Opioid-Related Harm

This topic was a Final FRCA CRQ in February 2024.

Questions on risk factors for persistent post-operative opioid use, management of fentanyl patches and opioid equivalence were poorly answered.

Resources

Opioids are effective anti-nociceptive medicines which are integral to analgesic strategies for the management of acute post-operative pain
However opioid related-harms, including persistent post-operative opioid use, have contributed to a near-global opioid crisis, which has significant socio-economic repercussions
Opioid-related harms include:

Opioids produce tolerance i.e. dose escalation is required to maintain the same degree of analgesia, increasing risk of side-effects
At the cellular level, tolerance is mediated by the DOP receptor
Animal models where DOP is inactivated (by antagonism or genetic knock-out) there is reduced tolerance to MOP receptor agonists
Models of MOP-agonist/DOP-antagonist bivalent ligands demonstrate reduced tolerance profile, decreased physical dependence (vs. morphine) and improved anti-nociceptive properties

Pharmacological	Service under-provision	Patient	Prescription	Industry-level	Societal	Healthcare
Addictive properties of drugs	Lack of resources to support chronic pain patients	Pre-operative opioid exposure (dose-dependent effect, up to 10x ↑ risk)	Poor opioid stewardship	Aggressive marketing inc. falsified claims	Lack of safe disposal routes	Use of unidemsnional pain scores
Long-acting formulations	Lack of recognition of chronic pain	Past/current substance dependence inc. tobacco, alcohol	Repeat prescriptions	Misbranding	Socio-economic deprivation	Incentivisation
Compound analgesics		Chronic pain	Poor knowledge of rates of dependence	Sponsoring drug trials	Opioid diversion
		Psychological co-morbidities e.g. anxiety, catastrophising, depression	Lack of de-prescribing	Fabricated research data
			Use of long-acting formulations

Patients taking any opioids prescribed post-operative pain for longer than 90 days after surgery
The incidence of persistent post-operative opioid use ranges from 0.1 - 26% (opioid-naïve patients) to 35-77% (patients with previous opioid exposure)
Although some surgeries are deemed 'higher risk' for PPOU, all patients undergoing surgery (even those considered 'low risk' surgeries) are at risk
Described by some sources as the most common complication after surgery

Coordinated interventions designed to improve, monitor and evaluate the use of opioids in order to support and protect health
Effective stewardship is important in minimising risk of opioid-related harm
Comprises of:

Knowledge issues

Insufficient understanding of the importance of opioid stewardship among healthcare professionals

Opioid stewardship should be embedded in the curricula of healthcare professionals
Staff need formal support and teaching for safe administration of opioids

The peri-operative team should provide education to patients and carers regarding expectations of pain and opioid stewardship
Clearly written patient information about the safe use of opioids should be available as leaflets or on websites
Patients and carers should be advised about the dangers and the legal implications of driving while taking opioids for postoperative pain

Policies and guideline issues

Multidisciplinary involvement of anaesthetists, surgeons, pain specialists, pharmacists, nursing staff, physiotherapists, primary care clinicians, hospital management, patients and carers is necessary to translate the recommendations from this consensus statement to local practice
Hospitals should have strategies to mitigate the occurrence of OIVI and standardised order sets automatically linking prescribing, monitoring and interventions

Pharmaceutical companies influencing guidelines; there should be clear separation between opioid manufacturers and the formulation of prescription practice guidelines
Adherence to the ‘Pain is the 5th Vital Sign’ recommendations; opioid analgesia provision should be guided by functional outcomes, rather than unidimensional pain scores alone
Inadequate safe disposal; patients and carers should be advised on safe storage and disposal of unused opioids, and directed to avoid opioid diversion (e.g. sharing with friends and family)
Inadequate recognition and management of patients developing PPOU

Refer surgical patients to pain specialists if still taking postoperative opioids beyond the normal healing period for that surgery and certainly if still taking opioids 90 days after surgery

Research and audit issues

Lack of acknowledgement of regional and national differences in opioid prescribing

Country-specific research is needed to address national and cultural issues around PPOU and OIVI

Research should be undertaken into the optimal strategies required to implement safe opioid stewardship practices

Opioid-related serious adverse events should be routinely audited and investigated

Strategies to reduce risk of persistent post-operative opioid use

Identify patients taking long-term opioids and wean or taper prior to surgery
Identify psychological comorbidities and use psychological interventions to reduce anxiety, depression and catastrophic thinking
Educate patients and carers about expected pain levels, pain management options including non-pharmacological methods, and safe use

Use multi-modal opioid-sparing analgesic strategies to minimise opioid requirements

Use functional outcomes rather than unidimensional pain scores to measure pain
Identify early patients with abnormal pain trajectories as this may signify post-operative complications
Use multi-modal analgesia including non-pharmacological techniques
Avoid initiating long-acting or modified-release formulations
Do not prescribe compound opioids
Ongoing education about analgesia, safe use and non-pharmacological techniques

Quantity of dispensed opioids at discharge directly impacts opioid consumption after surgery
40-94% of opioid tablets prescribed end up being unused which poses risks
Limit duration to 3-5 days, up to 7 days in some circumstances

Educate patients and carers about reducing opioid use first (de-prescribing) when analgesic needs reduce

Educate re: opioid storage and disposal to reduce opioid diversion and accidental overdose

90% fail to dispose of them
50% of adults and 55% of adolescents who misuse opioids obtain them via diversion
Mortality from unintentional overdose has increase three-fold in the past 20yrs

Advise patients of dangers and legal implications of driving while taking prescribed opioids