Wed Apr 27

Patients leaving hospital sometimes need opioids. Doctors can reduce risks of long-term use and dependence

Written by Ria Hopkins, PhD Candidate, National Drug and Alcohol Research Centre, UNSW Sydney

Hospital patients are often given strong, opioid pain medicines when discharged home after surgery and other treatments. This can sometimes lead to long-term use and dependence ^[1].

New national standards ^[2], released today by the Australian Commission on Safety and Quality in Health Care ^[3], aim to reduce prescribing that increases the risk of dependence.

The standards encourage hospital doctors to consider prescribing alternative pain relief such as paracetamol and ibuprofen for mild to moderate pain where possible.

When stronger pain relief is required – and medicines such as oxycodone, morphine, fentanyl, tramadol and codeine are prescribed – the standards recommend discharging patients with up to seven days’ supply, depending on their circumstances.

So what are the risks of dependence? And how can clinicians ensure pain is adequately managed?

Treating pain is a human right

Acute pain isn’t just unpleasant to experience. Pain causes the body to enter a stress response ^[5]. This can have wide-ranging effects on the body, from raising your heart rate, to reducing the functioning of your immune system.

Uncontrolled pain in hospital may lead to poorer patient outcomes ^[6]: people in pain take longer to recover and may experience longer hospital stays.

Uncontrolled acute (short-term) pain may even progress to chronic pain ^[7], which is much harder to manage and can have significant impacts on a person’s quality of life.

Treating pain is also ethical, and access to adequate pain management has been recognised as a fundamental human right ^[8].

Man sits on the edge of a hospital bed in the dark.

Patients have a right to adequate pain management. Shutterstock ^[9]

There are several reasons why people may experience pain in hospital, including injury, illness or surgery. Internationally, 84% of hospital patients ^[10] report experiencing pain. And up to three-quarters ^[11] of patients experience moderate to severe pain after surgery.

Opioid medicines are commonly used to manage pain in hospital. But with hospitals encouraged to get patients home earlier, many people may still be experiencing pain when they’re discharged. So opioids are also often prescribed on discharge.

Opioids are high-risk medicines

Although opioids are effective in treating many types of pain, they are considered “high risk medicines”. They can cause multiple unwanted effects ^[12] which range in severity ^[13] from nausea and constipation, to life-threatening breathing problems and loss of consciousness.

Prescription opioid use has increased internationally over the past 30 years. In Australia, we’ve seen a 15-fold increase ^[14] in opioid prescriptions dispensed on the Pharmaceutical Benefits Scheme between 1995 and 2015.

Over the same time period, harms ^[15] from opioids ^[16] have also risen ^[17]. Between 2001 and 2012, deaths from pharmaceutical opioid overdoses in Australia rose from 21.9 per million population to 36.2 per million population ^[18]: an increase of 6% per year.

Prescription opioids are now involved in more deaths than illicit opioids ^[19] such as heroin.

To address these issues, government bodies have introduced strategies ^[21] to improve the safety ^[22] of opioid use. Although many focus on addressing opioid use in the community, opioids are also commonly used in acute care settings such as hospitals.

Finding a balance between benefits and risks

Good pain management aims to ensure pain is well managed while making sure the risk of any unwanted effects is low.

One of the risks is that short-term opioid use may become long-term opioid use. Studies have found ^[23] that among people who receive opioids after surgery ^[24], 1-10% are still using ^[25] them up to one year later ^[26].

Existing opioid treatment guidelines ^[27] recommend doctors prescribe ^[28] the lowest dose ^[29] of opioids needed for sufficient pain relief, for the shortest amount of time possible.

However, this does not always occur in practice. There is wide variation ^[30] in what patients are prescribed at discharge, even within the same hospital or surgical unit ^[31].

Good pain management means balancing the risks and benefits of medicines. Shutterstock ^[32]

Guiding principles for clinicians

Clinical care standards are a set of quality statements written by an expert writing group for consistent and high-quality health care. They aren’t rules; they’re guiding principles that inform patients and clinicians about “best practice” for a clinical area.

In many ways, the new opioid standards aren’t new – they’re consistent with current guidelines and research. However, they provide “indicators” for health care organisations to measure their performance against. Given ongoing issues with opioids, indicators may provide important feedback on how opioids are being used.

Building on regulatory changes implemented in 2020 ^[33], such as smaller pack sizes when filling prescriptions from community pharmacies, these new standards ^[34] come at a good time and will play an important role in ensuring opioids and other analgesic medicines are used appropriately and safely for short-term pain.

However, they don’t cover chronic pain, cancer pain, palliative care, or patients with opioid dependence.

It’s now up to clinicians to ensure they’re implemented, with patients given adequate pain relief and prescribed the lowest dose for the shortest time possible.