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

- 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