78 Strong opioid substitution: a multi-site evaluation of clinical practice

Background Strong opioid substitution to a different route or a different strong opioid is common in palliative care. Variation in practice had been noted across the region despite the availability of regional, national and international guidance. Aim Within a regional palliative care audit program in the North West of England to; Evaluate opioid substitution practice in hospice, hospital and community settings; Update regional standards and guidelines for opioid substitution. Methods Systematic literature review; Multi–site retrospective case note analysis. Results 18 articles were identified to inform the update of the regional standards and guidelines. 285 patient records were analysed from 21 different sites. Patients had either undergone a change in route or a change to a different strong opioid. In 93% of cases the reason for opioid substitution was documented. The commonest reasons were neurotoxicity (58%), oral route being inappropriate (34%), renal impairment (14%) and inadequate analgesia (12%). In only 35% of cases was the rationale for the new dose documented (eg with a dose calculation or reference to a conversion table). In 21% there was documentation of alternative measures tried prior to the opioid substitution (n=281). The commonest alternatives were: treating adverse effects with medications (43%), using co-analgesics (38%), checking for drug interactions (18%) and making a dose reduction (16%). The opioid substitution was of clinical benefit (complete or partial) in 87% (n=52). Conclusion This study showed that strong opioid substitution was of benefit in the majority of patients. However there is risk involved in any opioid substitution. Clear documentation is critical to justify clinical decision-making. It is currently not widespread practice to be documenting rationale for the new dose of the strong opioid. This is now recommended in the updated regional guidelines.