Release of first standard for use of opioids in acute care

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The Australian Commission on Safety and Quality in Health Care has released the first national Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard.

The standard sets out the appropriate use of opioid analgesics in the emergency department and after surgery.

The commission said the new standard encourages doctors to consider alternate analgesics and, where opioids are required, promotes planning for their cessation.

More than 2.5 million people undergo surgery in public and private hospitals each year and some become persistent users of opioid analgesics after being treated for acute pain.

Opioid analgesics include oxycodone, morphine, buprenorphine, hydromorphone, fentanyl, tapentadol, tramadol and codeine.

More than three million people have at least one prescription dispensed each year for opioid analgesics.

Conjoint Professor Anne Duggan, the commission's chief medical officer, said there is a need to care for people who leave hospital after being prescribed opioids. A national survey found that 70 per cent of hospitals send people home after surgery with opioids ‘just in case’.

“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.

“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,” said Professor Duggan.

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 PBS and smaller pack sizes for immediate-release opioids.

The commission said recent data suggest the use of opioid analgesics is declining since the introduction of these changes.

Conjoint Associate Professor Jennifer Stevens, anaesthetist and pain management specialist at St Vincent’s Hospitals Sydney, said there is a large variation in how opioids are prescribed around Australia.

“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,” said Associate Professor Stevens.

“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.”

Professor Duggan added, “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.”