Epic Pharmacy Circuit Newsletter April 2023

clinical initiatives, research and current updates in treatment

Responding to Natural Disasters:

Learnings from a pharmacy’s response to the 2022 NSW flood disaster to ensure continuity of medication supply

Penny Lee, Epic Pharmacy Lismore

Australians are no strangers to natural disasters. In recent years, the country has seen numerous events such as bushfires and floods which can devastate health facilities and communities alike.

Emergency preparedness of health services can minimise detrimental effects following natural disasters with pharmacies fundamental to ensuring continued supply of medicines. Learnings from the International Pharmacy Federation and lived experience suggest emergency management can be broken down into four distinct phases; reduction, readiness, response and recovery.1

Reduction: In general, risk mitigation for a health service can be seen as steps taken to eliminate or minimise the risk. Prior planning and experience from previous flooding events assisted in minimising supply disruption. Hence, it is important for any health facility to consider and plan for unpredictable but possible events.

Readiness: Existing contingency planning which came to the forefront during the COVID-19 pandemic allowed the pharmacy to be agile in the first few hours of the emergency response with limited team members. An example of readiness was the pharmacy maintaining cold chain storage of all medication through intermittent power interruptions up to a week following the emergency.

Response: In 2022, Northern New South Wales (NSW) experienced two major floods within a month resulting in six out of nine community pharmacies inundated and inoperable. Adaptive inter-professional collaboration ensured continued medication supply for high-risk patients, and the community at large. In total, the pharmacy was able to provide care to 1537 new hospital and community patients between 1st March and 30th April along with temporarily rehoming a flooded general practice. Although private hospital day bed activity decreased during the disaster, community patients seeking medication supply increased fourfold, this included treatment for high-risk patients along with those with chronic conditions who could not access their regular community pharmacy.

Recovery: This involves the coordinated effort to bring about the immediate-, medium- and long-term regeneration of a community following an emergency event. Immediate responses are often community led and therefore up to date contact details for relevant health professionals are necessary to coordinate these efforts. It is important to note that communities can take years to recover following a natural disaster and often involves medium- and long-term responses from the government and health sector.

In 2022 our pharmacy team members conducted a number of research projects. Some were presented in various forms at the annual Society of Hospital Pharmacists (SHPA) and ACSQHC – World Patient Day conferences. We don’t often share this work so we have included four of these projects in this edition of Circuit to give you some understanding of our innovations.

Learnings from the 2022 NSW floods for health facilities to consider include the following four themes:

Resources

• Generator connected to essential services (e.g. refrigerators and other medical equipment) receive regular maintenance, and are labelled with capacity to inform refuelling intervals

• Safety and security for team members through ready access to alternate lighting, e.g. head torches, and more frequent security patrols

Health record keeping templates to ensure confidentiality of paper records and updated information for those displaced during the emergency

• Contingency plan for secondary power failure or fuel shortage, including second location for fridge items

Communication

• Up to date health professional/supplier contact details and alternative communication methods e.g. SMS and social media channels

• Alternate data sources such as hotspot mobile phones can be a useful tool to maintain clinical dispense systems

• Patient communication using generic email and phone messages along with onsite signage

• Liaise with other health professionals and health facilities to pool resources

Supply

• Legislation, which allows for continued essential health care and services during emergency situations

• Rationing and stockpiling of medicines to continue essential supply

• Alternate delivery options which utilise all options like the SES, defence department, helicopters and boats

• Insurances to cover loss of equipment and health care supplies as a result of the emergency

Human Resources

Team deployment to evacuation centres and external assistance where practical

• Fatigue management, ensure teams are offered Employee Assistance Programs

Staff entitlements due to the length of disaster leave

• Training for internal and external disasters and personal threats

This catastrophic event required pharmacists and other health professionals to step outside of usual roles to coordinate supply chain variants and respond to issues arising. Health facilities, especially those in at-risk rural or regional areas, need to consider capabilities to remain operational without power, dependable internet and a reliable medicine supply chain while also considering workforce wellbeing. A proactive emergency contingency plan combined with practical solutions will minimise detrimental consequences from natural disasters for health facilities and enable them to continue care for their patients and the wider community.

References available on request

New National Opioid Stewardship Standard to Avoid Long-term Harm from Opioid Analgesics

Nerida Jenkins & Kristen Thessman, Pharmacy Practice Unit

Perioperative Opioid Use

Opioids are important analgesic options for managing severe acute pain following surgery.1,2 However, there are potential significant harms related to their use, in hospital and at discharge, including opioid

induced ventilatory impairment (OIVI), prolonged post-discharge use, misuse and diversion (see figure 1).3-11

When compared to immediate-release (IR) opioids in the management of acute

pain, slow-release (SR) opioids have been shown to provide less effective pain relief, and are associated with an increased risk of prolonged opioid use and complications following surgery, such as OIVI.2,3

The number of opioids prescribed on discharge often far exceeds the number used. of opioids are left untaken.

40-94%

40-94%

The number of opioids prescribed on discharge often far exceeds the number used. of opioids are left untaken.

T h i s r eser v oi r o f unused opioids p r esent s s ignificant r i s k t o t h e communi t y

T h i s r eser v oi r o f unused opioids p r esent s s ignificant r i s k t o t h e communi t y

In a study of over one million opioid naive patients undergoing surgery, the duration of opioid use post discharge was found to be the strongest predictor of misuse. The rate of misuse increases by with each prescription refill and 44% with each additional week of opioid use.

M o r e t han on e- t h ir d of ad ul t s takin g

lo n g- t erm opioids r ep o rted th at thei r fi r s t

M o r e t han on e- t h ir d of ad ul t s takin g lo n g- t erm opioids r ep o rted th at thei r fi r s t p r escripti o n was wri t te n by a surgeon, indicating that postsurgical prescribing i s an importa n t poi n t

of intervention.

p r escripti o n was wri t te n by a surgeon, indicating that postsurgical prescribing i s an importa n t poi n t

of intervention.

3-13%

20%

20%

In a study of over one million opioid naive patients undergoing surgery, the duration of opioid use post discharge was found to be the strongest predictor of misuse. The rate of misuse increases by with each prescription refill and 44% with each additional week of opioid use.

With around 2.5 million patients undergoing surgery annually in Australia, there is substantial implications for the treatment of pain in the hospital setting.13,14 Almost 70% of Australian hospitals report sending patients home with powerful opioid analgesics for ‘justin-case’.14

National Action

Opioid-associated harms have been identified as a national priority, with risk reduction initiatives taking place across the regulatory landscape, such as TGA & PBS changes to approved indications and quantities, and real-time prescription monitoring.11,12 Furthermore, in April 2022, the Australian Commission on Safety and Quality in Health Care, in conjunction with the TGA, launched the new Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard (CCS).11,12 This new national standard was introduced to reduce risks of long-term reliance on opioid analgesics following short-term use for acute pain in hospital.11

3-13%

o f o p i o i d naı v e pat i en t s

c o ntin u e t o ta ke opi o id s

o f o p i o i d naı v e pat i en t s

f o r mo r e t ha n th r ee mo n t h s

c o ntin u e t o ta ke opi o id s

a fte r t h e i r p r ocedu r e.

f o r mo r e t ha n th r ee mo n t h s

a fte r t h e i r p r ocedu r e.

The standard highlights the importance of shared decision making with patients and assessment of pain, as well as appropriate prescribing in terms of dose and duration.11 It also focuses on review of therapy and ensuring clear transfer of care after discharge.11

Opioid Analgesic Stewardship

The Opioid Analgesic Stewardship in Acute Pain CCS describes opioid analgesic stewardship as, the supervising or taking care of opioid analgesics, that applies a systematic approach to optimising the use of opioid analgesics.11

The benefits of an opioid stewardship program include:11

- Ensuring appropriate dose and duration of opioid analgesics

- Reducing inappropriate opioid analgesic use

- Limiting use of SR opioid analgesics for acute pain, so they are only used in exceptional circumstances and not routinely

- Reducing incidence/potential for opioid-related harm

- Reducing healthcare and economic costs associated with inappropriate opioid analgesic use

Developing

an Opioid Stewardship Program

A qualitative study of 35 pharmacies, which provide services to acute care hospitals, was undertaken to determine a baseline of current opioid stewardship activities, including pharmacist participation, at these hospital sites. The results of which informed the development of an opioid stewardship program to support a diverse range of healthcare facilities in meeting the new CCS requirements.

Responses included (see figure 2):

- One hospital had an opioid stewardship or pain management multi-disciplinary committee with pharmacist representation

Figure 1: Risks associated with post-operative opioid supply 3-11

- Audits targeting inappropriate opioid use had been undertaken by 16% of pharmacies

- In total, 80% of sites reported that they use a supporting patient brochure for patients discharging with opioids, with 71% using the pharmacy branded version of the brochure

- Oral SR opioids were reported to be prescribed for acute pain at discharge in 74% of sites and SR opioid patches in 29%

- Approximately half the respondents indicated that opioid use was ‘always’ (14%) or ‘often’ (34%) reviewed in the 24-48 hours prior to discharge.

This was performed by surgeons (20%), anaesthetists (14%), other doctors (40%), pharmacists (23%) or nurses (3%)

- At this stage, 14% of pharmacy services indicated that a discharge pain management plan or de-escalation plan was used at their sites

Patient education 16% 1

Research/Audits Formal pain services

Use at discharge

Icon Group's Opioid Stewardship Program

To support the pharmacy teams and healthcare facilities in best practice changes through the introduction of opioid stewardship principles at a clinical level, the Icon Group Pharmacy Services developed an opioid stewardship program. The program is a coordinated intervention designed to improve, monitor, and evaluate the use of opioids in pain management (see figure 3). It is a packaged initiative that contains a selection of adaptable interventions that can be utilised by sites and includes:

- Hospital CCS gap analysis tool to identify priority areas and develop local strategy

- Pain Management Plan template to improve discharge planning and communication at transitions of care

- Opioid surveillance trending and comparison graphs reporting on monthly average total oral morphine milligram equivalents (OMME) per patient on discharge per hospital

- Quality improvement resource toolkit to undertake local audits to build engagement and buy-in at site

- Healthcare professional and consumer education including the ‘Managing your pain medicines at home’ patient counselling support brochure

Individualisation of dose

40% Other Doctor

23% Pharmacist

20% Surgeon

14% Anaesthetist

3% Nurse

References available on request

Figure 2: Summary of qualitative opioid stewardship baseline-survey responses

Figure 3: Opioid Stewardship Program Key Action Areas

Investigating postoperative opioid prescribing in a private hospital to improve patient outcomes

Roya Roohizadegan and Lauren Beard, Slade Pharmacy Richmond

Background

Opioids are an important treatment option in acute postoperative pain [1] and are commonly used in this setting [2]. However, literature suggests that overprescribing of opioids can contribute to the pool of unused opioids in the community, and duration of use is correlated with risk of long-term use [3-5]. Guidelines do not recommend slowrelease (SR) opioids for acute pain due to an increased risk of complications such as opioid-induced ventilatory impairment [6]

Aim

To gain an understanding of postoperative opioid analgesia prescribed at discharge and subsequently consumed, and identify opioid stewardship opportunities to improve patient care.

Methods

A prospective medication chart audit was conducted on orthopaedic wards at Epworth Hospital Richmond, the largest private hospital in Victoria. Patients who underwent total knee arthroplasty (TKR), total hip arthroplasty (THR) or anterior cruciate ligament (ACL) surgery were included in the study.

Results

Forty-two patients were audited during the three-week data collection period. 98% of the patients were opioid naïve on admission. All patients were prescribed at least one opioid on discharge, with the most common being immediate-release (IR) oxycodone (67%). 50% of patients received a SR opioid (see figure 1).

Knowledge of correct opioid disposal processes was only recalled by 17% of patients. Unsafe disposal responses included:

Discussion

Although guidelines do not recommend SR opioid formulations for acute pain in opioid naïve patients, a large percentage of patients received this at hospital discharge. Patients who had THR or TKR were more likely to go home with SR opioid and combination opioids, compared to those who had an ACL.

A high proportion of patients had opioid tablets left over. Despite this, some patient’s perceptions of need for opioids did not align with current recommendations. 11 patients (31%) contacted their surgeon or had a GP consult to obtain more opioids, reasons included: they had run out of supply; or wanted more. Incorrect disposal or keeping of unused medications contributes to the pool of unused opioids in the community which carries the risk of accidental or intentional future misuse. To address the issues highlighted in the study, an effective way to ensure consumers adsorb information and follow best practice is with a combination of written and verbal information.

Next Steps

Excess quantities of opioids are being prescribed to patients post orthopaedic surgery with half receiving SR opioids to manage acute pain. Planned strategies to address the findings in this study include:

Of the 35 patients interviewed, 63% had leftover opioids. A total of 1005 opioid tablets were supplied, with 385 tablets remaining and unused (38%) (see figure 2).

Phone interviews showed patient’s perception regarding the need for opioids did not consistently align with current recommendations. Patients requested additional supply for:

¬ Discussion with the medication safety management committee to leverage engagement with opioid stewardship activities

¬ Pharmacist-led intervention to tailor opioid prescription to individual pain requirements

¬ Prescriber feedback

¬ Patient education and provision of written information regarding opioid weaning and cessation plan as well as safe opioid disposal

Figure 1: Opioid formulation prescribed to

Figure 2: Total number of opioid tablets prescribed vs. remaining post hospital discharge

Reshaping opioid prescribing in acute pain management post caesarean section

K. Thessman¹, J. Lee² and L. Bruna³

¹ Icon Group, Kristen.Thessman@icon.team

² Epic Pharmacy Wesley/University of Queensland, Jane.Lee@epicpharmacy.com.au

³ Epic Pharmacy/University of Queensland, Luc.Bruna@epicpharmacy.com.au

Background

In recent years, the risks of opioid medications have escalated to become a key global health priority. In response, Australia has launched the Opioid Analgesic Stewardship (OAS) in Acute Pain Clinical Care Standard (CCS). Translating the CCS into an actionable program is still emerging, and with 60% of surgical procedures¹ occurring in private hospitals, innovative strategies are required. Caesarean section births represent over a third of total births in Australia,² and patients are typically discharged with opioid medicines for the first time.³ The complexities of the post-partum period place these women as potentially vulnerable to the risks of opioid harms. There is a paucity in Australian research that explores current prescribing trends and guides optimal pain management post caesarean section. Preliminary findings from a retrospective study in 2021 at a private metropolitan hospital discovered that over 67% (n=33/49) of caesarean section patients received slow-release (SR) opioid formulations on discharge, with 43% (n=21/49) receiving greater than seven days supply.

Aim

To evaluate the impact of obstetrician, midwifery and pharmacist education on discharge opioid prescribing practices in the context of the CCS for patients post caesarean section.

Methods

An education session and executive summary highlighting the audit results from 2021 and key opioid prescribing recommendations was developed and presented to clinicians in January 2022. An ethics approved, retrospective chart review was then conducted on another sample of patients who had caesarean births between February and April 2022, (figure 1).

Results

The 2022 audit found that 47% (n=24/51) of patients received SR opioid formulation on discharge representing a reduction of 20% compared with the 2021 audit, (figure 2). Patients receiving an opioid supply of greater than seven days as determined by the total oral morphine milligram equivalent (OMME) discharge prescription and OMME dose required 24 hours prior to discharge was 39% (n=20/51).

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Similar results were seen in the 2021 audit of 43%, (figure 3). Paracetamol and non-steroidal anti-inflammatory medicines were prescribed for 82% (2022) and 92% (2021) of patients on discharge.

Discussion

This study demonstrates that audit feedback and targeted education to a multidisciplinary team has the potential to impact opioid prescribing trends. This study was potentially limited due to a small sample size and the national supply interruption with TarginTM which overlapped with the study period; however the pharmacy was able to maintain supply throughout the shortage. This quality improvement activity assisted in leveraging engagement from key stakeholders and introducing concepts of OAS into the private hospital setting. Interventions such as, opioid prescribing surveillance reporting and pain management plans, will be evaluated for their impact on optimising safe opioid prescribing.

References available on request

If you have any queries regarding Circuit content and authors please contact the Epic Pharmacy Practice Unit by email: circuit.editor@epicpharmacy.com.au

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