There are significant concerns regarding prescription and misuse of prescription opioids in the perioperative period. The Faculty of Pain Medicine at the Royal College of Anaesthetists have produced this evidence-based expert consensus guideline on surgery and opioids along with the Royal College of Surgery, Royal College of Psychiatry, Royal College of Nursing, and the British Pain Society. This expert consensus practice advisory reproduces the Faculty of Pain Medicine guidance. Perioperative stewardship of opioids starts with judicious opioid prescribing in primary and secondary care. Before surgery, it is important to assess risk factors for continued opioid use after surgery and identify those with chronic pain before surgery, some of whom may be taking opioids. A multidisciplinary perioperative care plan that includes a prehabilitation strategy and intraoperative and postoperative care needs to be formulated. This may need the input of a pain specialist. Emphasis is placed on optimum management of pain pre-, intra-, and postoperatively. The use of immediate-release opioids is preferred in the immediate postoperative period. Attention to ensuring a smooth care transition and communication from secondary to primary care for those taking opioids is highlighted. For opioid-naive patients (patients not taking opioids before surgery), no more than 7 days of opioid prescription is recommended. Persistent use of opioid needs a medical evaluation and exclusion of chronic post-surgical pain. The lack of grading of the evidence of each individual recommendation remains a major weakness of this guidance; however, evidence supporting each recommendation has been rigorously reviewed by experts in perioperative pain management.

The misuse of opioids, including codeine which is sold over-the-counter (OTC) in United Kingdom (UK) community pharmacies, is a growing public health concern. An educational Patient Safety Card was developed and piloted to see if it nudged customers into the safe and appropriate use of OTC codeine. Exploratory analysis was conducted by (i) recording quantitative interactions for people requesting OTC codeine in community pharmacies; and (ii) a web-based pharmacy staff survey. Twenty-four pharmacies submitted data on 3993 interactions using the Patient Safety Card. Staff found the majority of interactions (91.3%) to be very or quite easy. Following an interaction using the card, customers known to pharmacy staff as frequent purchasers of OTC codeine were more likely not to purchase a pain relief medicine compared to customers not known to staff (5.5% of known customers did not purchase any pain relief product versus 1.1% for unknown customers (χ2 = 41.73, df = 1, p < 0.001)). These results support both the use of a visual educational intervention to encourage appropriate use of OTC codeine in community pharmacy and the principles behind better self-care.

There has been a marked increase in the number of patients in the UK taking opioids from 2.5% in 2000 to 5% in 2015.1 More patients are taking opioids at higher doses for chronic pain,2,3 for which there is limited evidence of effectiveness. A public facing4 audit with educational resources of high-dose opioids (≥120 mg oral morphine equivalent [OME]) prescribed for chronic pain was carried out in 74 general practices in the East of England, representing 663 418 patients. The dose of ≥120 mg OME was chosen as doses above this are not associated with increased benefit but are associated with increased harms.2 The aim of this study was to quantify: This study also aimed to record practice reflections and plans on their results. In total, 517 practices throughout NHS England Midland and East (East) were emailed (January 2018), inviting participation in an audit of high-dose opioids prescribed for chronic pain. Downloadable searches were provided. It was suggested that …

Prescribed opioid misuse in North America is a public health crisis, with huge social, medical and economic repercussions. Surgery is an identified driver for persistent opioid use and misuse. The UK has also seen a surge in opioid consumption per capita and it is now necessary for primary and secondary care to work together to mitigate the problem of perioperative prescribed opioid misuse.This review discusses the identified drivers for persistent opioid use following surgery and discusses the remedial actions that must be taken by all stakeholders to mitigate the UK developing its own perioperative prescribed opioid crisis.

If a living worm is put into the hand of a child before he is baptised, and kept there until the worm is dead, that child will have power in afterlife to cure all diseases to which children are subject.1 Not all of us will have had the foresight to do this so we need other systems to aid diagnosis and management of symptoms.

This article describes what happened when we attempted to set up an educational development project to design a syllabus and implementation strategy for GP education in England. Grounded in good practice our approach involved consultations with a range of relevant professionals. Because we adopted a rigorous approach to the definition of our plans and to the recording of data collected we attracted research ethics and research governance attention. The governance processes involved were cumbersome. Requirements were inconsistent and there was also much replication. Considerable resources were consumed. We question some of the implications of our experience for educational development projects in terms of quality assurance, resources and professional inclusivity.

A systematic and evidence informed approach to new service developments (the “spotlight” approach) was developed with members of a new primary health care team. The approach aimed to ensure that service developments were relevant, grounded in evidence, documented and clearly owned by the practice team. A total of 13 spotlight developments were defined and documented during the first nine months. All considered relevance to local policy, all used research evidence and/or other accepted sources of appropriate expertise and all were discussed at team meetings. The spotlight approach quickly became accessible and familiar to new team members. It provides a common structure and language for discussion and documentation and is applicable to a wide range of service‐linked developments. It provides a vehicle for translating research into practice and the documentation to facilitate transfer of what has been learnt to others in the community for whom the development and its evidence base is relevant.