title: A service improvement project to review prescribing information provided by general practitioners for new referrals to a UK National Health Service hospital pain clinic: potential implications of CYP2D6 enzyme inhibition.
abstract: BACKGROUND
  Chronic pain is often managed using co-prescription of analgesics and adjuvants, with concomitant medication prescribed for comorbidities. Patients may have suboptimal response to some analgesics or be at risk of drug interactions or adverse drug reactions (ADRs) due to polypharmacy affecting CYP2D6 enzyme activity. The aim of the service improvement project was to determine the proportion of patients referred to a specialist pain service in the UK National Health Service (NHS) by general practitioners (GPs) who may be at risk of suboptimal analgesic response or ADRs due to CYP2D6 inhibition through polypharmacy. This was achieved by reviewing clinical prescribing information provided by GPs at time of referral. It was hoped that the findings could be used to aid clinical and prescribing decisions without conducting CYP2D6 genotyping or phenotyping.
  
  
  METHODS
  A review of letters from 250 patients referred to an NHS hospital pain service from GPs over a 3-month period was undertaken. Information about current and concomitant medications was analysed to identify the potential for CYP2D6 inhibition and adverse events.
  
  
  RESULTS
  Letters failed to provide information about current pain medication for 20 (8%) patients or non-pain concomitant medication for 54 (21.6%) patients. Of 176 patients, 52 (29.5%) patients with information about non-pain concomitant medication had been prescribed at least one known CYP2D6 inhibitor. A total of 35 (19.9%) patients were identified as being at risk of an adverse drug reaction and 33 (18.75%) patients at risk of suboptimal analgesic response due to co-administration of CYP2D6 inhibitors.
  
  
  CONCLUSIONS
  The review revealed the need for improved detail in GP referral letters used to transfer care to UK NHS hospital pain clinics. There is a need to consider an individual's CYP2D6 phenotype when prescribing analgesic prodrugs to manage persistent pain. Caution is needed when patients are co-prescribed codeine or tramadol with selective serotonin reuptake inhibitors (SSRIs).
authors.affiliation: Faculty of Health & Social Sciences, Leeds Beckett University, Leeds, UK; Centre for Neurosciences, The Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Pallium Research Group, Leeds, UK.
authors.forename: Helen
authors.initials: H
authors.lastname: Radford
authors.affiliation: Faculty of Health & Social Sciences, Leeds Beckett University, Leeds, UK.
authors.forename: Pauline
authors.initials: P
authors.lastname: Fitzgerald
authors.affiliation: Faculty of Health & Social Sciences, Leeds Beckett University, Leeds, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Martin
authors.affiliation: Faculty of Health & Social Sciences, Leeds Beckett University, Leeds, UK; Leeds Pallium Research Group, Leeds, UK.
authors.forename: Mark I
authors.initials: MI
authors.lastname: Johnson
keywords: CYP2D6; Pain management; analgesic drugs; general practitioner; polypharmacy