 diabetes

 

7. Evaluation projects

We have recently analysed the results of a survey of users of the Scottish Palliative Care Guidelines toolkit.  Key findings from 61 respondents include:

  • Most respondents (64%) are frequent users of the toolkit, using it either daily or weekly. A further 25% use it once or twice per month.
  • 5% of respondents use the toolkit to deliver direct patient care and 82% use it for learning
  • Impact on practice and decision-making was rated as very high, with 80% of respondents rating these at a 4-5 on a 5 point scale.
  • Impact on time saving was also high, with 74% of respondents rating it from 3-5.
  • 74% also reported that the toolkit improved their knowledge and skills, rating these at 4-5 on the Likert scale

Key strengths identified included:

  • The information is useful, succinct, and easy to understand (31%).
  • Coverage is comprehensive (15%)
  • All information is readily accessible in one place and users value the offline access via mobile app (15%)
  • Information is reliable, evidence-based and up to date (13%)

Users highlighted key areas for improvement in terms of navigation and search functionality. The survey was very valuable in enabling us to uncover the specific issues affecting the user experience. Many of these can be addressed through content management approaches. The issues identified with search results echo other user feedback, and we are costing improvements with a view to implementation in the next RDS deployment.

8.RDS High risk prescribing (polypharmacy) decision support embedded in Vision and EMIS primary care E H R systems

This decision support software, sponsored by Scottish Government Effective Prescribing and Therapeutics Division,  is now available for all primary care clinicians across NHS Tayside. Board-wide implementation is also planned for NHS Lothian, and NHS GGC, NHS Ayrshire and Arran and NHS Dumfries and Galloway have initial pilots in progress. The University of Dundee has been commissioned to evaluate impact of this decision support software on prescribing practice.

9. Video tutorials for RDS editors

Ten bite-size (5 mins or less) video tutorials for RDS editors are now available in the “Resources for providers of RDS tools” section of the RDS.  These cover core functionality including Save and preview, content page and media management, password management and much more.

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

  • Wednesday 23rd October 4-5 pm
  • Tuesday 29th October 11 am -12 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.)

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

 

Amber - For medicines normally initiated by a specialist but may be used by generalists

Introduction

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).

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.

Note that for small dose titrations matrix patches may be cut diagonally (unlicensed practice). Seek specialist advice.

 

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.

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.

 

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 at the end 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/