The opioid trap


prescription pad doctor

How many people fall into addiction after getting a script from their doctor, and what role does the ED play?

University of Sydney pharmacist researcher Dr Jonathan Penm recently conducted research evaluating the use of opioids in emergency departments (ED) in Ohio, US.

In his talk at Medicines Management Conference last weekend in Sydney, Dr Penm explained that US doctors prescribe about five times the amount of opioids than they do in Australia, “so they’re much more likely to overdose”.

Ohio has the third highest rate of opioid overdose deaths in the country.

Dr Penm’s research found that ED doctors were providing similar number of opioids scripts as orthopaedic surgeons.

“There’s a lot of clinical inertia, not started by the ED but continued by the ED,” said Dr Penm.

About 60% of people with opioid use disorder were found to have got it from a doctor, and 30% of these were from the ED.

Dr Penm’s survey of hospital directors/CEOs found that 75% had an opioid prescribing policy in ED.

Despite this, about 40% of ED doctors were prescribing opioid supply to last more than three days.

“If your ED does not [have a guideline] then it’s something to think about,” Dr Penm suggested to delegates. “And you might want to increase patient involvement in the very beginning.”

Across the Pacific Ocean…

While Australia has not reached US “opioid crisis” levels just yet, the numbers of scripts are still cause for alarm.

“Australia is not quite in the same boat just yet but prescriptions are increasing here too,” said fellow speaker Benita Suckling, a senior pharmacist with Queensland Health.

She said areas around her hospital provides on average 76,000 opioid scripts annually per 100,000 people, with nearby Bribie Island having the highest rate of prescribing in the state, according to Atlas of Healthcare data.

“There is no doubt that shifting prescribing from hospitals will help turn the tide on this trend.”

Ms Suckling was part of a team that trialled a hospital-based, pharmacist-led opioid stewardship service.

“The first and most surprising problem was a run of patients early in follow up who had misunderstood their medication plan,” she said.

And in outpatient follow up, they found patients don’t always follow through with discharge plans, or misunderstand instructions.

Of 207 opioid prescriptions collected from ED in a month, a “really frightening” amount were codeine, said Ms Suckling.

A breakdown of the stats revealed the most commonly prescribed drugs were: oxycodone (49%), codeine (26%), paracetamol/codeine (17%), tramadol (4%) and morphine (1%) among others.

Amy Minett from Illawarra Shoalhaven Local Health District in NSW, who held a poster session at Medicines Management conference, shared some statistics about amounts of opioids being prescribed.

Her research revealed 91% of patients who received discharge analgesia received opioids; 42% of these received ≥ 2 opioids.

“We know opioids can cause harm, and with increasing opioid prescribing, risk of divergence and misuse in the community also rises,” said Ms Minett.

A second hospital-based review

Another review of opioid supply on hospital discharge in Victoria found the most commonly prescribed opioid was immediate release oxycodone (85.2%).

Puji Faitna, a pharmacist at University Hospital Geelong in Victoria who was involved in the review, also shared results of an email survey sent to GPs and junior hospital prescribers, aiming to assess attitudes towards opioid discharge prescribing.

Of the hospital prescribers, 39% answered they “never” write a pain management plan.

Not one said they “always” write a pain management plan.

And how often did GPs perceive patients seeking further supply of opioids?

“Every GP has had this happen to them in their practice, with 50% responding that this happens to them ‘frequently’ or ‘very frequently’.”

Seventy-four percent felt there was a delay in receiving discharge summaries from hospitals.

And 71% did not feel they received adequate communication regarding pain management plan on discharge summaries.

“The systems involved in the delivery of opioids play a major role in overprescribing,” said Ms Faitna.

“The literature tells us that compliance with guidelines varies greatly. There is a need for specific training on appropriate supply of opioids on discharge from hospitals.”

The Queensland Health trial has seen some early successes, with the average number of oxycodone tablets per discharge trending down.

“We’re still collecting more data and research but we’re already pleased with the results that we’ve seen,” said Ms Suckling.

Her message is to collaborate with other teams.

“Implementation of this service has revealed ways to do more about opioid prescribing in the future.”

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