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Appendix D Appendix D: Monitoring of controlled drug prescribing Objectives To identify unusual prescribing habits of individual prescribers (GPs, Dentists and Nurse prescribers) across Kirklees in both NHS and Private practice. What characterises unusual? This could be defined as: • Consistently high amount of milligrams of any CD preparation prescribed compared to peers. • Large amounts of injectable Sch2 CDs – unless this can be explained though specific local service provision of which the AO has knowledge and has investigated to verify. • Choice of drug (% of morphine, diamorphine, fentanyl and oxycodone should be very high compared to other Schedule 2 CDs) Unusual choices should be investigated – high use of Pethidine for example is unusual. • Prescribing trend analysis indicates low variation from the prescribers average. • Large quantity prescribed on prescriptions. • Longer treatment periods (>28days) • High amount of personally administered CDs What drugs should be monitored? • All Schedule 2 CD injections • All preparations of Schedule 2 CDs: Morphine Fentanyl Cocaine Hydromorphone Dexamfetamine Methylphenidate Diamorphine Methadone • •

Oxycodone Pethidine

Buprenorphine Benzodiazepines: Alprazolam Chlordiazepoxide Clobazam Clonazepam

Diazepam Flurazepam Loprazolam Lorazepam

Lormetazepam Midazolam Nitrazepam Oxazepam Temazepam

How should use be monitored? The level and depth of monitoring will vary as some drugs have a much lower abuse potential and / or risk in relation to overdose etc. Therefore drugs deemed to be of lower risk do not require the same levels of monitoring as do drugs with high associated risks. When monitoring, all factors including their CD schedule (as defined in the Misuse of Drugs Regulations) will guide the level of monitoring required. t lower levels of routine monitoring depending on their CD schedule, frequency of use and hazardous nature.

Approved: 25/3/09

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Review by: March 2011


Appendix D Report methodology to be used Issues to be identified High volumes of use of Injectable Schedule 2 CDs

Who to monitor • • •

Doctor (NHS) Doctor (private) Non-medical prescribers

Drugs to monitor All schedule 2 CD injections

e-PACT reporting requirements • •

Items/PU Cost/PU

Consistently high number of mg prescribed (drugs for pain relief)

• • •

Doctor (NHS) Doctor (private) Dentist private

Consistently high number of mg prescribed (drugs for pain relief)

Non-medical prescribers

Consistently high number of mg prescribed (drugs for substance misuse)

Doctor (NHS) Doctor (private) Dentist (priv) Non-med prescribers

• • •

Approved: 25/3/09

Schedule 2 CDs for pain relief: • Diamorphine • Fentany • Hydromorphone • Morphine • Oxycodone • Pethidine • Temgesic (buprenorphine) Schedule 2 CDs for pain relief: • Diamorphine • Fentany • Hydromorphone • Morphine • Oxycodone • Pethidine • Temgesic • Methadone • Buprenorphine (subutex) • Cocaine

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• • •

Items/PU Cost/PU Quantity x items

Information presentation

Data interpretation

Pivot table of data – down to individual GP or practice and Non-medical prescriber Graph ranking practices Pivot table of data (including drug, form strength)– down to individual GP or practice Graph ranking practices

Consistent ranking in top 25% over at least 6 of 8 quarters need for further checks

Appropriate use of pivot table to assess individual prescribers

Consistent ranking in top 25% over at least 6 out of last 8 quarters need for further checks

Appropriate use of pivot table to assess individual prescribers

Appropriate use of pivot table to assess individual prescribers

Items

Table of nonmedical prescribers ranked, with suppressed zeros in pivot table by drug / strength

Cost /PU

Table of prescribers ranked, with suppressed zeros by drug / strength

Review by: March 2011

Assess use against role definition for non-medical prescriber activities • Trend of use over 8 quarters • Trend of use over 8 quarters Unusual trend or increasing use further checks

Additional requirements


Appendix D Issues to be identified Low variation in use

Who to monitor • •

Drugs to monitor

Doctor (NHS) Doctor (private)

Doctor (NHS) Doctor (private)

Large quantity per prescription issued

Treatment supply greater than 28 days

High volumes of personally administered CDs

• •

Doctor (NHS) Doctor (private)

• • •

Doctor (NHS) Doctor (private)

Approved: 25/3/09

All Schedule 2 CDs

e-PACT reporting requirements

Cost / PU by: Practice • Individual prescriber All Schedule 2 Quantity x items: CDs • Practice Burprenorphine • Individual Benzodiazepines prescriber All Schedule 2 DDD/item by: • Practice CDs Buprenorphine • Individual Benzodiazepines prescriber All personally • Items/PU administered CDs •

Information presentation Pivot table & trend over 8 quarters Pivot table

Pivot table

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Table of all CDs administered Comparison table by practice, ranked

Review by: March 2011

Data interpretation

Additional requirements

Consistent low variation in use – further investigation Large quantities on prescriptions - further investigation Treatment over 28 days - further investigation

Appropriate use of pivot table to assess individual prescribers Appropriate use of pivot table to assess individual prescribers Appropriate use of pivot table to assess individual prescribers

High volumes compared to other practices – further investigation

http://www.kirklees.nhs.uk/fileadmin/documents/publications/policies_procedures/Medicines_Management  

http://www.kirklees.nhs.uk/fileadmin/documents/publications/policies_procedures/Medicines_Management/Appendix%20D%20Monitoring.pdf

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