Evidence review for safer prescribing
Evidence review O
NICE Guideline, No. 225
Safer prescribing
Review question
What are the key principles of safer prescribing for people who have self-harmed?
Introduction
According to the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness 2015, self-harm by self-poisoning is the second most common method of self-harm. Some medications, such as opioids and tricyclic anti-depressants, in overdose can be fatal. Many people who have harmed themselves will have been prescribed medications for physical and/ or mental health-related problems, or will have access to the medications of others close to them. As a result, there is the potential for people who have self-harmed using other methods to self-poison in the future if they have access to medications that are harmful in overdose. It is therefore imperative to review the evidence on what constitutes safe prescribing to reduce rates of self-poisoning from any medication that could potentially cause harm through overdose. The aim of this review is to identify the key principles of safer prescribing for people who have self-harmed using any method.
Summary of the protocol
See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
For further details see the review protocol in appendix A.
Methods and process
A modified version of the GRADE approach to rate the certainty of evidence in systematic reviews was used as part of a pilot project undertaken by NICE. Instead of using predefined clinical decision/minimal important difference (MID) thresholds to assess imprecision in GRADE tables, imprecision was assessed qualitatively during committee discussions. Other than this modification, GRADE was used to assess the quality of evidence for the selected outcomes and this evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document (supplementary document 1).
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
Effectiveness evidence
Included studies
A systematic review of the literature was conducted but no studies were identified which were applicable to this review question.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review are listed, and reasons for their exclusion are provided in appendix J.
Summary of included studies
No studies were identified which were applicable to this review question (and so there are no evidence tables in Appendix D).
Summary of the evidence
No studies were identified which were applicable to this review question (and so there are no GRADE tables in Appendix F).
Economic evidence
Included studies
A single economic search was undertaken for all topics included in the scope of this guideline but no economic studies were identified which were applicable to this review question. See the literature search strategy in appendix B and economic study selection flow chart in appendix G.
Excluded studies
Economic studies not included in the guideline economic literature review are listed, and reasons for their exclusion are provided in appendix J.
Economic model
No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.
Evidence statements
Economic
No economic studies were identified which were applicable to this review question.
The committee’s discussion and interpretation of the evidence
The outcomes that matter most
Self-harm repetition, suicide and adverse events relating to prescribed drugs were prioritised as critical outcomes by the committee. Self-harm repetition and suicide were prioritised as critical outcomes because they are direct measures of any differential effectiveness associated with the interventions and capture both fatal and non-fatal self-harm. Occurrence of adverse events of prescribed drugs (such as self-poisoning or overdose, accidental or intentional) was chosen as a critical outcomes as it is associated with inappropriate prescribing practices and may capture differential effectiveness associated with the intervention not captured by repeat self-harm and survival.
The committee agreed that quality of life, service user satisfaction, concordance/ adherence/ compliance and financial impact were important outcomes. Quality of life was chosen as an important outcome as this is a global measure of well-being and may capture aspects of effectiveness of the interventions not captured by any of the other outcome measures. The committee recognised that some prescribing practices may be associated with a higher financial burden than others due to the potential for more frequent prescription charges, and service user satisfaction and financial impact were therefore chosen as important outcomes as both may influence whether the patient adheres to the prescription as recommended. Concordance/ adherence/ compliance was chosen as an important outcome which can directly capture whether the patient adhered to the prescription as recommended as it is also an indicator of the acceptability and success of the intervention.
The quality of the evidence
No studies were identified that met the inclusion criteria so the committee based the recommendations on their own knowledge and experience.
Despite the lack of evidence, the committee decided not to prioritise this topic for research recommendations because the general issue of the relative toxicity of drugs and their potential use for self-harm or suicide is not specific to people who have self-harmed, but is a wider issue for people receiving both mental and physical healthcare. Therefore, the population for any study on safe prescribing should not realistically be contained to people who have self-harmed. Additionally, the committee agreed that any new evidence would be unlikely to change recommendations, which were based on the committee’s knowledge and experience of current best practice.
Benefits and harms
The committee agreed that when prescribing medication to people following an episode of self-harm using any method, it is important to take into account the toxicity of the prescribed medications, particularly for people who have self-poisoned. Based on their knowledge and experience, the committee highlighted the particular risk of opiate-containing painkillers and tricyclic antidepressants with regards to fatal overdoses, but agreed there were a number of medications which could cause significant harm through overdose. It is also important to assess the person’s drug and alcohol consumption because concurrent use can increase the toxicity associated with some medications. The committee agreed the prescriber should also take into account the person’s wider access to medications when prescribing to reduce rates of self-poisoning. This decision was based on their knowledge that people can self-poison using medications bought online, prescribed for unrelated conditions, or prescribed to people who they live with or are close to. The committee discussed the ethics and feasibility of obtaining information about the person’s wider access to medication and agreed that it should be discussed with the person or assessed through medical records. Based on their experience that communication can sometimes be lacking between professionals when multiple prescribers are involved in a person’s care, the committee agreed that effective communication between prescribers is important to ensure all relevant professionals are kept up-to-date regarding any prescribing decisions made. The committee also referred to NICE’s existing guidance on Preventing suicide in community and custodial settings (NG105) when making these recommendations.
The committee identified that a key component of safer prescribing was limiting the quantity of medications prescribed to people with a history of self-harm. The committee discussed the importance of shared decision-making when deciding on the quantity of medications to prescribe as this may have financial implications for the person, which affect adherence and service user satisfaction, and they referred to the NICE guidance on Shared decision making (NG197). The committee agreed that the prescriber should find an appropriate solution that prioritised the person’s safety while promoting adherence to medication, and that the prescriber should encourage the person to return any unwanted medicines for safe disposal.
The committee agreed, based on their experience, that this would reduce rates of self-poisoning.
The committee agreed that all existing and any new medications prescribed should be reviewed following an episode of self-harm and any repeat episodes. The committee discussed that this was important to ensure that any new prescriptions took into account toxicity associated with concurrent use of medicines, as they may not have specialist knowledge on the pharmacokinetic properties of medicines. If necessary, prescribers should contact a local medicines information centre through the UK Medicines Information service. The committee also referred to the NICE guidance on Medicines optimisation (NG5) and the STOMP-STAMP principles for information regarding prescribing for people with learning disabilities, autism, or both.
The committee highlighted that the role of community pharmacy staff in relation to self-harm was identifying people who may be purchasing medication with the intent of self-poisoning, and using their position as community-placed healthcare staff to discuss intent with people who might self-harm. They agreed based on experience that this was usually indicated when people were in acute distress or purchasing large quantities of medicines over the counter, and that pharmacy staff should be aware of these warning signs so they can respond appropriately. The committee agreed that such a response should include consultations and medicines reviews whereby pharmacy staff can discuss self-harm with people as appropriate and enact safe prescribing principles, such as using shared decision-making to limit the quantity of medicines supplied to the person. Consultations would also give staff the opportunity to provide support to people who they might already have an established relationship with, especially pharmacists who work in the community and regularly interact with the same people. The committee pointed out that other healthcare professionals, including GPs, should also use consultations and medicines reviews as an opportunity to assess how self-harm may interact with substances that could be taken in overdose, particularly when prescribing new medications. The committee discussed the harms and benefits of this approach, and agreed that while this may have the inadvertent outcome of some people being inaccurately identified as intending to self-harm, the benefits of correctly identifying when an individual is intending to self-harm and responding appropriately include the prevention of self-poisoning or overdose.
Despite the lack of evidence, the committee did not choose to make any research recommendations for safer prescribing. The committee agreed that existing NICE guidelines on safe prescribing are relevant for people who self-harm and there is no need to make recommendations specifically for people who self-harm further to those made in this guideline.
Cost effectiveness and resource use
The committee noted that no relevant published economic evaluations had been identified and no additional economic analysis had been undertaken in this area. They drafted recommendations aimed to promote changes in service delivery and to reduce variation across the NHS in delivering safe prescribing for people who have self-harmed. The committee based such recommendations on the evidence and on existing NICE guidance. They expressed the view that for prescribers, these recommendations may mean that they review current prescriptions more routinely after an episode of self-harm with respect to the person’s risks of toxicity from overdose. For primary healthcare professionals, these recommendations may increase communication with healthcare professionals from other settings, such as specialist mental health centres and specialist pharmacies when prescribing and reviewing medications. Improved communication between healthcare professionals should limit variations in prescribing practices and improve continuity of care. The committee expressed the opinion that potential changes in current practice should not result in a significant resource impact.
The committee expressed the view that any resource implications associated with medicine reviews following an episode of self-harm would ensure the person’s safety and would therefore be outweighed by benefits.
Recommendations supported by this evidence review
This evidence review supports recommendations 1.13.1-1.13.5.
References – included studies
Effectiveness
No studies were identified that met the inclusion criteria.
Economic
No studies were identified that met the inclusion criteria.
Appendices
Appendix A. Review protocols
Appendix B. Literature search strategies
Appendix C. Effectiveness evidence study selection
Appendix D. Evidence tables
Evidence tables for review question: What are the key principles of safer prescribing for people who have self-harmed?
No evidence was identified which was applicable to this review question.
Appendix E. Forest plots
Forest plots for review question: What are the key principles of safer prescribing for people who have self-harmed?
No meta-analysis was conducted for this review question and so there are no forest plots.
Appendix F. Modified GRADE tables
Modified GRADE tables for review question: What are the key principles of safer prescribing for people who have self-harmed?
No evidence was identified which was applicable to this review question.
Appendix G. Economic evidence study selection
Appendix H. Economic evidence tables
Economic evidence tables for review question: What are the key principles of safer prescribing for people who have self-harmed?
No evidence was identified which was applicable to this review question.
Appendix I. Economic model
Economic model for review question: What are the key principles of safer prescribing for people who have self-harmed?
No economic analysis was conducted for this review question.
Appendix J. Excluded studies
Excluded studies for review question: What are the key principles of safer prescribing for people who have self-harmed?
Excluded effectiveness studies
Excluded economic studies
Table 4. Excluded studies from the guideline economic review
Appendix K. Research recommendations – full details
Research recommendations for review question: What are the key principles of safer prescribing for people who have self-harmed?
No research recommendations were made for this review question.
Final
Evidence reviews underpinning recommendations 1.13.1 to 1.13.5 in the NICE guideline
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.