Recurring concern

Unreliable specialist support for reducing and withdrawing from prescribed opioids

First to latest report 14 Nov 2019 — 3 Mar 2026

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
14

What this concern includes

Includes failures in arrangements for identifying patients needing support to reduce or withdraw from prescribed opioids, providing or commissioning specialist advice and treatment, accepting referrals, coordinating GP and specialist care, and maintaining safe support during dose reduction or withdrawal.

What is not included
  • Excludes general opioid prescribing, dosage, monitoring, toxicity-warning, medication-review and administration failures where specialist reduction or withdrawal support is not the deficient condition.
  • Excludes treatment and support for dependence on illicit drugs or alcohol unless the assertion explicitly concerns dependence arising from prescribed opioids.
  • Excludes generic pain-service access or psychological-support deficiencies where safe reduction or withdrawal from prescribed opioids is not the shared concern.
  • Excludes isolated patient reluctance or non-engagement where the specialist support pathway itself is adequate.
  • Excludes medication shortages, routine continuity-of-supply failures and ordinary prescribing changes that do not concern supported reduction or withdrawal.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Derby and Derbyshire

    AI-generated summary

    Wendy BODDINGTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Wendy BODDINGTON was found deceased at home on 24 March 2025 after friends had been unable to contact her for several days. She had two fentanyl patches on her body instead of the single prescribed patch; toxicology found fentanyl at a fatal level, with prescribed codeine adding to the toxicity. The principal concern was that people receiving long-term, often high-dose opiate and opioid prescriptions for chronic pain may not receive adequate support to reduce, stop, or substitute these medications.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of specialist services for dependence on prescribed opiates and opioids

    Wider context from the report

    “The context for my concerns is the well-recognised situation of long-term prescription of opiate and opioid medications, often at high doses, for chronic pain. It is now recognised that such prescribing will usually cause other health problems, including dependence and tolerance, and over time becomes limited in controlling pain. Whilst current guidance is against such prescribing, there are many people who have been taking these medications for a long time for whom stopping or reducing the medications is very challenging. Use of those medications carries risk of accidental or deliberate overdose and death. Wendy’s inquest heard that her GP practice has initiated a targeted programme to identify patients who have been receiving long-term prescription of opiate and opioid medications and engage them in focussed review to agree planned reduction, stoppage, or substitution of those medications. This programme involves 2 senior GPs and 2 pharmacists and so is a significant commitment. The practice is incrementally concentrating on those patients with high-dose prescriptions. Relatedly the practice has introduced a number of measures to try and avoid patients being inappropriately prescribed these medications for chronic pain in the first place. In evidence the GP partner stated that he was unaware of other GP practices in the Derbyshire area undertaking similar programmes. The inquest also heard that there are no specialist services for patients who have developed dependence on opiates and opioids, and that substance misuse services will only work with people with non-prescribed drug issues. The inquest did hear anecdotal evidence that NHS England may be pursuing some relevant initiatives but the details and extent of this was unclear. My specific concern is that there appear to be a significant number of people who are being prescribed opiate and opioid medications for chronic pain, often at high doses and for long periods, but may not be receiving support to reduce, stop, or substitute those medications. It appears to me that the ICB is in a position to consider this problem and potential remedies on a regional basis, and feed into national strategies. ”

    Source location

    Wendy BODDINGTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Participate in a system-wide GIRFT chronic-pain review to identify pathway variation and service-delivery challenges.

    Verbatim wording from the response

    “Getting it Right First Time (GIRFT) chronic pain review”

    Source location

    Response from NHS Derby and Derbyshire Integrated Care Board
    Page 3 · response
    Published 9 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement recommendations from the GIRFT chronic-pain review in line with national and organisational objectives.

    Verbatim wording from the response

    “In January 2026, the ICB participated in an NHS England GIRFT chronic pain virtual system review, working in collaboration with the Faculty of Pain Medicine and the British Pain Society. The review looked to identify variation and challenges across the whole chronic pain pathway to help address challenges in service delivery for pain management, in line with the strategic aims of the Department of Health and Social Care and NHS England. The aim is to develop a structured model to ensure patients receive personalised, holistic and evidence-based care at each stage, with seamless transitions between services– in turn, improving the patient experience. This is part of a programme of multiple ICS reviews, at the end of which a joint report will be published, highlighting priority areas for national improvement.”

    Source location

    Response from NHS Derby and Derbyshire Integrated Care Board
    Page 3 · response
    Published 9 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and re-procure pain-management services.

    Verbatim wording from the response

    “Considering the concerns raised by the coroner in this report, the ICB is undertaking the following further actions:”

    Source location

    Response from NHS Derby and Derbyshire Integrated Care Board
    Page 4 · response
    Published 9 March 2026

    Open published response

  2. Essex

    AI-generated summary

    Michael Paul Barry · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Michael Paul Barry died at Broomfield Hospital from fatal complications of community-acquired pneumonia, with excessive codeine use contributing to his death. The principal concern was the lack of a commissioned specialist service to help patients and GPs safely reduce or withdraw from prescribed dependency-forming medication, creating a risk of avoidable future deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of commissioned specialist services for safely reducing and withdrawing from prescribed dependency-forming medications

    Wider context from the report

    “Notwithstanding the positive finding that the specific medication prescribed by Mr Barry’s GP had not been the source of the excessive codeine taken prior to admission to hospital, compelling evidence was received at the inquest from a Partner at the GP Practice (with a particular specialism in this area of dependency-forming medications) that there remains no specialist commissioned service available for GPs to which they might refer their patients to manage reduction of their intake of prescribed dependency-forming medications. This is in contrast to the availability of commissioned services for patients who are dependent on illicit drugs and/or alcohol. The evidence confirmed that reduction or cessation of dependency-forming medications needs to be very carefully managed due to the risk of withdrawal symptoms and, in the context of the unchallenged evidence received, requires specialist input and training to maximise the prospects of success and to avoid potentially fatal consequences. The evidence, again unchallenged, was that the continuing absence of such a commissioned service gives rise to the risk of avoidable future deaths. The long-standing and continuing lack of commissioned services in primary or secondary care for assisting people to safely reduce and withdraw from such prescribed medication was confirmed in her evidence by the Director of Pharmacy and Medicines Optimisation within the Mid and South Essex Integrated Care Board (the ICB). This witness helpfully set out important steps currently proposed and/or being taken to educate clinicians and service users alike of the dangers of opiate based prescription medications (alongside their relatively limited benefits in most, though not all, cases) with a view to reducing the size of the cohort of patients at risk of becoming dependent/addicted in the medium and longer term. However, this does not - absent a commissioned service to which GPs and patients may turn for specialist advice and assistance - address the immediate and on-going risk of future deaths to those currently dependant on/addicted to these medications, with the numbers of such patients having significantly increased in the post-COVID 19 period as a consequence of lengthy delays to, for example, chronic pain-relieving surgery. Precisely this issue was highlighted in a previous PFD Report from 14th November 2019 issued by the former Senior Coroner in this jurisdiction. The response from the (then) Clinical Commissioning Group had indicated an intention to roll-out a Prescribed Opioid Dependence Local Enhanced Service in early 2020, but this was not implemented due to the COVID 19 pandemic. Since then, including at the date of Mr Barry’s death in November 2023 and through to today, there remains no such, or similar, commissioned service across Essex or, it appears, consistently across England and Wales with only rare pockets around the country where such a service is commissioned. ”

    Source location

    Michael Paul Barry · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish the framework for personalised care of adults prescribed medicines associated with dependence or withdrawal symptoms.

    Verbatim wording from the response

    “In March 2023, NHS England published ‘Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for ICBs and primary care’.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 23 June 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver a chronic-pain medicines safety programme to reduce prescribed opioid use and help Integrated Care Systems adopt effective whole-system practice.

    Verbatim wording from the response

    “Other developments”

    Source location

    Response from NHS England
    Page 3 · response
    Published 23 June 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Offer accredited dependence-forming-medication e-learning on opioid reduction in chronic pain and cognitive behavioural therapy for persistent pain to primary care practices.

    Verbatim wording from the response

    “Concurrent to this, regionally funded accredited Dependence Forming Medications (DFM) e-learning on ‘Reducing opioids in chronic pain’ and ‘Cognitive Behavioural Therapy for persistent pain’ training was offered to all practices through a locally commissioned Medicines Optimisation Local Enhanced Scheme in 2023-24.”

    Source location

    Response from Mid and South Essex Integrated Care Board
    Page 2 · response
    Published 23 June 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and disseminate guidelines for acute and chronic non-malignant pain management, including opioid tapering guidance for chronic non-cancer pain.

    Verbatim wording from the response

    “As further support for clinicians treating patients who are prescribed dependence forming medications, the ICB has developed and disseminated comprehensive guidelines for the management of acute and chronic non-malignant pain, including specific guidance on Opioid Tapering for Chronic Non-Cancer Pain. These resources provide a structured framework for identifying at-risk patients and supporting safe withdrawal.”

    Source location

    Response from Mid and South Essex Integrated Care Board
    Page 2 · response
    Published 23 June 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Procure and implement a Community Musculoskeletal Service opioid reduction and discontinuation pathway providing structured deprescribing support and coordination with GPs.

    Verbatim wording from the response

    “A new Opioid Reduction/Discontinuation Pathway is planned within the Community Musculoskeletal (MSK) Service, currently in procurement and due for implementation in February 2026.”

    Source location

    Response from Mid and South Essex Integrated Care Board
    Page 2 · response
    Published 23 June 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work up a business case to scale the Aegros primary-care-network model across the Integrated Care Board, including clinician upskilling for deprescribing and dependency prevention.

    Verbatim wording from the response

    “The ICB Executive Committee has endorsed a proposal to work up a business case to scale up the Aegros Primary Care Network (PCN)-based model across the ICB, aiming to deliver this service affordably while maintaining a primary care focus and upskilling clinicians to both deprescribe and prevent new cases of dependency.”

    Source location

    Response from Mid and South Essex Integrated Care Board
    Page 2 · response
    Published 23 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    ICBs are responsible for commissioning services supporting safe withdrawal from prescribed dependency-forming medicines and should commission appropriate local provision.

    Verbatim wording from the response

    “The commissioning of services to support people with chronic pain (including services to support people to safely withdraw from prescribed medicines that may cause dependence and withdrawal) now lies with ICBs as a delegated specialised service. NHS England expects ICBs to commission appropriate services to meet the needs of the population that each ICB geographically covers. This includes taking due regard of the above national commissioning and clinical guidance. A multi-disciplinary team (MDT) approach is needed with input from, for example, pain specialists, dependence services, mental health services and peer support groups. I note that your Report has also been addressed to Mid and South Essex ICB and trust that they will be able to respond further on this issue.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 23 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NHS England cannot comment on the locally proposed service because it was not nationally commissioned.

    Verbatim wording from the response

    “First, regarding the lack of specialist commissioned services available to GPs, NHS England has advised that the Prescribed Opioid Dependence Local Enhanced Service referenced in your report has been a locally proposed initiative that was not commissioned nationally. Therefore, whilst I do understand your concerns on this matter, NHS England is not able to comment on this specific service.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 23 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Trust cannot provide a stand-alone prescription medication dependency service because it is not commissioned to do so.

    Verbatim wording from the response

    “At present, however, the Trust is not commissioned to provide a specialist service for a stand-alone prescription medication dependency service that would allow direct referral from GPs solely for tapering and withdrawal management of these medicines.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 23 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Integrated Care Boards are responsible for commissioning chronic pain and prescribed-medicine withdrawal services for their local populations.

    Verbatim wording from the response

    “Commissioning of services to support people with chronic pain (including services to support people to safely withdraw from prescribed medicines that may cause dependence and withdrawal) now lies with Integrated Care Boards (ICBs). NHS England expects ICBs to commission appropriate services to meet the needs of the population that the ICB geographically covers. This includes taking due regard to any of the above national commissioning or clinical guidance.”

    Source location

    Response from Department of Health and Social Care
    Page 3 · response
    Published 23 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Limited resources constrain the pace and scale of developing services for dependence-forming medication support.

    Verbatim wording from the response

    “The Mid and South Essex Integrated Care Board (ICB) is committed to improving patient safety and outcomes across all areas of care. However, as with all healthcare systems, we must continually balance a wide range of competing priorities, including urgent and emergency care, mental health, cancer services and cardiovascular disease. While the issue of dependence-forming medications remains a significant concern, and we are taking meaningful steps to address it, the pace and scale of service development are inevitably influenced by the need to allocate limited resources across multiple areas of critical need. Nonetheless, we fully recognise the risks highlighted in your report and remain committed to reducing harm and improving support for patients affected by medication dependency.”

    Source location

    Response from Mid and South Essex Integrated Care Board
    Page 1 · response
    Published 23 June 2025

    Open published response

  3. Essex

    AI-generated summary

    Joanna Clare Alice Flynn · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Joanna Clare Alice Flynn, aged 31, was found slumped over her bed on 26 May 2019 after last being seen on 23 May 2019. The inquest returned an Open conclusion against a background of long-standing prescribed opiate addiction, with concerns about the lack of specialised support and referral pathways for patients needing help to withdraw from addictive prescription drugs, as well as GP training and education.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of specialised assistance and referral agencies for general practitioners supporting patients dependent on prescribed opiates

    Wider context from the report

    “The General Practitioner who gave evidence told the court that there was a lacuna in the healthcare provided for patients such as the deceased in terms of giving assistance for weaning off addictive prescription drugs such as opiates. It was clear that General Practitioner’s require highly specialised assistance in order to help such patients and agencies within the healthcare system to which to refer them. This was all lacking in this particular sad set of circumstances. The court was informed about a proposed pilot scheme – a substance misuse Locally Enhanced Service for people with dependence to prescribed opiates. There was no assurance that this had commenced or indeed yet been funded. I would like an assurance that this hopeful initiative has got off the ground and indeed I would like to have information about any other initiatives to endeavour to address this dreadful problem. I would also like to hear what strides have been taken to improve training and education for general practitioners and GP practices in this worrying area of care. ”

    Source location

    Joanna Clare Alice Flynn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Request NICE guidance on safe prescribing of dependence-associated medicines and careful withdrawal management.

    Verbatim wording from the response

    “In addition, the Department asked the National Institute for Health and Care Excellence (NICE) to develop guidance on the safe prescribing of drugs associated with dependence”

    Source location

    2019-0369-Response-from-the-Department-of-Health-and-Social-Care
    Page 1 · response
    Published 9 December 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and mobilise a commissioned Management of Prescribed Opioid Dependence Local Enhanced Service providing multidisciplinary support, weaning plans and primary-care education.

    Verbatim wording from the response

    “• Working closely with our local substance misuse service provider, mental health trust and local pain consultants to develop a Management of Prescribed Opioid Dependence Local Enhanced Service, more details of which are provided below.”

    Source location

    2019-0369-Response-by-Mid-Essex-CCG
    Page 2 · response
    Published 9 December 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Configure Scriptswitch to flag high-dose opioid risks, provide specialist contact details and link to the opioid resource pack.

    Verbatim wording from the response

    “2) Inclusion of pop-up information message on Scriptswitch®”

    Source location

    2019-0369-Response-by-Mid-Essex-CCG
    Page 4 · response
    Published 9 December 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue supporting primary care through additional funding, staff and organisational development for vulnerable, high-risk patients.

    Verbatim wording from the response

    “It is important to acknowledge the current pressures on primary care. NHSE continues to support primary care with additional funding, staff and organisational development to ensure time and resources are available to care for these vulnerable patients who are potentially high risk and will often need input from the most experienced staff.”

    Source location

    2019-0369-Response-from-NHS-England-and-NHS-Improvement
    Page 2 · response
    Published 9 December 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure appropriate expertise and resources are universally available to support patients dependent on prescribed medicines and reduce associated morbidity and mortality.

    Verbatim wording from the response

    “NHSE is committed to fully understanding contributing factors to this serious problem and ensuring that all appropriate expertise and resources are universally available to support these patients and reduce the likelihood of future associated morbidity and mortality.”

    Source location

    2019-0369-Response-from-NHS-England-and-NHS-Improvement
    Page 2 · response
    Published 9 December 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Specialised services for people dependent on prescription medicines are the responsibility of local commissioners.

    Verbatim wording from the response

    “Finally, the provision of specialised services to support people dependent on prescription medicines is a matter for local commissioners. I am aware that the Mid-Essex Clinical Commissioning Group (CCG) has responded to your report explaining the services that are in place locally to support patients and GPs. This includes the new Management of Prescribed Opioid Dependence Locally Enhanced Service (referenced in your report), that is anticipated to be in place from 1 April 2020. I am advised that other measures are being taken locally to promote better prescribing and reduce the amount of opioids being prescribed.”

    Source location

    2019-0369-Response-from-the-Department-of-Health-and-Social-Care
    Page 4 · response
    Published 9 December 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Commissioning substance misuse services is a public health responsibility of local authorities.

    Verbatim wording from the response

    “The ‘pilot’ scheme referred to by ████████ at the request is a local service that the CCG has been seeking to introduce to support patients with a dependency upon prescribed medicines. Whilst the commissioning of substance misuse services is one of the public health responsibilities of Local Authorities, the Essex Specialist Treatment and Recovery Service (STaRS) commissioned by Essex County Council only provides advice and support to help GPs manage patients dependent on prescribed opioids. STaRS will only see people for adjunctive problematic use of prescribed and/or over-the-counter medications, if their primary problematic substances are alcohol or illicit drugs.”

    Source location

    2019-0369-Response-by-Mid-Essex-CCG
    Page 3 · response
    Published 9 December 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Extending the existing service to support prescribed-opioid dependence was not possible, so an alternative service model was developed.

    Verbatim wording from the response

    “To address this gap in services, Mid Essex CCG agreed in November 2018 to fund a service to support GPs and patients dealing with this issue. Initially the CCG was hoping to work with Essex County Council to extend the existing STaRS service to include patients dependent upon prescribed opioids. Unfortunately after an extended dialogue with the Council and also directly with Essex Partnership University Trust (the provider of STaRS) it became apparent that this would not be possible and so the CCG has been working with local GPs and pharmacists to develop an alternative service model.”

    Source location

    2019-0369-Response-by-Mid-Essex-CCG
    Page 3 · response
    Published 9 December 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Specialist support beyond general practice is usually delivered through services commissioned by clinical commissioning groups.

    Verbatim wording from the response

    “Many of these patients will require input beyond ‘conventional’ general practice, usually via a CCG commissioned service that could take the form of a Locally Commissioned Service (in effect an enhanced GP service) or through a contract with an alternative provider, usually across a CCG footprint.”

    Source location

    2019-0369-Response-from-NHS-England-and-NHS-Improvement
    Page 2 · response
    Published 9 December 2019

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026