Volume 213 - Issue 9
Opioid stewardship can reduce inappropriate prescribing of opioids at hospital discharge
Author: Stephan A Schug
Med J Aust 2020; 213 (9): 409-410. || doi: 10.5694/mja2.50818
Published online: 2 November 2020
Published online: 2 November 2020
The associated risks, particularly that of long term use, are underestimated, and appropriate measures are needed
The associated risks, particularly that of long term use, are underestimated, and appropriate measures are needed
Before 1990, opioids were primarily used to treat severe acute and cancer pain. In the subsequent 30 years, opioids have been increasingly used for treating chronic non‐malignant pain; prescribing has increased exponentially in the developed world, particularly in the United States, but also in Canada and Australia.1 Regrettably, this has not only resulted in poor outcomes for patients living with chronic pain; the analgesic efficacy of opioids for this indication are limited, and they do not improve, and often reduce, function and quality of life.2 Further, diversion of prescribed opioids and their misuse have risen in parallel with increased prescribing, leading to higher numbers of overdoses deaths. In Australia, about 1100 people died following opioid overdoses during 2018, and 75% of cases involved prescription opioids (similar to the number of deaths from car accidents in that year).3
While opioids are most frequently prescribed for patients with chronic pain, it is increasingly recognised that those prescribed for treating acute pain, particularly at hospital discharge, contribute to problems related to inappropriate use.4 In addition, prescribing opioids at discharge can lead to long term opioid use by previously opioid‐naïve patients.5 These opioids are also a potentially large reservoir for misuse, particularly as unneeded opioid medications are often shared; a friend or relative is the most common community source of prescription opioids.5
Understandably, interest in improving this situation with more appropriate and individualised prescribing of discharge opioids is increasing. In analogy to antibiotic stewardship for reducing the risks of multidrug‐resistant bacteria, “opioid stewardship” describes a universal precautions approach to prescribing opioids at hospital discharge.6 The responsibility lies with the doctors discharging patients requiring analgesia, including anaesthetists in acute pain services. The underlying principles of opioid stewardship are the identification of risk factors for misuse, the assessment of analgesia requirements, the provision of appropriate but limited amounts of discharge opioids, and communication with the patient and, importantly, their general practitioner. The overall process should be governed by a hospital opioid discharge policy or guideline.7
The risk factors for prolonged opioid use after a hospital stay are complex. Pre‐admission opioid use is important; as this is also a risk factor for poor treatment outcomes (for instance, after joint replacement), opioids should be de‐prescribed or their dose at least reduced before elective surgery.8 Other risk factors include alcohol or substance use disorders, use of benzodiazepines, and depression and anxiety.9
The risk of instigating long term opioid use by acute prescribing is greater when slow release opioids are prescribed on discharge.10 In any case, their use for treating acute pain should be limited, as the associated risk of opioid‐induced ventilatory impairment is greater than for immediate release formulations, and slow release opioids are not suitable for the rapid titration required by this indication. The Australian and New Zealand College of Anaesthetists and its Faculty of Pain Medicine have advised against their routine use for treating acute pain.11
The duration of initial prescribing also influences the risk of long term opioid misuse, as does the number of repeat prescriptions provided.12 The initial amounts prescribed should therefore be conservative and based on requirements during the 24 hours before discharge, and should take into account the anticipated decline in need for analgesia. Prescribing lower numbers of opioid tablets was recently facilitated by the Therapeutic Goods Administration (TGA) introducing a requirement for smaller pack sizes of immediate release opioids as one of its regulatory changes in response to concerns about opioid overdose. Multimodal analgesic strategies, particularly the use of non‐opioid analgesia, can be opioid‐sparing and sometimes even render opioids unnecessary.5
Patients should be educated about the limited duration of acute pain and the consequently limited need for opioids, and also about the risks associated with their use: increased risk of falls, impaired driving, interactions with sedatives and alcohol, misuse and toxicity, as well as opioid dependence and addiction. Patients should also be advised to return unused opioids to pharmacies,5 an approach supported by a TGA‐sponsored program.13 Last but not least, GPs undertaking ongoing management of patients require advice on all aspects of opioid use, particularly about how long the patient is likely to need opioid analgesia.
In this issue of the MJA, Hopkins and colleagues14 report the effects of one opioid stewardship approach. Educating junior hospital doctors and hospital pharmacists improved discharge opioid prescribing in terms of reducing the numbers of opioids prescribed, particularly slow release opioids, and improving the frequency of providing de‐prescribing recommendations for GPs. These findings are in line with those of a number of studies that found similar programs to be beneficial.7,15 The principles of opioid stewardship should therefore be promoted and applied in all Australian hospitals; currently, there are still significant shortcomings in achieving this goal.16
Competing interests
The Anaesthesiology Unit of the University of Western Australia and Stephan Schug personally (since his retirement in October 2019) have received research and travel funding and speaking and consulting honoraria from Grünenthal, Indivior, Mundipharma, Pfizer, iX Biopharma, Seqirus, Xgene, Biogen, Luye Pharma and Foundry during the past 36 months.
References
- Häuser W, Schug S, Furlan AD. The opioid epidemic and national guidelines for opioid therapy for chronic noncancer pain: a perspective from different continents. Pain Rep 2017; 2: e599.
- Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: a systematic review and meta‐analysis. JAMA 2018; 320: 2448–2460.
- Man N, Chrzanowska A, Dobbins T, et al. Trends in drug‐induced deaths in Australia, 1997–2018 (Drug Trends Bulletin Series). Sydney: National Drug and Alcohol Research Centre, UNSW Sydney, 2019. https://ndarc.med.unsw.edu.au/resource/trends-drug-induced-deaths-australia-1997-2018 (viewed Sept 2020).
- Roughead EE, Lim R, Ramsay E, et al. Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study. BMJ Open 2019; 9: e023990.
- Schug SA, Palmer GM, Scott DA, et al, editors. Acute pain management: scientific evidence. 4th edition. Melbourne: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2015; here: pp. 365–368.
- Macintyre PE, Huxtable CA, Flint SL, Dobbin MD. Costs and consequences: a review of discharge opioid prescribing for ongoing management of acute pain. Anaesth Intensive Care 2014; 42: 558–574.
- Stewart JE, Tuffin PH, Kay J, et al. The effect of guideline implementation on discharge analgesia prescribing (two years on). Anaesth Intensive Care 2019; 47: 40–44.
- McAnally H. Rationale for and approach to preoperative opioid weaning: a preoperative optimization protocol. Perioper Med (Lond) 2017; 6: 19.
- Stark N, Kerr S, Stevens J. Prevalence and predictors of persistent post‐surgical opioid use: a prospective observational cohort study. Anaesth Intensive Care 2017; 45: 700–706.
- Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long‐term opioid use: United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017; 66: 265–269.
- Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine. Position statement on the use of slow‐release opioid preparations in the treatment of acute pain. Mar 2018. https://www.anzca.edu.au/getattachment/d9e2a7c5-0f17-42d3-bda7-c6dae7e55ced/Position-statement-on-the-use-of-slow-release-opioid-preparations-in-the-treatmentofacute-pain (viewed Oct 2020).
- Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ 2018; 360: j5790.
- Therapeutic Goods Administration. Return your unused opioids: resource kit. July 2019. https://www.tga.gov.au/publication/return-your-unused-opioids-resource-kit (viewed Sept 2020).
- Hopkins R, Bui T, Konstantatos AH, et al. Educating junior doctors and pharmacists to reduce discharge prescribing of opioids for surgical patients: a cluster randomised controlled trial. Med J Aust 2020; 213: 417–423.
- Stevens J, Trimboli A, Samios P, et al. A sustainable method to reduce postoperative oxycodone discharge prescribing in a metropolitan tertiary referral hospital. Anaesthesia 2019; 74: 292–299.
- Allen ML, Leslie K, Parker AV, et al. Post‐surgical opioid stewardship programs across Australia and New Zealand: current situation and future directions. Anaesth Intensive Care 2019; 47: 548–552.
Provenance: Commissioned; externally peer reviewed.