Opioid Analgesic Stewardship in Acute Pain

Opioids are high-risk medicines that are associated with significant harm or death when misused. A report commissioned by the Australian Institute of Health and Welfare (AIHW) highlights the harms caused by opioids. It shows that there are three drug-induced deaths involving opioids and almost 150 hospitalisations involving opioid harm each day in Australia.

There has been a raft of changes implemented to address these issues. This includes scheduling changes for codeine, increased restrictions for opioids supplied on the Pharmaceutical Benefits Scheme (PBS), and the progressive rollout of real-time prescription monitoring by the states and territories. However, the inappropriate use of opioids continues to be a problem in Australia

The World Health Organization (WHO) launched the third Global Patient Safety Challenge in 2017 with the theme of ‘medication without harm’. One of the priority actions identified in the Australian response was to develop a national guideline for the peri-surgical management of high-risk medicines such as opioids.

Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard

The Australian Commission on Safety and Quality in Health Care (the Commission) has recently published the first national Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard (acute care edition).

Opioid analgesic stewardship can be defined as coordinated interventions to optimise the use of opioid analgesics. The benefits of an opioid analgesic stewardship program are many. They include improved patient safety, improved patient satisfaction regarding pain management, reduced inappropriate opioid use, and reduced potential for opioid-related harm. This may result in reduced healthcare and economic costs associated with the inappropriate use of opioids.

This new clinical care standard addresses the priority actions identified for the Global Patient Safety Challenge and aims to support the appropriate use of opioid analgesics for acute pain. The standard is relevant to the care of people of all ages with acute pain where opioids may be considered or prescribed. It does not relate to the management of opioid use disorders, chronic non-cancer pain, cancer pain, palliative care, or pain in labour and delivery. While it does apply to acute pain in the emergency department and following surgery, it does not apply to patients presenting with acute major trauma in categories 1, 2 or 3 of the Australasian Triage Scale.

The standard focuses on the following key areas of care that have the greatest need for quality improvement:

1. Patient information and shared decision making;
2. Acute pain assessment;
3. Risk-benefit analysis;
4. Pathways of care;
5. Appropriate opioid analgesic prescribing;
6. Monitoring and management of opioid analgesic adverse effects;
7. Documentation;
8. Review of therapy; and
9. Transfer of care.

Consideration of alternatives to opioids is encouraged in the emergency department and following surgery. Opioid-sparing strategies may include the use of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), and non-pharmacological options such as physiotherapy, exercise, splinting, and heat packs. Where opioids are required, a cessation plan is important.

When the prescriber considers it appropriate to initiate an opioid in an opioid-naïve patient with acute pain, the standard makes the following recommendations:

• Use an immediate-release preparation;
• Use the lowest appropriate dose;
• Limit the duration; and
• Prescribe in line with best practice guidelines.

Modified-release opioids

Modified-release opioids should generally be avoided in acute pain as they cannot be safely or rapidly titrated. The Australian and New Zealand College of Anaesthetists (ANZCA) previously issued a position statement advising against the use of modified-release opioids in this setting. This document advises that the inappropriate use of modified-release opioids in acute pain is associated with a significant risk of respiratory depression, which may result in severe adverse events or death. This recommendation is in line with the indications approved by the Therapeutic Goods Administration (TGA) for modified-release opioids.

Review

Limiting the duration of opioid use is vital. Studies demonstrate that the duration of the first opioid prescription is more strongly related to misuse in the postoperative period than the dosage prescribed. Therefore, documentation of the intended therapy duration and plans for review and referral are vital.

Opioid dose reduction should begin as soon as possible. Following major surgery or trauma, dose reduction can often begin within one or two days as pain intensity quickly reduces for most patients. The standard also advises that opioid analgesics should generally be ceased before non-opioid analgesics.

These recommendations aim to minimise adverse effects and also reduce the incidence of persistent postoperative opioid analgesic use.

Persistent postoperative opioid analgesic use

Persistent postoperative opioid analgesic use (PPOU) can be defined as the continued use of opioids prescribed for postoperative pain for longer than 90 days after surgery. Australian studies have found rates of PPOU, from 3.9% to 10.5% overall. However, analysis suggests that this may be largely affected by surgery type, with a prevalence of 23.6% following spinal surgery and 13.7% after orthopaedic surgery observed in one study. Preoperative anxiety has also been identified as an independent risk factor for persistent opioid use.

Summary

It is known that the initiation of opioids for the management of acute pain can lead to chronic use in some cases. Identifying risk factors associated with PPOU and implementing the recommendations contained in the clinical care standard may minimise the risk of acute use transitioning into chronic use. The clinical care standard should be referred to for details on how to implement these quality standards into practice.

Further reading

The opioid hub on the TGA website contains current information on regulatory changes. The Therapeutic Guidelines: Pain and Analgesia and Acute Pain Management: Scientific Evidence (5th edition) may be referred to for guidance on current best practice. The PROSPECT (PROcedure-SPECific postoperative pain managemenT) initiative provides procedure-specific evidence-based recommendations for the treatment of postoperative pain.