1. Aims: What matters to the individual about their condition(s)?
Review diagnoses and consider:
- Therapeutic objectives of drug therapy
- Management of existing health problems
- Prevention of future health issues, including lifestyle advice
Ask person to complete PROMs (Questions to answer before medicines review) before their review
Person specific issues to address
- Wishes to manage her pain
- Wishes to reduce her need for out of hours contacts and find ways to better manage her condition
2. Need: Identify essential drug therapy
Identify essential drugs (not to be stopped without specialist advice)
- Drugs that have essential replacement functions (e.g. levothyroxine)
- Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)
Person specific issues to address
- Methadone maintenance is essential as substance dependence therapy and should not be stopped abruptly. Methadone is normally initiated by specialist services and the risks of prescribing in OOH services is high. Individuals presenting with opioid discontinuation/withdrawal symptoms during the OOH period should be signposted to the emergency department for assessment and management of their symptoms. Consider elimination half-life of medication requested (see below) and risk of harm from prescribing without access to daytime medical records
- If prescribing, prescribe the smallest quantity needed to allow follow up in daytime GP services and clearly document in case records the strength and quantity supplied
3. Does the individual take unnecessary drug therapy?
Identify and review the continued need for drugs
- what is medication for?
- with temporary indications
- with higher than usual maintenance doses
- with limited benefit/evidence for use
- with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)
Person specific issues to address
- Multiple medications prescribed for pain, all associated with a risk of dependency and which would require support to withdraw safely in daytime practice:
- Amitriptyline
- Co-codamol
- Gabapentin
- Pregabalin
- Tramadol
4. Effectiveness: Are therapeutic objectives being achieved?
Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives
- to achieve symptom control
- to achieve biochemical/clinical targets
- to prevent disease progression/exacerbation
- is there a more appropriate medication to achieve goals?
Person specific issues to address
- Be aware of any local or national policies around prescribing of medicines with risk of dependency during the OOH period
- Take a person-centred approach to management and prescription request in OOH services. Review any management advice on case records/ ECS from daytime GP and discuss the benefits, risks and alternatives to prescribing. Where prescribing in the OOH period, use the smallest quantity to allow daytime GP practice follow up and document clearly in records
- During daytime follow up discuss effective pain management options for chronic pain considering physical function, mental health, social and emotional factors. Record clear instructions on patients ECS with indication for use and management of prescription requests during the OOH period
- Tolerance to opioids occurs therefore higher doses are required to maintain the same level of pain relief
- Good practice not to combine opioids
- During daytime follow up target tramadol first for gradual reduction
- Work with individual to develop a plan to gradually deprescribe gabapentinoids (gabapentin and pregabalin separately) and opioids (tramadol first, then codeine in co-codamol). Agree a plan to communicate to OOH services using ECS
- Explain potential for discontinuation/withdrawal symptoms and that the tapering may take months. Leave clear instructions for OOH management and prescription requests during this time ensuring safety across transitions of care
5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?
Identify individual safety risks by checking for
Identify adverse drug effects by checking for
- specific symptoms/laboratory markers (e.g. hypokalaemia)
- cumulative adverse drug effects (see ADR table)
- drugs used to treat side effects caused by other drugs
Medication Sick Day guidance
- Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness
Person specific issues to address
- Constipation possibly a side effect of opioid use
- Increased risk of adverse effects such as drowsiness, respiratory depression and interactions with multiple opioids and gabapentinoids (see MHRA alert)
- Ensure awareness of need for contraception to reduce teratogenic effects with gabapentin
- Potentially increased risk of drug-related death due to use of multiple opioids, gabapentinoids and street drugs
6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?
Identify unnecessarily costly drug therapy by
- considering more cost-effective alternatives, formulary choices, safety, convenience
Consider the environmental impact of
- Inhaler use
- Single use plastics
- Medicines waste
- Water pollution
Person specific issues to address
- During daytime practice review, consider reducing ineffective pain medication and introducing non-pharmacological therapy such as physiotherapy, yoga, CBT. Support may be available from a community link worker to identify the best plan for the individual
7. Person-centredness: Is the person willing and able to take drug therapy as intended?
Does the person understand the outcomes of the review?
Ensure drug therapy changes are tailored to individual’s preferences. Consider
- is the medication in a form they can take?
- is the dosing schedule convenient?
- what assistance is needed?
- are they able to take medicines as intended?
Agree and communicate plan
- discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
- include lifestyle and holistic management goals
- inform relevant health and social care providers of changes in treatments across the transitions of care
Ask person to complete PROMs (Questions to answer after medicines review) after their review
Agreed plan
- In OOH establish what pain medication is requested and take a person-centred, risk/ benefit approach to management, in line with local and national policies, until reopening of daytime GP services
- Recommend follow up with regular GP practice in a suitable time frame
- In daytime practice recommend stepwise reduction plan for any ineffective medicines in agreement with the individual. Record indication for medicine, any reduction plans and management options for prescription requests during the OOH period on the individual’s ECS
- Consider option of physiotherapist and community link worker support
- Signpost to National Wellbeing Hub
- Alcohol: discussed the effects of alcohol and potential to worsen symptoms related to pain and depression and signpost to local support if available
- Smoking: recommend smoking cessation services and reduction/cessation of cannabis
Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029
