A new standard of care will help to prevent long-term reliance on opioid analgesics used for acute pain.

The first national Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, developed by the Australian Commission on Safety and Quality in Health Care (ACSQHC), details appropriate opioid use in emergency departments and after surgery. 

Released today, the standard suggests considering alternate analgesics and promotes cessation plans where opioids are required.

The aim is to recalibrate the opioid-first habit and provide a guideline to ensure all patients receive the same level of evidence-based safe and effective opioid prescribing. 

‘We need to fine-tune our prescribing and use of opioid analgesics for acute pain, to reduce the harms associated with inappropriate prescribing and avoid short-term use becoming a long-term problem,’ said ACSQHC Chief Medical Officer and Conjoint Professor at the University of Newcastle Anne Duggan.

With around 2.5 million operations in Australia per year, PSA General Manager Policy and Engagement Chris Campbell MPS said the standard should help to improve opioid safety in acute care and beyond.

‘Too many Australians use opioids for far longer than intended post-surgery,’ he said. ‘PSA endorses the standard, which should be embedded in practice to improve the management of opioid use in acute care, and prevent harm upon discharge back into the community.’

Pharmacists’ role in opioid management

As medicines experts, pharmacists in all areas of practice play a big role in ensuring opioids are used appropriately, Prof Duggan said.

Hospital pharmacists in charge of stewardship programs should educate junior medical staff, who typically compile discharge summaries.

‘Around 70% of patients in hospitals are discharged on opioids, just in case,’ Prof Duggan said. 

‘[Pharmacists] should be reminding clinicians that there is no role for modified-release opioids and clinicians should be prescribing the immediate-release medications,’ she said. 

Pharmacists should also educate junior clinicians to not only test for pain, but also function.

‘They should be thinking, “How long does this patient need opioids? How do I calculate, based on the day before discharge, how much they need? How do I calculate what to give them when they get home? And how do I write to the GP?”’

When patients are assessed for opioid prescriptions, pharmacists should ensure clinicians know what other medicines they are taking.

‘[This will prevent] overdose in terms of sedatives, and ensure they’re getting the right opioid,’ Prof Duggan added.

With many acute-care patients discharged to residential aged care facilities, on-site pharmacists play a significant role in ensuring opioids are used appropriately.

‘There are few other people with the same expertise to make sure that there’s a good indication for why the patient is on the medication, that the patient is on a sensible dose, that somebody has thought about their other medication and that there is a weaning plan,’ Prof Duggan said.

‘They can certainly raise the alarm with the GP that something’s not right.’ 

Promoting the standard in a community setting

Patients may also be discharged back into the community with opioid scripts, making community pharmacists important gatekeepers in preventing opioid misuse and overdose.

‘When a patient goes to collect their script, pharmacists should educate them on the use of the drug and misuse, and [ensure] that they understand the side effects, risks and benefits of the opioids and what the [discharge] plan is,’ Prof Duggan said. 

All patients discharged on opioids should eventually come off them, she warned. 

With pharmacists often on the receiving end of prescribing, there are several checks they can conduct to ensure the guidelines have been followed.

Along with screening for modified-release opioids, pharmacists can pick up issues on prescriptions that don’t make sense.

‘[For example], the patient is X weeks postoperative and they are still on the same dose,’ Prof Duggan said. 

‘Pharmacists can identify patients who haven’t got a weaning plan, check the patient knows when to take it and why they’re taking it, and identify and address [adverse] effects.’

Pharmacists can also assess patients in terms of the risk benefit. 

‘If the patient is in trouble, pharmacists have a great role to play by ringing the GP and saying, “This patient’s on this. I don’t know why they’re on it and they’re having problems”.’

Real Time Prescription Monitoring (RTPM) can also be used to screen patients at risk of opioid misuse.

‘RTPM is another string to the bow with all the things we’re currently trying to do to reduce the harm from opioids,’ Prof Duggan said. ‘It’s a great complementary initiative.’

Carefully dispensing opioids

To educate patients about the risks of opioids, pharmacists should take additional measures including labelling the medicines correctly, and providing take-home information and naloxone.

A fact sheet in the Australian Pharmaceutical Formulary Handbook (APF) digital issue, approved by the Therapeutic Goods Administration, outlines use of the Cautionary and Advisory Label 24 for opioid medicines.

Label 24, which states, ‘Use of this medicine has the risks of overdose and dependence’, is recommended for opioid medicines including buprenorphine, codeine, dihydrocodeine, fentanyl, hydromorphone, methadone, morphine, oxycodone, tapentadol and tramadol.

The risk of harm from opioids increases when patients use opioids in high doses, for longer than 90 days, or with medicines or substances with sedative or central nervous system depressant effects (including alcohol and illegal drugs). The risk of harm also increases when patients have complex comorbidities. 

Harm from opioids includes overdose, physical dependence and opioid use disorder such as addiction and psychological dependence.

Pharmacists should provide the Opioid medicines patient information handout to patients receiving opioid medicines marked with Label 24. However, the label and handout may not be appropriate in some circumstances, such as when patients are using opioids for cancer or palliative care needs. 

Pharmacists should also consider supplying take-home naloxone nasal spray or injection to patients receiving opioid medicines. For more information, see Naloxone for opioid overdose in the APF.

Opioid safety is everyone’s responsibility

Like most aspects of healthcare, the solution to opioid safety doesn’t lie with one root source, Prof Duggan said.

‘From the pharmacist point of view, they are the medication experts and they are in a fantastic position to influence prescribing practices,’ she said. 

‘The doctor holds the pen, and the consumer is the one who is getting the medication and should be asking questions. They also know all the side effects [they are experiencing].’ 

Lastly, hospital pharmacists can ensure the standard is met by developing stewardship programs.

‘Everyone has a bit of expertise, so if everyone works together, you get a much better outcome,’ Prof Duggan added.

Read the full Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard here.