4. Mr O complains the ICB has refused to agree to prescribe fentanyl lozenges to help him manage his ongoing back pain.
5. Mr O says not being able to access appropriate pain relief means he has difficulty walking. He says he has also endured episodes of severe pain.
6. Mr O asks the ICB to agree to prescribe him fentanyl lozenges.
7. Mr O has a history of back pain. He has been under the care of a pain clinic since November 2019.
8. In November 2020, there was a multidisciplinary team (MDT) meeting (where a group of staff from different healthcare areas meet to discuss the care of individual patients) to discuss Mr O’s request to be prescribed fentanyl lozenges. The meeting concluded it was not appropriate to agree to the request.
9. Mr O complained about this to the ICB but it did not change the decision about not prescribing him the medication he had asked for.
12. Before we decide if we should consider a complaint in more detail, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
13. Mr O says he has had chronic back pain for a number of years. He says he is allergic to all non-steroidal anti-inflammatory drugs (NSAIDS) and can only take intravenous (through a needle or tube inserted into a vein) morphine and intravenous or lozenge-form fentanyl or ketamine (an anaesthetic and painkiller) without an adverse reaction. Mr O says he tried fentanyl lozenges on one occasion and found them helpful. So he is asking for them to be prescribed in future. He believes he will be able to improve his quality of life if he is able to manage his pain levels.
14. Fentanyl is a strong opioid painkiller. It is used to treat severe pain, for example, from a serious injury or pain caused by cancer. It can also be used for some types of chronic pain (persistent pain lasting longer than 12 weeks despite medication or treatment), when other weaker painkillers which have been used for a long time have stopped working.
15. NICE’s BNF information on fentanyl explains this drug carries a risk of addiction and dependence. The risk is increased for patients with current or previous substance use or mental health disorders.
16. Fentanyl lozenges are fast acting, or ‘immediate release’. NHS England’s guidance for CCGs says immediate-release fentanyl is only licensed for use in cancer treatment. If it is felt it would be beneficial for a patient who does not have cancer (which should only be in ‘exceptional circumstances’), it can only be prescribed in a primary care setting (for example, a GP, not a hospital) after discussion with an MDT or other healthcare professional.
17. Mr O complains the ICB has refused to agree for him to be prescribed fentanyl lozenges. He says this is despite his GP and his pain clinic supporting his use of this medication.
18. The ICB declines to allow the requested medication to be prescribed. The CCG told Mr O it was following NHS England guidance and was not prescribing the medication for Mr O’s own safety and to ‘[limit] the risks to professional accountability and responsibilities for those involved in [his] care’.
19. Mr O’s records show he has a history of excessive alcohol and substance misuse. They show he was abstinent for many years but had a brief relapse in January 2017. We can also see Mr O has diagnoses of borderline personality disorder (a disorder of mood and how a person interacts with others), dissocial personality disorder (a condition characterised by a disregard for social obligations and unconcern for the feelings of others) and paranoid schizophrenia (schizophrenia is a long-term mental health condition, while someone experiencing a paranoid delusion may believe they are being harassed or persecuted). He has also expressed feelings of self-harm and suicide. So, given both Mr O’s mental health conditions and history of substance abuse, it seems reasonable to conclude Mr O is in the increased risk category.
20. Mr O does not meet the initial criteria for fentanyl to be prescribed – that is, he does not have cancer. As the guidance says should happen, An MDT meeting took place to discuss his case in November 2020. At that meeting, it was decided Mr O should not be prescribed the requested medication on the basis of his previous suicidal thoughts.
21. As the CCG has explained to Mr O, the prescribing clinicians have a responsibility to prescribe appropriately. As the complaint is not about a prescribing clinician, we do not go into the details of this here other than to say we consider the CCG’s response on this point to be appropriate.
22. The ICB has considered Mr O’s request in line with NHS England’s guidance. We are satisfied it has done this reasonably and appropriately. So, we have not seen signs of any failing by the ICB and will not consider the complaint further. This is not to take away from the importance of this matter to Mr O. It is clear he is in a lot of pain and it is understandable he wants to improve his quality of life. Unfortunately, it is not currently appropriate for this to happen through the use of fentanyl lozenges.
1. The Parliamentary and Health Service Ombudsman has carefully considered Mr O’s complaint about NHS South East London Integrated Care Board (the ICB), formerly South East London Clinical Commissioning Group (the CCG). We are sorry to hear Mr O is in pain and struggles to find suitable relief. It is clear this has caused him significant worry and upset.
2. We consider the ICB is right to decline Mr O’s request for fentanyl lozenges (a strong opioid painkiller). Mr O does not meet the criteria for this to be prescribed nor would it be appropriate for the ICB to do so given his medical history.
3. So, we have decided not to consider this complaint further.