Tapentadol for chronic non palliative pain in adults pro-forma – Final version approved by HMMC September 2014

Patient NHS No. / Trust: / GP name:
PatientHospital Number: / Consultant Name: / GP code/Practice code:
Patient initials:
Patient DoB: / Consultant Contact Details: / GP post code: / ENHCCG
Herts Valleys CCG
This form is to be used to notify the Trust pharmacy department and the CCG Pharmacy & Medicines Optimisation Team of treatment initiation.
The completed form along with a copy of the current pain scale scores to be sent to the Trust pharmacy department. Copy to be forwarded to the CCG Pharmacy & Medicines Optimisation Team.

Please indicate which of the following criteria apply to this patient:

The patient has chronic pain for more than 6 months duration? /

Yes/ No

Copy of BPI short form enclosed to confirm baseline scores? /

Yes/ No

Patient has some identifiable neuropathic component of pain eg dysthesia, spontaneous pain, allodynia, phantom limb?

/

Yes/ No

There are no other aspects of patient’s history to raise concern about pure mu agonist prescribing eg previous history of large-dose escalation of opioids; previous opioid addiction; concerns about supply diversion? /

Yes/ No

Previous Opioid Treatment

Patient has received a trial of at least TWOstrong opioids, including morphine, oxycodone &/orfentanyl patch: Yes/ No

  • Please provide details of previous or current treatment. Please note that within discontinuation section, the generic term ‘adverse effects’ is unacceptable. Please state intolerance. Inefficacy is acceptable. State contra-indication if relevant.
Drug name / Drug dose / Drug frequency / Duration of treatment / Discontinued? / Rationale for discontinuation / change of treatment
Yes/ No
Yes/ No
Yes/ No
Supportive Medications

Have the following been co-prescribed at adequate doses for adequate periods?

Laxatives for constipation

/

Yes/ No

Antiemetics for nausea

/

Yes/ No

Stopping Criteria

Has a discussion been had with the patient that this is a trial of tapentadol for 3 months & if it is ineffective it will be stopped & treatment changed back to the most effective/best tolerated previously used strong opioiod? /

Yes/ No

Baseline Pain Severity andTreatment Goals

Baseline BPI short form completed (enclose copy)
/

Yes/ No

Treatment Goals (eg avoid escalation to inpatient pain management, avoid need for spinal cord stimulation, reduce other medicines) /

Treatment goals:

Clinician Declaration:
I confirm that I have discussed with the patient and that they understand and consent to their personal information being shared with commissioning and commissioning support organisations. I have also recorded this discussion in the patient’s notes.
I confirm the risks and benefits of treatment have been fully discussed with the patient and documented.
Name of supervising consultant:
Signature: Date: / Name of Trust Chief Pharmacist (or deputy):
Signature Date:

Review of tapentadol treatment at 3 month follow up

The completed form along with a copy of the pain response scores to be sent to the Trust pharmacy department. Copy to be forwarded to the CCG Pharmacy & Medicines Optimisation Team.

Patient NHS No. / Trust: / GP name:
PatientHospital Number: / Consultant Name: / GP code/Practice code:

Current Dose:

Pain Response
Has there been a 20% pain improvement compared to baseline using the BPI short form (enclose copy)?
AND
Has a score of 5-7 been achieved on the Patients' Global Impression of Change scale (enclose copy)?
NOTE treatment should only be continued if the answer to BOTH of these questions is YES /

Yes/ No

Yes/ No
Side-Effects
Beneficial improvement to side-effects compared to previous opioids?
If so confirm relevant side-effect and comparative benefit: /

Yes/ No/ N/A

Continuation

Is treatment with tapentadol to be continued?

/

Yes/ No

if NO confirm tapentadol has been discontinued: Yes/ No
Reason for discontinuation (eg intolerance, poor pain response):
When transferring prescribing responsibility to the GP willa further 1 month’s supply be prescribed and will comprehensive ongoing management information as outlined in the Pain Guidelines be supplied? / Yes/ No
Has a 3 month follow-up appointment been arranged with the pain specialist? / Yes/ No
All sections above need to be completed by the pain clinic before referring the patient to the GP for ongoing prescribing

Review of tapentadol treatment at 12 month follow up

The completed form along with a copy of the current pain response scores to be sent to the Trust pharmacy department. Copy to be forwarded to the CCG Pharmacy & Medicines Optimisation Team.

Patient NHS No. / Trust: / GP name:
PatientHospital Number: / Consultant Name: / GP code/Practice code:

Current Dose:

Pain Response and Treatment Goals
Has 20% pain improvement compared to baseline using the BPI short form been maintained (enclose copy)? /

Yes/ No

Has a score of 5-7 on the Patients' Global Impression of Change scale been maintained (enclose copy)? /

Yes/ No

Have the Treatment Goals recorded at initiation been achieved (provide update)? /
Side-Effects
Beneficial improvement to side-effects maintained?
If so confirm relevant side-effect and comparative benefit: /

Yes/ No/ N/A

Continuation

Is treatment with tapentadol to be continued?

/

Yes/ No

if NO confirm tapentadol has been discontinued: Yes/ No
Reason for discontinuation (eg intolerance, poor pain response):

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Approved by Hertfordshire Medicines Management Committee September 2014