Recurring concern
Inadequate guidance for safe opioid prescribing
- Reports that mention this concern
- 3
- Times this concern has been raised
- 5
- Stated actions linked to this concern
- 5
What this concern includes
Includes deficiencies in guidance, policies or standardised procedures specifically governing opioid prescribing, including discharge oramorph prescribing, long-term opioid prescribing, high-dose or multiple-analgesic prescribing, supply limits, monitoring, review and referral thresholds.
What is not included
- Excludes generic medication-prescribing failures where opioid prescribing is not the material concern.
- Excludes opioid storage, administration, dispensing, access-control and post-prescribing follow-up failures unless the asserted deficiency is specifically in opioid-prescribing guidance.
- Excludes guidance for non-opioid medicines or unrelated clinical conditions.
- Excludes failures to follow clear opioid-prescribing guidance when the guidance itself is adequate.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 3 reports
See individual reports that have raised this concern, and the actions taken in response
-
Concerns raised3
Lack of GP practice policy for co-prescription of opioids and benzodiazepines
Lack of GP practice policy for long-term opioid prescribing
Lack of practice policy requiring agreement of an opioid treatment strategy and end-of-treatment plan
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Petroc Group Practice
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Petroc Group Practice
Develop a comprehensive practice policy for opioid prescribing.
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Petroc Group Practice
Raise opioid prescribing as a significant event for practice-wide consideration.
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Petroc Group Practice
Discuss the opioid prescribing policy and its application at the scheduled practice-wide meeting, then circulate the minutes and policy to staff.
-
Concerns raised1
Failure of the BNF to provide caution and monitoring guidance for simultaneous amitriptyline and oxycodone prescribing
Linked response
- NHS Central East Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS Central East Integrated Care Board
Not all opioid–tricyclic combinations should be stopped because low-dose combinations may be clinically appropriate; risks should be reviewed individually.
-
Concerns raised1
Lack of formal guidance for prescribing oramorph to discharging patients
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cwm Taf Morgannwg University Local Health Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Cwm Taf Morgannwg University Local Health Board
Develop a corrective Action Plan for Improvement addressing the concerns identified in the Regulation 28 report.
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Cwm Taf Morgannwg University Local Health Board
Implement a Standard Operating Procedure governing the appropriate use of oral opioid medication for acute pain.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026