NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update Primary Care

PostScript Primary Care - November 2013

Healthy Start Vitamins

Most community pharmacies in NHSGGC have signed up to participate in a national pilot scheme to supply NHS Healthy Start vitamin tablets or drops.  Eligible women and children will be provided with a ‘Vitamin D Sunshine’ card by their GP, health visitor or midwife.  Tablets are supplied to women who are pregnant or had a baby in the past 12 months and who are either obese, dark skinned or financially challenged.   Drops are provided to children aged 6 months to 4 years, of these women and to dark-skinned breastfed babies whose mothers did not take the vitamins during pregnancy. 
The vitamins may be purchased in pharmacies by individuals who are not eligible for the above scheme.

Preferred Brand of Oxycodone MR

Several brands of generic oxycodone MR are now available. NHSGGC policy is that modified release controlled drugs should be prescribed by brand name. Longtec® is the NHSGGC brand of choice for modified release oxycodone and will be supplied in the acute sector.

• Morphine is the preferred choice of strong opioid within GGC 
• Oxycodone use remains second line restricted to patients in whom morphine is ineffective or not tolerated.
• Modified release oxycodone should be prescribed as “Longtec”.
• Immediate release oxycodone should continue to be prescribed generically.

Unless there are clinical reasons suggesting otherwise, GPs should prescribe Longtec® to avoid confusion and ensure consistency of supply across primary and secondary care.

An electronic message will be used on ScriptSwitch to prompt the change from Oxycontin MR® or oxycodone MR. The implementation date for the Scriptswitch message will be mid-December.  Community pharmacies have been given one month’s notice to allow management of existing stock.

Please contact Heather Harrison, Chronic Pain Primary Care Service Development Project Manager on 0141 201 5157 for more information.

Morphine Prescribing Caution

A dispensing error was recently identified within NHS Greater Glasgow and Clyde where the incorrect branded product was dispensed against a modified-release (MR) morphine prescription.  A pharmacist was destroying Controlled Drugs (CDs) at a hospice for a recently deceased patient when it was noted that the patient had been prescribed a mixture of morphine MR tablets and MR capsules prior to admission to the hospice.

Upon looking into this further with the GP practice it was discovered the following prescriptions were written:
- morphine sulphate MR 60mg capsules ONE twice daily – pharmacy correctly dispensed Zomorph® 60mg
- morphine sulphate MR 60mg capsules ONE twice daily – pharmacy incorrectly dispensed MXL® 60mg which is a 24hr preparation
- morphine sulphate MR 120mg  tablets ONE twice daily – pharmacy correctly dispensed MST Continus® 120mg

Contributing factors
• Multiple GPs involved in the care of the patient and writing prescriptions
• Patient’s condition deteriorated quickly and increasing doses of morphine required
• Some GPs noting "MST" in the notes but then generically prescribing morphine sulphate MR caps
• When prescribing in EMIS if you type in “morphine” and scroll down the list then you come to MR caps before the MR tabs
• Community pharmacy not familiar with the difference between the two preparations of morphine sulphate MR capsules available (Zomorph® a 12hr preparation and MXL® a 24hr preparation).

Key Recommendations
• Modified-release preparations of oral strong opioids such as morphine or oxycodone should be prescribed by brand name
• When prescribing, dispensing or administering CDs confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient

New Website on Management of Chronic Pain

The NHSGGC Chronic Pain MCN Education Subgroup announces the launch of its new pain website www.paindata.org. Aimed at clinicians and patients it contains general information, patient information leaflets and educational resources relating to all aspects of chronic pain management.

Clinicians can access:
• opioid dose converter tool that will facilitate conversion of opiates to give 24 hour equi-analgesic doses. The tool can convert multiple opioids when consolidating treatments and also automatically calculates the recommended 25% dose reduction when switching opioids.
• video files of MCN educational presentations delivered to primary care meetings in Glasgow on clinical and service topics relating to chronic pain.
• links to a new Chronic Pain Learn-Pro module consisting of 5 parts:
Physiology of chronic pain
Assessment of chronic pain
Physiotherapy for chronic pain
Non–pharmacological therapies for chronic pain
Pharmacological therapies for chronic pain.
• links to current guidelines, audits and a noticeboard detailing upcoming pain meetings and a forum for discussions.

Patients can access:
• Information on drugs used in the management of chronic pain, including drug information leaflets with titration guidance.
• Links to supporting websites.
• A pain diary app for android devices which both records pain scores and also provides a portal to information contained on the website.
• A link to research currently being undertaken in the Pain Service and a patient forum for feedback on the site.

The website goes live in October and additional educational material and patient resources will be added as they become available.