Episode 46: The safe use of opioids in acute pain

Dr Kate Annear:
Hello, I'm Dr. Kate Annear. I'm a GP and I'm also a Medical Advisor for NPS MedicineWise. Thanks for joining us on this podcast. Now, today, we are revisiting the important topic of opioid analgesic prescribing. This time with a slightly different focus and that is the acute pain setting. Opioids have established efficacy in treating acute pain, but they also come with significant risk of harms. A particular concern is the rate at which short term use results in persistent and long term problematic use. Now I'm joined by Professor Pamela Mcintyre, who is an Emeritus specialist pain medicine physician and consultant at Royal Adelaide Hospital and a clinical professor at the University of Adelaide. Prior to her retirement in 2020, she was the Director of the Acute Pain Service at the Royal Adelaide hospital, the first in Australasia. Professor Mcintyre has co-authored a book on Acute Pain Management, which is currently in its fifth edition. Throughout her career, she's advocated for better and safer acute pain management, and her more recent work has examined the role of acute pain medicine in the opioid epidemic, including prescribing of opioids after discharge from hospital. Now there have been no conflicts of interest declared for this podcast. So welcome Pam, and thanks for joining me today.

Prof. Macintyre:
Thanks so much, Kate. Thanks for having me.

Dr Kate Annear:
So, if we could start by setting the scene here, could you take us through this important crossroad where a patient has found themselves in the emergency department with acute pain, say they have acute abdominal pain or they're having a surgical procedure done, how do opioid prescribing practices in this acute setting potentially impact on the long term outcomes for some of these patients?

Prof. Macintyre:
Look, firstly, I think it's important to say upfront that the severe acute pain needs to be treated properly in the first instance. And I know anecdotally that concerns about the opioid epidemic are sometimes now leading to underdosing of opioids in the acute setting, where they are really needed. So you mentioned trajectory and I think the key is to track the patient's progress, look at the trajectories of pain scores, look at trajectories of opioid requirements over the next few days, and they should be decreasing. And as we'll probably talk about later, trajectories that are not decreasing can mean there's an increased risk of opioid use for longer than is desirable which you've already mentioned as one of the issues with longer term acute pain management.

Dr Kate Annear:
So, one really alarming statistic that I came across was from a recent Australian study in 2019 that found that initiating opioid analgesia after surgery leads to ongoing use in about 4% of people. So if we look at the frequency of surgical procedures carried out in this country each year, this equates to over a hundred thousand people that are at risk of persistent use of opioids. So that's quite alarming, isn't it?

Prof. Macintyre:
It is alarming, and 4% I think was from the Australian data, it's even higher in some American studies and it's higher after some kinds of surgery. Sometimes, I think we'll probably mention later, it's because slow-release opioids were used rather than immediate release, but it is alarming, and it is in most instances I think preventable.

Dr Kate Annear:
Yeah. So why is long term opioid use such an issue and something that we as health professionals need to try and prevent?

Prof. Macintyre:
Look, there's many reasons why long term opioid use can be a problem. And firstly, we know, and the Therapeutics Goods Administration was keen to emphasize, that opioids are not the best way to manage chronic pain in most patients. And after three months of pain, we would consider that chronic pain, but there are other effects related to opioids that I think we need to be aware of. Most doctors would know about problems that might be related to tolerance, dependence or, in a small percentage of patient's, addiction may become an issue. Most will have heard of opioid-induced hyperalgesia where, quite counterintuitively, a reduction in opioid dose can improve pain relief, or if you look at it the other way, giving more opioid can make pain worse. But there's more recent evidence, probably only the last decade or less, shows that long term opioid use is associated with an increased risk of infections. So there is some degree of immunosuppression. This might be infections in the community like pneumonia, or it can be hospital-acquired pneumonia or infections that occur after some types of surgery. And we also know that endocrine function can be affected, I think many doctors are aware that sex hormone levels can be suppressed. But probably fewer [doctors] are aware that patients may have a secondary adrenal insufficiency. So adrenal function can also be suppressed. And in very rare instances addisonian crisis have even been reported. There's also effects on bone metabolism, so there's a high risk of osteoporosis and fractures. And in the acute pain setting, which is my area, or was my area of practice, there's been a huge increase in the number of papers published, really just in the last five to seven years, which show that patients who are taking opioids in the long term and then undergo surgery have a much higher risk of poorer postoperative outcomes. So for example, one of the biggest study groups is patients having hip and knee replacement. And we know from those data, and it's usually big data from big data so we can't prove causality, but the pre-operative opioid use is associated with an increased risk after hip and knee replacement of wound infection of periprosthetic joint infection, which is a terrible outcome. And these patients are likely to spend longer in hospital. They're more likely to require a revision of their joint replacement and they may have higher readmission rates. So, all of this is not good either for the patient in particular, but it also will lead to higher healthcare costs. There is early good evidence, or the good news is there's early evidence, to suggest that weaning opioid doses ideally back to zero, but even weaning the doses some months out from surgery, may be able to reduce these risks back down to baseline levels. It's not an easy thing to do, but it may be worth trying.

Dr Kate Annear:
That’s interesting. So long term opioid use can lead to a multitude of damaging effects on the body in addition to potential issues with tolerance and addiction.

And I think that GPs can use these points to talk to their patients when having those risk-benefit conversations about opioid use in that acute pain setting. Now as a GP, I’m aware of quite a few recent changes in the regulation space around the issue of opioid prescribing for acute pain. Could you walk me through the important recommendations of the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard that was recently published by the Australian Commission for Safety and Quality in Health Care?

Prof. Macintyre:
Well, yes, the new Clinical Care Standards built on really changes that were introduced by the Therapeutic Goods Administration (TGA) or in part built on them that were introduced by the TGA back in July 2020, where they made quite significant changes to approved indications for the use of opioids, prescription of opioids, particularly slow release opioids. They also made changes to pack size so that fewer than 20 tablets could be dispensed so this will make it easier for the standards to be followed. I think looking at the standards they firstly, and I think importantly right up front, emphasize the importance of giving the patient and their carers appropriate information about both non-pharmacological and pharmacological options for managing acute pain. They then look at how we should best assess a patient with pain because surprisingly, that's not done as well as it should be. Well, it says that we should be thinking about risk-benefit whenever prescribing an opioid, but I suspect that applies to prescribing any medication for a patient. There's some good information about appropriate analgesic prescribing because I think this isn't done well still. And they absolutely promote the idea that for acute pain management only immediate release opioids should be used unless there are exceptional circumstances, and the TGA actually says exceptional circumstances. So they're indicating the need for a shift away from what has become reasonably common practice of prescribing slow release opioids for the management of acute pain. They also look briefly at how to monitor the patient, given an opioid you'd think that is common knowledge. Again, it's not. And patients and carers also need to know a little bit about this because if a patient is given an opioid to take home, they and their family need to know about some of the adverse effects and what to do. And the standards then finally, and most importantly, cover the things that are needed for a proper transfer of care to the patient's general practitioner.

Dr Kate Annear:
Yeah, that's right. And I'll just mention there too, that NPS MedicineWise has also released two educational PDFs for use in the emergency and the postoperative setting, and that's intended as supportive resources for that clinical care standard. And thanks Pam for your work in assisting us in creating those resources.

Prof. Macintyre:
Oh, that was good. That was fun.

Dr Kate Annear:
So how important is individualizing the approach to acute pain management? So, for example, should the prescriber's approach be different for a young fit, healthy person as opposed to an older and more frail person?

Prof. Macintyre:
Absolutely. And even regardless of age, the key to safe, effective management of acute pain really is to tailor the regimen to suit each patient every time, especially when it comes to opioid doses. And you mentioned old frailer patient. We actually know as patients get older, there is a steady decrease in the amount of opioid a patient needs to get good pain relief. So initial doses, firstly should be based on the age of the patient. But it's not just that doses need to suddenly be lower in elderly or frail patients as you sometimes read in product information sheets, but the dose requirements actually decrease at a steady state over all age groups. And we give information to our junior doctors, but the information's also been incorporated into Therapeutic Guidelines and Australian Medicines Handbook about different suggested initial doses for severe pain, but also moderate acute pain that divide the patients into different age brackets and give suggested starting doses. Once you've given the dose, then you need to tailor that dose to suit each patient. Either increase or decrease it.

Dr Kate Annear:
Yeah. So, that's interesting. So it's a lot of individual variability there, isn't there in what patients will require and obviously what type of surgery they're having will also have an impact, won't it?

Prof. Macintyre:
Yes. When we looked at this way back, we published about age-based dosing back in 1996. We were looking at patients who were using patient-controlled analgesia. So by definition, reasonably major surgery. The type of surgery and patient weight really didn't figure in the calculations, the big differences, the big predictor was patient age. And I don't think people realize, or we certainly didn't realize, that even in each age group, there was an eight-to-10-fold variation in first 24 hour opioid requirements. So there's a massive interpatient difference that most guidelines, certainly when you looked at the product information sheets that accompany the medications, they just don't take into account.

Dr Kate Annear:
Yeah, that's interesting. Now the Clinical Care Standards also refer to the use of functional assessment tools to evaluate and monitor acute pain. Why the shift in focus to assessing function? And how important is monitoring that trajectory of pain and function scores in your individual patient?

Prof. Macintyre:
Well, as I said before, in monitoring, the key is individual titration to each patient. And monitoring is absolutely key to this to make it safe. We know that pain scores vary enormously between patients. There are some recognized predictors of high pain scores after surgery, including pre-existing chronic pain, patients who've been taking on opioid prior to surgery, and those with psychological comorbidities, especially anxiety, depression, or those who exhibit catastrophic thinking. The introduction of pain scores started with the pain as the fifth vital sign, which was developed by the American Pain Society in the USA back in the mid '90s. And it encouraged staff, and I think quite appropriately, to assess pain in all patients on a regular basis and try to improve the management of their pain. They were encouraging really quite aggressive management of pain as they were in that time for chronic pain, which we know now was slightly misguided. But in the US the requirement for pain scoring in particular became part of accreditation requirements. And it meant that in many centres, staff were encouraged to give patients enough opioid to keep their pain scores below an arbitrarily acceptable level, often a pain score of four. And then later one study in 2005, showed that this approach of trying to lower patient’s pain scores ideally below four, absolutely improved patient satisfaction and pain relief., but it had the unfortunate effect of doubling the instance of respiratory depression. So it clearly showed that titration of opioids to pain scores alone wasn't safe.

Dr Kate Annear:
Right.

Prof. Macintyre:
So around about 12 years ago, 10, 12 years, I can't remember. It was suggested that a patient's function should be assessed as well. I think this is something we'd all done clinically, but a colleague of mine in Melbourne, David Scott, put together a very simple three point function activity score. So it was assessing a patient's function relative to their surgery or injury. For example, if they'd had abdominal surgery, it was their ability to take a deep breath and cough. And an example of this functional activity scale is actually outlined both in the standards document and in the NPS Acute Pain Management document that you've just mentioned. So it meant that if a patient has high pain scores, and there may be many reasons for it, but if they have good functional activity, then more opioids are not indicated at that time at least. If they are very anxious, they may benefit from someone sitting down and chatting to them about what's been happening, how they're going, what's going to be happening over the next day or two. So, we need to listen to their concerns, but it just reinforces i think that not all patients with high pain scores don't always need more opioid. Functional activity is the key and it’s function pain related, movement related pain. that is the pain that's going to inhibit their good recovery after surgery or trauma.

So we've switched to doing both functional activity, really to help titration of opioids. Pain scores, I don't think we should abandon them, but they're more useful as you've mentioned to track a patient's progress over time,so look at their trajectory rather than an individual pain score.

Dr Kate Annear:
That's right. And then that functional score is just so important, isn't it for the recovery, so monitoring someone's ability to progress through to that recovery process?

Prof. Macintyre:
Absolutely. It's the key.

Dr Kate Annear:
Yeah. Now I'm interested too, in your experience as a clinician, how open did you find patients were to the use of non-opioid analgesics or other opioid sparing strategies to manage their pain. And how effective can some of those strategies be?

Prof. Macintyre:
Look, I think many of them were receptive. I think ideally the time to talk about this is not when a patient is in severe pain. Certainly, for elective surgery, the time to give appropriate information about all of this, from pre-admission to after discharge, is when the patient is seen before their surgery. And then their patient carers can be given some information about it. There are simple things. Some of the nonpharmacological techniques could be quite advanced that would need a psychologist, but simple things like distraction watching television, playing computer games, sometimes the nurses will be able to get warm towels or warm blankets to put over their abdomen. I think most of them are very receptive to it. It's just that it's often not explained to them.

Dr Kate Annear:
That's right. So it's about making sure that they fully understand how it can be helpful and what the options are. Isn't it?

Prof. Macintyre:
Absolutely.

Dr Kate Annear:
Yeah.

Prof. Macintyre:
We often find patients say their pain is worse at night-time. And we used to say that's because the whole ward is quiet. You're not watching television; pain does get worse at night. Whereas when we can be distracted during the day, it's not as bad often.

Dr Kate Annear:
That's right. And encouraging mobility rather than rest or that gradual return to normal activities is especially important. Isn't it?

Prof. Macintyre: Absolutely. It's especially important and that's another reason I think immediate release opioids are good because we can explain to the patient activity based analgesia is what we're after, not to sit and watch television. And if you take an immediate release opioid and then wait about an hour, it will be having its peak effect, and that's when you could get up and walk or do physio or any other activity.

Dr Kate Annear:
That's right.

Prof. Macintyre:
It also gives the patient some control over what they're doing.

Dr Kate Annear:
Yeah. Now you mentioned earlier that there's been that shift away from the use of modified and slow-release preparations of opioids in the acute setting. Could we chat a bit more about why immediate release preparations are preferred now?

Prof. Macintyre:
Yes. The practice of slow-release opioids became embedded in many institutional acute pain management protocols very quickly after slow-release oxycodone was released in the US for the management of chronic non-cancer pain. The US had less tight restrictions on the use of slow-release opioids at that time, it was basically for any pain that might last more than a couple of days.But it rapidly became embedded in, as I said, institutional pain protocols in early enhanced recovery after surgery protocols. Surprisingly, there was, and still is, no good evidence of benefit with slow-release opioids. Well, in fact the opposite. And I need to go back, there was one particularly influential study I think published in 1999, so, three years after the release of OxyContin, that did show slow-release oxycodone to be much, much better than immediate release oxycodone in terms of pain relief, in terms of patient's sleep, in terms of activity. And I suspect it likely influenced clinical practice for a while because it was published in a prestigious journal. It probably had some influence until it was retracted 10 years later because of scientific fraud.

Dr Kate Annear:
Right.

Prof. Macintyre:
None of the other papers that I could find when I looked showed any benefit. So it kind of... they slipped in under the radar. Part of the information that was given about why it might be good for patients with acute pain is, as with chronic pain, the slow-release formulations would provide constant plasma concentrations over about 12 hours. So, the patients would get constant pain relief, and that would be easier not just for the patients, but twice daily dosing is obviously easier for nursing staff. There were two major problems with this. For a start acute pain isn't constant, and you've already mentioned that movement-evoked pain is the problem inhibiting function activity is the problem. And we know that movement-evoked pain can be significantly high than pain at rest. There was a study a decade ago that showed the difference between movement-evoked pain and pain at rest, maybe as much as 200%. So, any analgesic protocol needs to take this into account. Slow-release opioids with a slow onset and slow offset, mean it is just absolutely impossible to titrate appropriate opioid doses to the patient's requirement, particularly pain with movement.

We also know that the information that was given out about plasma concentrations being relatively constant over 12 hours, actually wasn't true. The initial graphs of plasma concentration that were used in the oxycodone product information sheet, for example, appeared to show relatively constant levels, but they'd used a logarithmic scale on the vertical axis, which blurred the differences when they plotted on a linear axis, there's quite a significant decrease over 12 hours. So even if acute pain was constant which it is not, the plasma concentrations weren't constant. So, it's no surprise really that more recent publications, particularly a couple of really good ones that Jenny Stevens, a colleague of mine at St. Vincent in Sydney, has been involved in, have shown that immediate release opioids result in better pain relief.

Dr Kate Annear:
Yeah.

Prof. Macintyre:
Also, there's increasing evidence that slow-release opioids we use not only with analgesia is no better, but it increased the risk of harms and in particular respiratory depression related to opioid and in particular persistent postoperative or post discharge opioid use, which you've already mentioned as being an issue.

Dr Kate Annear:
Right. So there's lots of reasons there that explain that shift. And look, if we just talk a little bit more about the respiratory depression issue. How important is monitoring and managing adverse effects such as sedation and respiratory depression in that acute pain setting?

Prof. Macintyre:
Again, key, you can't safely titrate opioids to affect without good monitoring. Respiratory depression is an interesting one because we know the only true measure of respiratory depression is obviously if we can measure a patient's blood carbon dioxide levels, but this isn't possible even on a routine basis. And it certainly would never be available for every patient given an opioid in hospital, and we also need to think about how we monitor when a patient goes home. The one thing, unfortunately, that is still not well recognized ,even though it's a problem that's been known probably for 25-30 years, is that measurement of respiratory rate is a hugely unreliable indicator of respiratory depression. And we will still see studies published in papers to this day that say that they use a cut-off respiratory rate of less than eight or less than 10 breaths a minute to say whether or not a patient had respiratory depression.

We know, we've known for a long time, as I said, that patients can have very severe respiratory depression and yet have a respiratory rate that is considered to be within normal limits. Sedation seems to be the best clinical indicator, we have at the moment of respiratory depression. So the nurses need to assess the patient's sedation on a regular basis and that basis should be tied to the route of administration. So, if a patient is given an oral immediate release opioid for example, we would like the nurses in our hospital and local health network, would do sedation scoring at the time of administration, but then just pop back an hour later when we expect the peak effect to be seen of the opioid. They'll pop back and check on the patient sedation scores then, because that's the time to work out whether also you've given enough opioid or whether that was an inadequate dose for the patient.

Dr Kate Annear:
Right.

Prof. Macintyre:
Having said that, there then needs to be written instructions for the actions to be taken, interventions to be taken, should the patient become over sedated. The loop needs to be closed. So if a patient has a sedation score of two or more, and the sedation score systems we use are outlined in both the new standards and the NPS [MedicineWise] document, the nurses need to know for example, if the sedation score is two, not to give any more opioid to the patient, and then regardless of the pain scores to use a lower dose next time. Two is the patient is easy to rouse, but has difficulty staying awake. If the sedation score is three and the patient is difficult to rouse or unconscious, the nurses need to be able to straight away give naloxone, call medical emergency response team. And absolutely if patients need opioids later on, when all this has been sorted, the dose must be lower again regardless of pain scores.

Dr Kate Annear:
Yeah, that's right. So, look, if we shift now just to talking a little bit about discharge planning and communications. Now, if a patient is prescribed an opioid when they're discharged from hospital, for example, after a surgical procedure, what considerations should the prescriber make in determining the strength and quantity of opioids to give a patient on discharge? And what sort of information should be given to the GP?

Prof. Macintyre:
The main consideration when it comes to prescribing opioids on discharge is not to prescribe excessive doses at that time and not to prescribe them for too long. Now in Australia with PBS prescribing, too long would mean that there needed to be repeat prescriptions, because of the limitations to the number of tablets in each box that you can prescribe unless you get permission. In the United States, they had no limitation on how many tablets patients could go home with. And I know I've seen studies where patients went home with 2-300 oxycodone tablets which is silly. So in Australia, we could do things a lot better. We've not had the same problems with the opioid epidemic that they have in the States, and I think that's probably because we've had the PBS limitations on prescribing amounts and the fact that you can't give repeats. So there's been many studies from the States, looking at prescribing after different types of surgery and it was quite clear, and some studies in Australia have shown the same, that the opioid prescription hasn't always been appropriate in terms of the anticipated pain severity. I know in one study, or there's a second one just come out recently, where patients were given an opioid after cataract surgery, which is not appropriate. So the prescription we know is not always appropriate in terms of how much pain we think the patient's likely to have, or how long we think they're likely to have that pain for. And if you prescribe very large amounts of opioids that are not needed, it means there's a large amount of unused opioid available, which poses risks not just to the patient, but also risks to family. And there's been reports of children and pets coming to harm for example., especially if the leftover opioid, or opioid even when it's being used, is not stored securely. And there's risk to others in the community. We know that about 50% of patients, and this is information from Australia and the US, about 50% of patients of people who misuse opioids source them from family and friends. So we need to make sure that when we send a patient home with oxycodone, that we are not unwittingly adding to this community pool.

We also know that prescribing too much, again, increases the risk of persistent postoperative opioid use. The more you send a patient home with, the longer they're likely to use it for. And after a stage, they end up taking an opioid for a pain that's no longer acute. So it's not appropriate treatment anyway.

Dr Kate Annear:
That's right.

Prof. Macintyre:
So many publications used to suggest particularly in the US that we base the discharge amount on the type of surgery the patients have, but this isn't individualizing patient care. And we know now it's much better, and these standards recommend this, to base the discharge dose on the amount of opioid the patient has shown they need in hospital before they go home. So no just in case prescribing.

Dr Kate Annear: 

Yeah, that's right.

Prof. Macintyre:
So where it's possible, obviously with day surgery that's not possible, but we need to look better at individualizing discharge opioid prescribing, just as we need to better individualize it in hospital.

Dr Kate Annear:
That's right. My understanding too, is that it's the duration or the number of days of the first opioid analgesic prescription rather than the actual dose that's more strongly related to that misuse in the early postoperative period. Would that be correct?

Prof. Macintyre:
They've certainly shown the number of days is a problem and will lead to long term opioid use. So the patients and the patient's general practitioner, so they both need to be... the general practitioner needs to know what our patients have been told and that’s that they should decrease their dose a little each day or two, as they recover, not necessarily as pain scores go down, but as they recover functionally. They shouldn't have any alcohol when they go home. If they're requiring opioids, they shouldn't take sedatives. If they do become sedated the patient won't notice, but their family will. So again, we need to outline the intervention the family should take if their family member is over sedated, sedation scored two or three, and it's reasonably easy to teach that, then they need to be able to call an ambulance straight away. We need to remind them that they shouldn't be driving while they're taking the opioid that was prescribed for acute pain. We need to remind them, as I've said before, about safe storage and disposal. And as you've mentioned, again, they need to be reminded that the pain relief is for activity so, they should use that to improve their recovery.

Dr Kate Annear:
And so the more information that you give patients, I guess, about all of those important points that it just empowers them, doesn't it?

Prof. Macintyre:
And I think we need to help the general practitioners because we are not particularly good at giving good information to the general practitioner. The standards are suggesting, or we should say how long we think the patient will need opioids for example, but that's not always easy to tell. The standards do suggest you should give less than seven days’ supply of opioids, which might be not that easy in hospitals like ours that use PBS prescribing, but some patients may need more than seven days, but the general practitioner needs to know what we have told the patient. And so the patients can't say, but this big teaching hospital said I needed to continue oxycodone, for example. The GP needs to know that yes, we did prescribe oxycodone on discharge, but that after discharge, as well as in hospital, dose trajectories need to be going downwards. Some patients it'll be slower than others, but otherwise the trajectory should be downwards and the patient should be off all opioid as soon as feasible.

Dr Kate Annear:
Yeah. So, what does the GP do when they find themselves with a patient who is sent home from hospital with a short supply of opioids, who then comes in requesting more saying that their pain isn't well enough controlled and they need a longer supply. What sort of things should the GP be on the lookout for in that scenario?

Prof. Macintyre:
Well, as I said, there are going to be patients who do need more opioid than they were sent home with, particularly in where hospitals can't give a seven day supply. And as I said, even if we do limit it to seven days, that can be difficult. If we do give an indication of how long we think opioids are needed, that estimate can be quite inaccurate. Again, mentioning my colleague, Dr. Jenny Stevens back at St. Vincent's in Sydney, they had been prescribing slow-release opioids routinely for patients having hip and knee surgery, knee replacement. They changed to immediate release opioids, and many patients now are not needing any opioid to go home. But whereas some would've been using it for maybe a couple of months after surgery, they aren’t now. So we need to give better information. It's not unreasonable for some patients to need more. And I think the thing again, I would be looking at, is the opioid dose trajectory.

Dr Kate Annear:
Yes.

Prof. Macintyre:
As I said, some patients will decrease a little bit more slowly than others, but as long as it's decreasing, I'd be a little bit less concerned. It doesn't mean it should decrease over weeks though, weeks and weeks, it should be over days. If the trajectories are not decreasing or the pain is persisting firstly, we need to think about non- opioid responsive pain. And we know after some types of surgery that patients will have a mixed, nociceptive neuropathic pain. Opioids will be good for the nociceptive pain, but not for neuropathic pain. Amputation, phantom pain after amputation would probably be the key example of neuropathic pain after surgery, but a significant proportion of patients for example after thoracotomy or breast surgery will have neuropathic pain. So it's important to look at that. See whether the pain that the patient has, is non-opioid responsive pain or a mix, because if we are treating neuropathic pain, it's a different set of medications.

We also need to look at, both in hospital and once the patient's gone home, whether they're developing any postoperative or post trauma complication, for example, as I said, periprosthetic joint infection after hip or knee surgery. And again, we need to take into account the patient's psychological comorbidities, because we know that trajectories that are not decreasing as predicted by one of the predictors, is patients who have anxiety, or depression or exhibit catastrophic thinking. This is not for one minute saying these patients shouldn't be given an opioid when they leave hospital, but they just may need closer watching or a more frequent review to make sure the dose trajectory is down.

Dr Kate Annear:
That's right. It's looking at the whole patient really, isn't it?

Prof. Macintyre:
Absolutely.

Dr Kate Annear:
Yeah. Look, just one final question Pam, the Clinical Care Standard talks about opioid analgesic stewardship as a shared responsibility. How important is the role of other healthcare professionals in this whole process?

Prof. Macintyre:
Absolutely crucial. It's just not going to work without. In the hospital setting, the nurses can be very helpful, particularly again, if they recognize that dose trajectories aren't going down. Sometimes dose trajectories, I forgot to mention, sometime the reason for not decreasing is actually very benign. The nurse might have seen that the previous two doses of opioid the patient was given worked well. Say three tablets, and they might give another three tablets of oxycodone, or the patients might say, "Look, three tablets worked really well. Can I have three tablets again?" And the nurses in a really good position to say, "You are recovering really well. In lay terms, you've got good functional activity. How about we try two tablets this time? Because if they're not enough after an hour, we can probably give you a bit more." So they're in a position to help with that.

The ward pharmacists are also, I think, often underused. In hospitals again, when they review the patients, they will be able to look at the dose trajectories in particular. And they're also crucial when it comes to the time of discharge, because they're the ones that usually get to give the patients the information about their analgesic medications. And they can run through the things I've mentioned about storage, about adverse effects and also about how to decrease and cease them. And there are some places now developing information sheets that will for example, the ward pharmacist can help fill in. The ward doctors are obviously key to this as well, they should be keeping an eye on dose and pain trajectories. But there are some information sheets now given to patients that will actually say to them how to decrease [the] opioid. And if they're prescribed, multimodal analgesia needs to continue after discharge. They still need to be told they should continue regular paracetamol, continue regular non-steroidal anti-inflammatory drugs, if not contraindicated. And they should continue those on a regular basis until the opioid dose has been tapered and then ceased. And I think certainly our ward pharmacists were absolutely key to helping provide this information. It's then up to the ward doctors to try and provide better information, I think, to the patient's general practitioners.

Dr Kate Annear:
Yeah. So it's really a team effort, isn't it? We all need to be on that same page.

Prof. Macintyre:
It has to be. And I should have [said] the patient and their carers are obviously part of that team.

Dr Kate Annear:
That's great. Look, there's obviously a lot more we could talk about here on this important topic, but I wanted to thank you Professor Pamela Mcintyre for taking the time to talk to me today about opioid stewardship in the acute pain setting. It's a really topical issue where we're seeing a lot of changes at the moment, and hopefully we'll start to see some improved outcomes for patients as a result of these changes. So, for those of you who are listening, who'd like more information you can go to our website, nps.org.au, where you'll find the resources that NPS MedicineWise has developed to support the safe use of opioids for patients presenting with acute pain within the emergency department and in the postoperative period. You can also visit the Australian Commission on Safety and Quality in Health Care's website for the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard. GPs can also go to our website for more information on CPD points related to this podcast. So thanks for joining us and bye now.