The opioid epidemic from the acute care hospital front line

Abstract

Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid ‘epidemic’ and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients. Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.

Implementation of a peri‐operative pain‐management algorithm reduces the use of opioid analgesia following pelvic exenteration surgery

“…Whilst previously accepted as part of the course of the disease, pain is increasingly recognized as a significant problem, both from functional and survival viewpoints [34, 35]. Furthermore, there is little data about long‐term opioid use in patients undergoing pelvic exenteration for a locally advanced pelvic malignancy, which has further implications in terms of opioid‐induced immunosuppression and other systemic adverse effects as a result of chronic opioid dependence [36].…”

Opioids caught in the crosshairs: Towards smarter and safer use of opioids in daily clinical practice

“…20,21 Reflections on this recent history with salutary lessons for patient care now and into the future are offered in the review by Macintyre in this issue. 22 However, this is not the first opioid epidemic nor the first time aggressive marketing to physicians of attractive opioid products of uncertain benefit has occurred. Glossy advertising materials promoting products, often unknowingly containing opium, direct to physicians, claiming to treat a wide range of conditions is recorded from the early 19th century in the USA.…”

“…20,21 Reflections on this recent history with salutary lessons for patient care now and into the future are offered in the review by Macintyre in this issue. 22…”

“…29,32 –34 Despite the lack of proven approaches, opioid stewardship is still considered a valuable adjunct to prescriber and consumer education. 22,35…”

“…29,[32][33][34] Despite the lack of proven approaches, opioid stewardship is still considered a valuable adjunct to prescriber and consumer education. 22,35 While strategies to improve the transitional care arrangements for people discharged from hospital acute care on opioids remain to be optimised, inhospital care has also been under scrutiny. In response to concerns about the increasing use and consequent harms from SR opioids in acute postoperative pain management, the Australian and New Zealand College of Anaesthetists (ANZCA) issued a position statement urging caution when prescribing these formulations, especially for opioid-naive patients.…”