When hospitals lead to harm: opioid year of action

This year there will be more than 2.5 million surgeries in Australia. The prescribing, administration and dispensing of opioids will follow many of these procedures.

Due to unrealistic expectations of pain management, overprescribing and lack of evidence-based educational programs for health professionals, use will grow into dependence and harm for some people.

The Spring 2018 issue of Hospital + Healthcare (page 86) highlighted how the complex issue of opioid harm in the community involves many touchpoints of information sharing and transitions of care. As such, collaborative input is essential if the health system is to successfully leverage the most promising initiatives on a state and national scale.

Since the inaugural multidisciplinary and collaborative Medicines Leadership Forum in Canberra in July 2018 framed the issue of hospital-initiated opioid harm from a pharmacy perspective, SHPA has released a landmark report detailing the problems Australia faces, and solutions that could help turn the tide.

Pharmacy role in preventing opioid misadventure

As critical centres of care for the most acutely unwell, the role of hospitals and hospital-based health professionals is central to discussion of opioid misadventure.

Using the simplest definition, hospital pharmacists undertake clinical pharmacy activities for individual patients to minimise the inherent risk associated with the use of medicines.

More broadly, clinical pharmacy activities support a collaborative care model of managing medicines — with patients, carers, prescribers and other health professionals — including the crucial activities of medication reconciliation, assessment of current medication management, clinical review, therapeutic drug monitoring, adverse drug reaction management, contribution to medicines management plans (MMP), and providing medicines information and discharge and transfer summaries.

As such, the insight gleaned from hospital pharmacists working in 135 public and private hospital facilities, regarding pharmacy service provision, workload, prescribing practice and dispensing activities post-surgery, was uniquely potent.

Unnecessary opioid prescriptions

Released last November, ‘Reducing opioid-related harm’ attracted significant national attention, shining a light on the link between the prescribing and supply of opioids to patients after surgery and heightened risk of long-term misuse and dependence.

Clear in the findings were national inconsistencies in the provision of pharmacy services to reduce risk of opioid misuse, extremely high use of sustained-release opioids, and poor handover of discharge information for use by general practitioners.

Current discharge practices in hospitals were resulting in opioid quantities in excess of patient need, carrying the potential to lead to preventable harm, while clinical pharmacy services were often unable to prioritise surgical patients who, in turn, missed out on appropriate review of their medication.

Alarmingly, more than 70% of hospitals frequently supplied opioids for patients to take home ‘just in case’, even when they had not required them in the 48 hours prior to discharge.

Pharmacists also reported extremely high use of sustained-release opioids in the treatment of acute pain for opioid-naive surgical patients, a known risk factor for future opioid harm.

There were bright spots, with data showing that hospital pharmacy initiatives including formal opioid stewardship programs and opioid de-escalation plans at discharge were effective at reducing unnecessary opioid supply and improving long-term outcomes.

Unfortunately, these were not widely implemented: less than 5% of hospitals have formal opioid stewardship programs and less than 10% of respondents reported provision of de-escalation plans.

Clear goal moving forward

The goal is clear, and hospital pharmacists are best placed to connect the many multidisciplinary players.

As then SHPA President Professor Michael Dooley stated at the time: “We seek to collaborate with other healthcare practitioners and organisations to prevent unnecessary harm caused by opioids initiated in the hospital setting, by beginning an important conversation about services in hospitals, innovation and collaboration.”

With new data on the prevalence of opioid dependency in the Australian community being released with alarmingly regularity, in 2019 that conversation is more important than ever.

May is ScriptWise Prevention Month At the moment in Australia, more people are dying due to the use of particular prescription pain and sedative medications than on our roads. With the increasing need for better awareness and information within communities to prevent prescription medication dependency (particularly opioids and sedative medications), ScriptWise will extend its Prevention Week in May to a whole month of awareness-raising activities, in partnership with SHPA. Last year, ScriptWise reached over a million people to raise awareness about how to prevent medication-related harms such as opioid or benzodiazepine dependence and aims to double its reach this year. To learn more, visit scriptwise.org.au/prevention-week/

*Kristin Michaels is the Chief Executive Officer of The Society of Hospital Pharmacists of Australia, with a keen interest and experience in health system design. She is a seasoned board director in the primary, acute and aged-care sectors. Kristin holds qualifications in arts, organisational leadership, governance and health service management. She is a Fellow of the Australian Institute of Company Directors and is accredited as an International Partnership Broker.

Top image credit: SHPA.