Smaller oxycodone pack sizes and an enhanced role for pharmacists are part of a model being suggested by Melbourne researchers

Dr Megan Allen and colleagues from the Royal Melbourne Hospital investigated how a group of surgery patients used opioids including oxycodone following discharge from four Melbourne hospitals, and found that two-thirds had stopped using their opioids before using up the pack, but hadn’t thrown the remainder away.

Suggestions arising from the research include the possibility of reducing the amount of oxycodone dispensed on discharge – with a number of caveats.

“For an eight-week study period, we approached surgical patients staying at least one night after surgery – that was to exclude really minor day surgery, as you’re more likely to get opioids if the magnitude of the surgery meant you needed to stay a night,” Dr Allen told the AJP.

Of 1450 patients on whom the researchers had discharge information, 1245 agreed to be followed up two weeks after discharge, and 581 met the inclusion criteria: they had surgery, had stayed a night, were contactable or alive at two weeks and had had opioids dispensed to them when they left the hospital.

The research is yet unpublished but the findings were presented by Dr Allen at the recent Annual Scientific Meeting of the Australian and New Zealand College of Anaesthetists.

“The first thing we found was that 60% of patients who had surgery and stayed more than one night had opioids dispensed at the time they left hospital,” Dr Allen says. “This tells us that it’s common that opioids are used after acute surgery.”

After telephoning the patients two weeks after discharge, the researchers found high variability in the actual use of the medicines.

“One quarter of patients were still taking their opioids at the two-week follow-up,” Dr Allen says. “But two-thirds had stopped taking their opioids.”

Most – 88% – of these patients said they still had the medicines and were not storing them in a locked container; in the next phase of the research this question will be refined to enquire about whether the container is out of reach of children, rather than necessarily locked.

“Only 9% reported receiving any disposal instructions when they left the hospital,” Dr Allen says.

“Only 5% of patients who had ceased their opioids had gone and actively disposed of them. They went in the household garbage in 12 patients, the sink or toilet in four and only one patient returned theirs to a pharmacy.”

Of the total patients eligible and followed up, another 24% took all their opioids and required more.

Targeted prescribing

“This tells us that we need to be a little more targeted with our prescribing,” Dr Allen says. “While the patient use is highly variable, prescribing looks to be fairly standardised – and over 98% of these prescriptions were written by junior doctors. A good proportion of patients probably need less than were prescribed, and some needed more.”

The researchers plan to roll out a multi-faceted opioids stewardship intervention, across the four study hospitals – the Royal Melbourne, the Western Hospital, the Royal Women’s Hospital and the Peter MacCallum Cancer Centre.

The first draft intervention will look at prescribing 12 oxycodone tablets in appropriate routine cases, rather than 20.

“There’ll be an important caveat to that: it’s unless advised otherwise by acute, chronic or palliative care services,” Dr Allen told the AJP.

“Along with a reduction in opioid prescribing there’s going to be a prompt to co-prescribe adjunct paracetamol or anti-inflammatories, unless there’s a specific patient contraindication.

“So we’re not aiming at restricting opioids per se, but at improving patient pain management and being more targeted.

“The 20 was excessive,” Dr Allen says. “We actually had 35 patients use none, or less than five pills. So while there is a group who need more, and 12 will also be excessive for some patients, overall it’s better than a box of 20 sitting there in the cupboard.”

As it stood 47% of the patients had reported having at least one episode of severe pain post-discharge.

The plan will include enhanced communication with GPs as the community prescribers as well as support for GPs in terms of communicating the intent when prescribing opioids for acute pain in hospitals.

“There’ll also be better engagement with our pharmacy colleagues, such as improved discharge counselling,” Dr Allen says.

“I see that as a really core role of the ward pharmacists. We’re looking at getting them involved in documentation and assessment of pain and communicating that to GPs, and also providing, in addition to verbal counselling, very simple handouts across opioids in the community.

“We appreciate that there’s going to be splitting box supply issues and we know it’s increased work, but there’s real appreciation that we need to partner and collaborate with all the health care professionals. We can’t be too siloed in our approach.”

Meanwhile, she encourages community pharmacists to let patients know that they can return unwanted medicines at the pharmacies.

“We hope that through these initiatives, there’ll be more patients coming into community pharmacy to do this,” Dr Allen says.

“They can also query patients who are getting opioid scripts, particularly repeated prescriptions, about the nature of their pain and whether they’ve had an appropriate review and follow-up for that. We do know that there’s a small percentage of patients who will transition from acute pan to chronic opioid therapy, so the community pharmacist could query patients on their stage of therapy and whether they’re having any interventions to reduce their opioid therapy.”