We talk to anaesthetist and pain specialist at St Vincent's Hospital Sydney, Associate Professor Jennifer Stevens, about the first national Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard.
The standard was developed by the Australian Commission for Safety and Quality in Health Care and introduced earlier this year. What does it mean for clinicians, primary care doctors and patients?
You were involved in the development of the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, as an expert panel member. What is the goal of the standard and who is it aimed at?
The goal of the clinical care standard is to ensure opioids are used safely for patients. And that as practitioners, we all know what safety involves. There’s been a big move over the last five to ten years to change the way we prescribe opioids and a recognition of the harms they can cause, and were increasingly causing, within Australia. GPs have changed their practice enormously and are initiating and continuing opioids much less. We are seeing a much lower rate of patients presenting to hospitals already on opioids, and fewer on the bigger doses of opioids, particularly.
With this standard, we now have a document that outlines what good usage of opioids looks like, and that supports first prescribers and other clinicians. The standard is based on data and research – including local Australian research – and provides guidance about prescribing that is good for the patient, while ensuring they are still getting the maximum benefit out of the opioid medication.
Up to 70% of Australian hospitals apparently report sending patients home with powerful opioid allergies ‘just in case’. Will the new standard help address this type of default dispensing?
One of the aims of the standard is to address default dispensing.
It's important to remember that a key driver for this happening is doctors trying to do the best by their patients. We were told by pharmaceutical companies that opioids delivered fantastic pain relief and didn't have as many downsides as was previously thought– but that was not the case. As doctors, we thought we were doing the right thing by giving patients more than they needed to go home with after an interaction with the health system. And it just turned out to be the wrong thing to do.
One of the important aspects of the standard is clear guidance on how to manage prescribing in hospital, and what kinds of opioids doses a patient may need post-surgery for example. Most importantly, it provides clear guidance on prescribing and communication at hospital discharge about how much people might need to go home with.
Research also suggests about up to 4% of patients who are given OAS for acute pain following surgery ore at risk of becoming persistent users of opioids down the track. What do you see as the harmful impacts of this?
As a pain physician, every day I see patients who have become long-term users of opioids. They experience more pain for the same event than somebody who is not on opioids. Long-term users of opioids tend to have longer hospital stays and can suffer a higher number of complications. That's the part that I see working within a hospital.
GPs are likely to see an increase in patient’s visits and dependence on their GP, as well as other health impacts such as sleep apnoea, constipation, depression, and potentially even other issues such as difficulty controlling blood sugars.
This means long-term users of opioids are probably getting little net benefit from a drug that is actually causing problems. The patient becomes more reliant on both GPs and hospital specialists to achieve a normal functional life.
The standard emphasises the roles and responsibilities of the first prescriber. Why is that role is so critical?
We know that the first prescriber is often somebody within the hospital system, but the ongoing prescriber is usually outside of the hospital system. This means the initial prescriber has no – or very little – ongoing responsibility for the opioid use.
As the first prescriber within a hospital system, we have a responsibility to the person who's going to be prescribing – or deprescribing – in the longer term. We owe it to them to explain to patients up front the pros and cons of using opioids, what their individual medication plan is, how to use the medications, and how long we expect them to be used for. And to communicate that plan so that the patient and the ongoing prescriber in the community are on the same page.
I think if a first prescriber is out in the community, the same applies. The patient and the initial prescriber, need to have a common understanding about the goals of the opioid therapy.
What can clinicians do to manage patient expectations around pain management and the effectiveness and risks associated with opioid use?
Number one is about involving patients in prioritising their own risk-benefit with really good information. It is vital to explain to patients these drugs have significant limitations, how good they are at reducing pain, as well as the side effects that they can cause.
This clear communication allows the patient to make their own risk-benefit calculation. It is about really involving the patient in making this assessment for their own life circumstances. That is going to be very different for each patient. For some patients, constipation is an enormous problem, and they might decide that they will tolerate a higher level of pain in the interests of not getting constipated.
Number two is about teaching patients about safe storage and disposal of medication.
Thirdly, sitting down with the patient and putting the opioid into the context of simple analgesics and non-medication techniques. There is often a perception that an opioid will provide the best possible pain relief – and that is not always the case. Even if an opioid is prescribed, combining use with simple analgesics and non-drug treatments can mean a lower opioid dose can be used, or for a shorter duration.
The standard recommends that clinicians avoid prescribing modified release opioids for acute pain. Why is that and what are the risks to patient safety associated with modified release OAs?
I think modified-release opioids have been a triumph of marketing and wishful thinking. Over time we have realised they don't work particularly well for acute pain or for cancer pain. There are many problems associated with these medications because of the increased opioid burden on the patient, which increases their risk of harm from side effects and overdose events.
Unfortunately, the number of milligrams of opioids you prescribe in 24 hours doesn't quite translate to 24 hours in the real life of the patient.
Immediate-release prescribing gives a patient much more control over when they have opioids in their system – for example when they're going to move, when they’re going for a walk, when they’re seeing a physiotherapist. We want patients to have less opioids in their system when they're in less pain, when they're not moving, and then allow them to be in control to get a maximal opioid effect safely, when they need it.
The standard recommends a weaning plan be included as part of the discharge summary for patients prescribed opioids. What does this mean for the primary care treating doctor?
We are hoping that by eliminating the use of modified-release opioids at the point of hospital discharge, weaning will be so much easier for the GP.
Unlike with modified-release opioids, the GP just needs to outline a plan for their patient to reduce the amount of immediate-release opioids they are using. In most situations the aim is to wean no later than five or seven days. At that point the patient shouldn’t be using opioids anymore – they should only be using simple analgesics if required.
For further details, please refer to the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard | Australian Commission on Safety and Quality in Health Care
Guidance for clinicians