New opioids standard encourages alternatives, cessation plans

Up to 70% of Australian hospitals reportedly send patients home with powerful opioid analgesics ‘just in case’¹, with emergency departments (EDs) and surgical services identified as common sources of opioid analgesic prescriptions.^2-4.

A 2018 study found that the rate of opioid analgesic dispensing per 100,000 people increased by 5% nationally between 2013 and 2017. The magnitude of variation in dispensing rates increased as well, from 4.8-fold to 5.1-fold. The first Atlas of Healthcare Variation (2013) reported that dispensing rates were highest in areas of low socioeconomic status and lower in areas of increasing socioeconomic status. Dispensing rates tended to be higher in inner and outer regional areas than in major cities or remote areas.

A report⁵ on national data and trends on opioid use and harms in Australia found that every day there were nearly 150 hospitalisations and 14 ED presentations involving opioid harm, and three drug-induced deaths involving opioid use.

In 2016–17, 3.1 million people had one or more prescriptions dispensed for opioids (most commonly for oxycodone). About 715,000 people used over-the-counter codeine products and prescription opioid analgesics for illicit or non-medical purposes, while about 40,000 people used heroin.

More than 2.5 million people undergo surgery in public and private hospitals⁶, some of whom become persistent users of opioid analgesics after being treated for acute pain — in that they continue to use opioids for more than 90 days after discharge from hospital.

Around 900 deaths were attributed to unintentional overdose of opioids in 2018, representing a 9% increase since 2014, according to Australia’s Annual Overdose Report 2020. Between 2014 and 2018, pharmaceutical opioids were the most common type of opioids associated with unintentional deaths.

Following extension consultation with clinicians, researchers and consumer representatives, the Australian Commission on Safety and Quality in Health Care (the Commission) has released the first national Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard.

A long-term problem

The new opioids standard sets out appropriate use of opioid analgesics in the ED and after surgery. It encourages doctors to consider alternate analgesics and, where opioids are required, promotes planning for their cessation.

Conjoint Professor Anne Duggan, Commission Chief Medical Officer, said there is a need to care for people who leave hospital after being prescribed opioids.

“Opioid analgesics are incredibly effective in providing pain relief for severe acute pain,” she said. “However, we must remember that these medicines can have significant adverse effects and may put people at risk of harm after they leave hospital.

“We need to fine-tune our prescribing and use of opioids analgesics for acute pain, to reduce the harms associated with inappropriate prescribing and avoid short-term use becoming a long-term problem.

Minimising over-reliance

“Ensuring adequate pain relief to avoid unnecessary suffering while minimising the risk of over-reliance on opioid analgesics is not an easy balance to strike. It is critical that when patients are discharged from hospital, there is a discussion with the patient and a clear medication management plan to wean off opioids,” Duggan said.

Since 2018, the Therapeutic Goods Administration has introduced regulatory reform for opioid analgesics to minimise harm and limit inappropriate prescribing. This includes changes in June 2020 to opioid listings on the Pharmaceutical Benefits Scheme and smaller pack sizes for immediate-release opioids⁷. Recent data suggest Australia’s use of opioid analgesics is declining since the introduction of the regulatory reforms.

Evidence-based prescribing

Conjoint Associate Professor Jennifer Stevens, Anaesthetist and Pain Management Specialist at St Vincent’s Hospitals Sydney, said there is large variation in how opioids are prescribed around Australia. She said the standard provides guidance for all patients to receive the same level of evidence-based safe and effective opioid prescribing.

“The clinical care standard encourages the use of simple analgesics such as paracetamol and anti-inflammatory medicines and non-medication techniques for mild to moderate pain. For severe acute pain, the standard recommends judicious opioid use,” Stevens said.

“As prescribers, doctors have an ‘opioid-first’ habit that we need to kick. Compared to many European and Asian developed nations, Australia places a high reliance on using opioids as first-line analgesia, despite evidence those countries with significantly lower reliance do not have poorer pain outcomes.”

A cessation plan

Dr Andrew Sefton, Orthopaedic Surgeon at Dubbo Base Hospital NSW and North Shore Private Hospital Sydney, said it was important for prescribing doctors to consider how and when opioids will cease after discharge.

“It might be quick and easy to provide a repeat on an opioid prescription when we have a patient experiencing pain, but we need to reflect on the individual patient to ensure the benefit outweighs risks.

“The clinical care standard highlights the need to support transition of care into the community, with communication and plans for opioid cessation. Providing the patient’s GP with a plan outlining the expected duration of opioid use and the amount of opioids supplied is a practical way to work together.”

Duggan concluded: “It is ironic that a medication that is designed to reduce pain for patients can in turn create long-term anguish for an individual who becomes a persistent user of opioid analgesics once they leave hospital.

“We hope this standard will provide a turning point for Australia to reflect on our opioid use in hospitals, to ensure that we are providing the safest possible care to our patients as they recover and return to their regular activities in the community.

References:

^{1 Society of Hospital Pharmacists of Australia. Reducing opioid-related harm: a hospital pharmacy landscape paper. Melbourne: Society of Hospital Pharmacists of Australia, 2018}

^{2 Stanley B, Collins LJ, Norman AF, Karro J, Jung M, Bonomo YA. Opioid prescribing in the emergency department of a tertiary hospital: a retrospective audit of hospital discharge data. EMA. 2020 Feb;32(1):33–38.}

^{3 Pouryahya P, Birkett W, Mc RMAD, Louey S, Belhadfa M, Ferdousi S, et al. Oxycodone prescribing in the emergency department during the opioid crisis. EMA. 2020 Dec;32(6):996–1000.}

^{4 Allen ML, Kim CC, Braat S, Jones K, Winter N, Hucker TR, et al. Post-discharge opioid use and handling in surgical patients: A multicentre prospective cohort study. Anaesth Intensive Care. 2020;48(1):36–42.}

^{5 Australian Institute of Health Welfare. Opioid harm in Australia: and comparisons between Australia and Canada. Canberra: AIHW, 2018.}

^{6 Australian Institute of Health and Welfare (2019). Surgery in Australia's hospitals – Hospitals at a Glance 2017-18. Canberra: AIHW}

^{7 Therapeutic Goods Administration (2021), Prescription opioids: What changes are being made and why Canberra: TGA}