Hospital pharmacists raise the alarm over post-surgery opioid prescriptions

Doug Hendrie

26/11/2018 3:21:58 PM

More than 70% of Australian hospitals send patients home with strong opioids ‘just in case’, according to a new report.

Concerns have been raised over hospital patients and opioid prescriptions.
Concerns have been raised over hospital patients and opioid prescriptions.

Hospital pharmacists have raised the alarm over ‘extremely high’ rates of prescribing opioids for acute post-surgical pain in a new report.
The Society of Hospital Pharmacists of Australia (SHPA) report surveyed Australian hospital pharmacy directors working across 135 hospitals. It found more than 70% of hospitals send patients home with powerful opioids ‘just in case’.
More than 60% of hospitals were found to be writing opioid prescriptions even before a decision had been made to discharge the patient.
This means patients undergoing one of the more 2.2 million elective surgeries taking place in Australia in 2016–17 would have been exposed to addictive opioids for the first time.
The Australian-first investigation of hospital pharmacies and opioids comes after a new Australian Institute of Health and Welfare (AIHW) report revealed that the number of deaths involving opioids had almost doubled in a decade.
The AIHW report found around 3.1 million Australians were given opioid prescriptions in 2016–17, with opioid deaths now two and a half times greater than deaths from heroin.
These trends pose problems for GPs. Opioid over-prescription, coupled with inconsistent information provided at discharge, means ‘many patients and their GPs are not receiving the appropriate information to best manage opioid therapy for patients recovering from surgery,’ according to the SHPA report.
Outgoing SHPA president Professor Michael Dooley told newsGP the report was intended to find out the extent of the issues.
‘The problem is significant,’ he said. ‘We’ve been seeing it on the [hospital] floor, we’ve seen opioids getting used an awful lot and seen the impact of that.
‘We now have a significant proportion of patients coming in on opioids from chronic pain or injury and, after surgery, we send a lot home with opioids who weren’t on them.’
Professor Dooley said a key issue is the fact the increasingly rapid turnaround and discharge post-surgery means opioids can often be used as a stopgap solution to a larger issue.
‘Patients get through system a lot quicker these days, and that means sometimes pain relief becomes routine,’ he said. ‘We tend to give them a script for 20 [opioid analgesics], and often when they don’t need them.
‘But we can just do it because patients need to keep moving through.’
To tackle the problem at Professor Dooley’s own workplace, Melbourne’s Alfred Hospital, pharmacists have shifted from packs of 20 down to individual tablets of oxycodone hydrochloride.
‘We give two tabs if they’re not in much pain, rather than a pack of 20. There’s clear evidence that the risk of addiction to opioids is related to how many you get on that first prescription,’ Professor Dooley said.
Professor Dooley said patient education remains key, as is allowing time for the discussion between patient and practitioners.
‘We need a key message from nurses, doctors, pharmacists that these opioids you take home are for when you really need them, and for the shortest time possible,’ he said. ‘We say, in some instances, a little bit of pain is not unexpected.
‘The pendulum has swung from when pain wasn’t managed that well to a big focus on pain now, where [we feel] patients shouldn’t have any pain. But we want to get away from that idea that pain needs to be killed.
‘Some pain [after surgery] can have a good message, telling the body not to do something.’

Hospital-opioids-text.jpgProfessor Michael Dooley said some hospital pharmacists have shifted from packs of 20 down to individual tablets of opioids when prescribing for patients following surgery.
The SHPA report calls for relabelling ‘painkillers’ to ‘medicines for reducing pain’ to reframe the purpose of opioid medications.
Professor Dooley said consistency of messaging is vital for all healthcare providers.
‘It’s like how we manage antibiotics to make sure they’re used the right way, to avoid downstream impacts,’ he said. ‘We need similar conversations around opioids – these are good medications, but only use them when you really need them.
‘When we discharged patients, [we used to think], “Let’s give them a couple of boxes [of opioids] so they don’t need to go to their GP”.
‘But now the way we look at it is, how bad the pain is and what the minimum we can give is. If pain escalates, they can go to their GP.’
Professor Dooley said the SHPA is seeking to collaborate with other healthcare professional bodies like the RACGP.
‘It’s key that we’re working together,’ he said.
The SHPA report also recommends pushing pharmaceutical companies to vary their packet sizes, encouraging hospitals to ensure every patient given opioids has a pain-management plan in place, and for hospitals to adopt opioid stewardship programs nationally.

Dr Hester Wilson, Chair of the RACGP Specific Interests Addiction Medicine network, told newsGP that hospitals discharging patients with strong medications, without necessarily stating the medications are for short-term use only, is a common issue facing GPs.
‘It can be tricky as a GP when the patient says “the specialist gave me this” to question how long it’s for and what the plan is,’ she said. ‘Then there’s the problem of continued scripts.  

‘Some of the patients I treat for opioids say nobody told them when they started that these medications are potentially dependency-forming. When you’re unwell, you’re not able to take everything in.’
Dr Wilson said it is important to have the messaging around opioids repeated by GPs, specialists and hospital pharmacists, making clear the risks of opioids and other techniques to manage pain.
Dr Evan Ackermann, former Chair of the RACGP’s Expert Committee – Quality Care (REC–QC), commended the report, which came after a meeting between the RACGP, SHPA and other specialist groups in March. 
‘We welcome the report from the SHPA on opioid use in hospitals, particularly highlighting the issues for pain management on discharge,’ he told newsGP.
Dr Ackermann said there is a need for GPs to receive the right information to best manage opioid therapy for patients recovering from surgery, and a need for a standardised pain management referral on discharge.

Hospital pharmacists opioids Society of Hospital Pharmacists of Australia surgery

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Tan Letran   27/11/2018 8:32:55 AM

Junior doctors including registrars of various specialty are the worst offenders . Most of my patients were sent home from attending ED or discharge from elective surgery with a script of Oxycodone . The best way to tackling the problem is removing the right of prescribibg S8 drugs from these junior doctors until they obtain their fellowship

Kate   27/11/2018 2:06:12 PM

It's not just post-surgery, it's not uncommon for patients who have been assessed in cas for abdominal pain or non-fracture limb injuries to be given 20 endone tablets as they leave. We then see them 3 days later when they have taken it all and of course want more because their pain is much better when taking them (oh, sorry, I forget opioids are no more beneficial for most pain than paracetamol). This leads to lengthy and often difficult discussion about non-opioid analgesic regimens which could have been avoided if they were not given so much in the first place.

Dr Sovan Dey   27/11/2018 4:28:26 PM

Strong pain medication prescribed in hospital getting worse and out of control and on discharge , GPs have to deal with the consequences of de-conditioning and de-addicting. Junior doctors prescribe it so they will not have deal with patients complaints and dont have to visit them regularly bec of pain in the middle of night or odd times. And agree that S8 should not be prescribed by junior doctors and same monitoring should apply for doctors in hospital as its monitored for GP opioid prescription.

Richard Mayes   27/11/2018 6:27:51 PM

Being one of many GPs who has been sent a letter threatening a departmental review of opiate prescribing, this situation has been particularly concerning. The bulk of the patients I am trying to assist in withdrawing from opiate dependency were initiated in hospital post surgeries. With a full assessment of their previous history of mental health issues and abuse of other drugs of dependency, I would have hoped this would have alerted discharging staff to safe methods of prescribing analgesia. It is the GPs that end up cleaning up the mess and are audited while trying to do the same. To think when I was working in hospital I needed to check with my senior if I was signing off on 2 panadeine forte in the early 2000's. My personal experience as a patient was leaving hospital feeling well post uncomplicated hernia operation, but given a "just in case" Endone 10mg and suffered nausea and syncope on the 1 hour drive home. Let us hope for change before the deparmental peer reviews commence.

Dr. Dave Jones   28/11/2018 12:00:12 AM

Sorry, but this comment from Professor Dooley: "‘Some pain [after surgery] can have a good message, telling the body not to do something.’" is completely contradictory to all teaching I have ever received on pain and it's management and indeed while rotating through pain clinic as a junior. While I am not denying there might well be an issue with overprescription and every case should be addressed individually, to say the above is absolute rubbish. How does he define "some pain"? How does he suggest doctors make a decision about what constitutes "some pain" aand decide on a regime? Does he think "some pain" is good for orthopaedic patients who especially need to mobilise with a new prosthesis, or risk a longer rehab period & a higher risk of VTE? And what of the psychological effects of prolonging pain in a patient? This can be potentially devastating.

Frankly, I have not had a single patient in 5 years of practise in Austalia who has had an ongoing problem with the withdrawl of opiates post surgery/medical discharge and compared to the problem of recreational drug use, this issue could be regarded as trivial by comparison. Further, inappropriate overprescription can and should be managed by the GP who is best placed to assesses the patient and advise and/or prescribe or withdraw subsequent analgesia along with other needs (physio/OT etc). There are MUCH bigger problems within secondary care than this.

Lou gallo   29/11/2018 7:34:04 PM

Have said this for a long time. Then it’s left up to GP to get them off the drugs . Time educate the residents!!!!!!!!!!!

Anthony McCarthy   1/12/2018 12:45:45 PM

The scale of handing out out of oxycodone in hospitals - particularly A&E- is ridiculous. It is positively dangerous for older people, including those in nursing homes and addictive for younger people.
An Orders of magnitude bigger problem than codeine ever was in my experience.