Quality improvement for opioids

Chronic pain is pain that lasts more than three months, or longer than expected for healing after surgery, an injury or a condition, or is due to an unknown cause. When the cause is not cancer, it is called chronic non-cancer pain.

Chronic non-cancer pain is an individual, multifactorial experience influenced by culture, previous pain events, beliefs, expectations, mood and resilience.¹ It is highly prevalent in Australia, affecting up to 17% of males and 20% of females.²

First-line therapies include non-pharmacological treatments such as patient education, gradually increasing physical activity and cognitive behavioural therapy (CBT). They may also include non-opioid medicines such as paracetamol and non-steroidal anti-inflammatories (NSAIDs).^1,3 These approaches and medicines need to be trialled and optimised before opioids are considered.

Opioids can be an effective component of the management of acute and cancer-related pain. However, evidence shows that for most patients with chronic non-cancer pain, opioids do not provide clinically important improvement in pain or function compared with placebo.⁴

Opioids for chronic non-cancer pain should be reserved for short-term trials for patients who have not responded to first-line therapies, after discussing the potential harms and benefits with the patient. Opioids should only be trialled as part of multimodal treatment.¹

The aim of the opioid trial is to determine a patient’s response to treatment as well as the lowest dose needed to achieve an improvement in pain and functioning.^5,6 A time-limited trial of opioids means starting, titrating, monitoring response and discontinuing the opioids if important improvement in pain or function is not achieved within a specified time period.³

Opioid use in Australia

Opioid prescriptions rose by 24% between 2010–11 and 2014–15, from 369 to 456 prescriptions per 1,000 people.⁷ Around 3.1 million people had opioid prescriptions dispensed in 2016–17.⁸ Based on data from the Bettering the Evaluation and Care of Health study, in 2015–16, 7.6% of total prescriptions in general practice were for opioids.⁹

Pharmaceutical opioids are associated with three deaths, 150 hospitalisations and 14 emergency department presentations each day in Australia. That’s more than twice as many people dying from pharmaceutical opioid overdose as from heroin overdose.⁸

Good clinical governance is supported by comprehensive practice policies aimed at a unified approach to drugs of dependence, which will support individual GPs to prescribe them safely and appropriately.¹⁰

Read more about opioids and chronic non-cancer pain.

Improvement measures can be used as part of practice quality improvement to:

1. review the care of those patients who are currently prescribed opioids
2. reflect on whole-of-practice opioid prescribing and identify opportunities to improve workflow, policy and procedures for future care.

The improvement measures recommended for opioids and chronic non-cancer pain are:

• Proportion of patients currently prescribed an opioid without a relevant diagnosis recorded
• Proportion of patients currently prescribed opioids for chronic non-cancer pain for longer than three months (or 7 or more prescriptions in the previous 12 months)
• Proportion of patients currently prescribed ongoing opioids who have not had a general practice management plan (GPMP) or team care arrangement (TCA) in the previous year
• Proportion of patients currently prescribed opioids who are also co-prescribed benzodiazepines
• Proportion of patients prescribed greater than or equal to 60 mg oral morphine equivalent daily dose (OMEDD)

Please contact [email protected] with questions or feedback about these measures.

What to do

Every practice is different and will have different priorities and ways of working. Determine, in collaboration with the practice team, how the practice wishes to prioritise patients for review and then agree on practice-wide systems for the management of drugs of dependence. Discuss what behaviours may need to change to achieve best practice and why they are occurring. 

Choose quality improvement interventions that address the cause of the behaviours.

For individual patients:

• This may include reminders to GPs in clinical software patient files to add a diagnosis.
• Consider generating patient recall requests to review treatment and refer for multidisciplinary care where appropriate, or initiating/updating of their GPMP or TCA.
• Discuss with the practice team the option of pharmacist consultations (or home medication reviews) for specific patients where tapering may be indicated.

For the practice:

• Discuss as a team at a clinical meeting and complete the RACGP Simple checklist for a general practice to review its quality management of drugs of dependence
• What policies and procedures need to be implemented or updated for future opioid prescribing? Who can take the lead on this?
• Decide if and what additional education or clinical update is needed (outreach or in-house), for example, NPS MedicineWise educational visiting
• Would a clinical audit of the practice’s opioid prescribing in the last 12 months be useful?

• NPS MedicineWise Clinical e-Audit – Opioids: Redefining ‘doing well’ on opioids
• RACGP Simple checklist for a general practice to review its quality management of drugs of dependence
• Starting a conversation about opioids with patients can be challenging. This NPS MedicineWise guide provides practice tips for GPs and pharmacists on communicating with patients about lowering or stopping opioids.

• Choosing Wisely Australia’s patient action plan – Managing pain and opioid medicines
  This patient guide offers 5 questions to ask when prescribed an opioid for non-cancer pain in hospital, tipis for taking opioids at home and a personal pain management plan. Note that the use of opioids in palliative care to manage symptoms of a life-limiting illness is not within scope of this resource.
• Painaustralia resources – Role of Medication, which includes:
  • medications for chronic non-cancer pain and changes to codeine access
  • videos explaining pain and what to do about it
  • material on the limited role of opioids, and
  • resources from factsheets to self-management tools.
• Pain Management Network resource – Pain and role of medications, which provides information and videos about medicines for chronic non-cancer pain.

• NPS MedicineWise’s patient action plan – Lowering your opioid dose

For GPs

• Educational visit – Opioids and the bigger picture when treating chronic pain
• Clinical e-Audit – Opioids: Redefining ‘doing well’ on opioids