Thread by @GongGasGirl

Opioid Stewardship in Acute Pain.

Luke Murtagh Canberra Hospital.

#ACE22TAS

Luke acknowledges the theme of our conference which is to be optimistic; glass half full; but there are also many issues we need to speak frankly about. #ACE22TAS

Notes that we should all read this document, #ACE22TAS.

2.5 million Australians have an operation annually.
4% will go on to develop chronic use.
100,000 people per year are at risk of becoming chronic users.

#ACE22TAS

Significant harm associate with over reliance on opioid analgesics for acute pain.

Nausea and vomiting. Itch. Drowsy. Respiratory. Hyperalgesia. Tolerance. Dependence. Unintended overdose. Harm from unsafe storage. Stigma.
#ACE22TAS

Clinical Care Standard let to an opioid stewardship program with quality care statements.

Implications for patients, clinicians, health services.

Developed by an expert multidisciplinary panel.

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Recommends watching you can't ask that - prescription drug use - on abc iview.

Really challenging themes for us from the community point of view.

#ACE22TAS

iview.abc.net.au/show/you-can-t…

CCS Quality Statements:

Patient information and shared decision making.
Acute pain assessment.
Risk-benefit analysis.

#ACE22TAS

safetyandquality.gov.au/publications-a…

Do pain scores do more harm than good?

Does asking about pain give a nocebo effect? But the trend is useful.

#ACE22TAS

(Messaging around opioids have absolute changed since my training. For me, we were trained that if still have pain, need to keep upping the dose. Now the emphasis is on the minimum amount needed, shared decision making, pros and cons of options).

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Does not recommend prescribing slow release opioids in acute pain as it's not clear what dose each patient will need. Better to give short acting and titrate to individual.

#ACE22TAS

(BTW This acute pain talk has many parallels to @ATraumaTick's talk previously about trauma - most improvement in our health will come from better systems and working in organised teams ... collecting and acting on data...doctor as solo expert is not a thing anymore).

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Pre-operative opioid reduction occurring in some places. Data coming.

This is a novel concept for me - 'pre-hab' for those on chronic opioids before their operation.

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Recommends that doctors register for real time script monitoring such as SafeScript.

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Opioid Analgesic Stewardship in Acute Pain Clinical Care Standards. April 2022.

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safetyandquality.gov.au/publications-a…

Quite difficult in practice to work out how much to chart an individual pt to be effective, but not too much.

Doesn't believe that SR opioids should be used acutely. Issue is variability between individuals. Use prn.

Notes @ANZCA statement.

anzca.edu.au/getattachment/…

#ACE22TAS

Notes shortage of pain specialists...

Difficulty for some to complete @ANZCA_FPM fellowship which takes two years after primary specialty. (There are some whispers about turning pain into a primary fellowship to address this in the future).

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Did you hear that audible gasp from me?

LM says tramadol is his first line opioid.

Feels is safer than others.

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Shout out to the @ANZCA_FPM opioid calculator.

#ACE22TAS

apps.apple.com/au/app/opioid-…

LM actively transitions away from opioids using agents such as nortriptiline (low dose in elderly) in a shared decision making framework as part of the pain teams work.

Ketamine, clonidine are other options.

#ACE22TAS

Emphasis on handover of care to GP / home teams as necessary with appropriate written and verbal communication on discharge.

#ACE22TAS

A note about tapentadol SR. Approved TGA Australia 2009. Evidence to suggest that it is as effective for acute pain than oxycodone IR with fewer side effects.

Difficulty with price ($0.04 tramadol IR vs $0.97 for tapentadol IR), private scripts, variable access.

#ACE22TAS

LM's usual for acute pain in 2022:

Tramadol IR as first line.
Add oxycodone IR if not controlled.
(If no access issues, tapentadol IR first line).

#ACE22TAS

What should we chart in Acute pain?

Many different guidelines:

LM’s suggestion for optimal dosing opioids. A little different to Shug / MacIntyre Acute Pain Management. And other from WA …

(Clearly look all these up yourselves, do what your place suggests).

#ACE22TAS

There are many difficulties in opioid prescribing.

For me, I’m constantly amazed re how different the response is with different people: so much variability.

#ACE22TAS

Very sage advice LM, #ACE22TAS.

Opioid stewardship is all our responsibility.

Future issues:

But can we develop national guidelines?
Can we add tapentadol IR to PBS?
Restrict SR drugs?
Develop novel drugs?
Optimise patients with long acute pathologies?

#ACE22TAS

Shout out to @ANZCA 20 September Webinar Updates in Opioid Stewardship:

anzca.edu.au/events-courses…

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Just as another pain point in case some are not aware:

This comprehensive practical resource - acute pain management the scientific evidence fifth edition - is available as a free download for everyone:

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anzca.edu.au/news/top-news/…