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WHETHER it comes to educating doctors or prescribing to patients, a personalised approach to pain management is the way forward, experts say.
The past 15 years have seen a steep rise in opioid-related dependence and deaths in Australia. Inappropriate prescribing for patients after surgery or trauma without proper de-escalation procedures is one of the ways patients can become exposed to the risk of chronic opioid use.
Which is why finding ways of reducing their introduction to opioid-naïve patients has become extremely important.
Research published in the MJA evaluated whether small group education sessions with junior doctors and pharmacists would reduce analgesia prescribing for surgery patients.
The researchers, led by Ria Hopkins, a Research Fellow at the Centre for Medicine Use and Safety at Monash University and Alfred Health, found that it does.
Junior doctors and clinical pharmacists assigned to surgical units that were randomised to the intervention arm of the cluster randomised controlled trial at the Alfred Hospital in Melbourne were invited to small group education sessions that covered pain management and discharge prescribing. Following the intervention, patients were prescribed slow release opioids less frequently and for those who were prescribed slow release opioids, a de-escalation plan was more often provided.
The key to the success of these sessions was the ability to personalise the message, the authors concluded.
According to Ms Hopkins, the small group size of five or six people meant the attendees could ask questions and really understand the message.
“We also tried to tailor examples to the practice arm that the people attending were in. If we knew that the five attendees were all working in neurosurgery, we could focus on some of the drugs that have seizure risk, for example. The feedback we had was that people wanted more cases and examples presented.”
Personalised education has made a difference to prescribing patterns at St Vincent’s Hospital Sydney, according to anaesthetist and pain specialist, Dr Jennifer Stevens.
Dr Stevens and her colleagues first attempted general education sessions during rounds but it didn’t make a difference to prescribing behaviour. In 2014, they went one step further.
“We got bigger changes in a shorter period by combining individual education with showing each doctor prescribing audit data.”
These data, available at all New South Wales public hospitals, give doctors real-time prescribing rates down to surgical or medical service. In supportive one-on-one sessions, Dr Stevens and her team showed doctors these rates and discussed the guidelines and what doctors in the same team used to prescribe.
As a result, the whole system has been changed.
“We have such good control of prescribing that we don’t need to (conduct education sessions) anymore. The message has changed. That group of junior doctors has grown into our senior doctors,” Dr Stevens told InSight+.
The Alfred Hospital research shows that education doesn’t necessarily have to be one-on-one to be successful. Small, yet personalised group education sessions and sharing general prescribing data can make a difference.
Ms Hopkins said that one piece of data they shared was that some people were being prescribed slow release opioids in the first instance before other pain medications had been tried.
“One of the things we observed was people were on slow release opioids and nothing else. As-needed opioids and paracetamol hadn’t been tried,” Ms Hopkins said.
Slow-release opioids are not recommended for use in the management of patients with acute pain and the Australian and New Zealand College of Anaesthetists has released a position statement outlining this fact.
The key message the researchers conveyed in the education sessions wasn’t about avoiding prescribing opioids at all. It was about thinking about what was best for each individual patient.
“It’s about taking an extra 5 minutes to think what exactly is needed,” Ms Hopkins said.
In some cases, the best thing could be reducing the opioid pack size so there aren’t any pills left over.
According to Associate Professor Suzanne Nielsen, Deputy Director of the Monash Addiction Research Centre, sometimes patients are prescribed extra opioids “just in case”, which can lead to issues.
“What tends to happen is that people are getting leftover opioids after these kinds of interventions. That is really important because we know that when opioids are used non-medically and when people are experiencing harm from opioids they often come from these leftover opioids.”
In many instances, prescribing opioids is necessary, but there needs to be a better plan for de-escalation.
Ms Hopkins urged clinicians to be thinking a few steps ahead.
“Is there a plan in place for when this medication could be ceased? Make sure that plan is communicated. Is the patient aware of it, is the GP aware of it?”
Communicating with patients about the level of pain could be another important factor in reducing opioids misuse.
According to Associate Professor Nielsen, even the term “painkiller” sets up unrealistic expectations.
“It sets an expectation that all pain should be able to be alleviated. Sometimes that’s not possible and it sets patients up for disappointment.”
It’s going to be particularly important communicating this in the next 20 years or so as the baby boomer population ages and experiences increased chronic and musculoskeletal pain, according to Professor Michael Farrell, Director of the National Drug and Alcohol Research Centre.
“The post-war cohort are more amenable to taking medication than the previous generation,” he said. “Having good management of that is going to be a significant challenge.”
All experts in the field are at pains to highlight that research like this isn’t about reducing overall opioid use, particularly in groups where they are providing great benefit.
“When you start to use words like reducing opioid prescribing, it can cause a lot of distress and fear,” said Ms Hopkins. “If you are someone with chronic pain who is already using opioids, this research isn’t talking about you.”
Professor Farrell agreed.
“We also don’t want people who are reasonably stable … to be suddenly switched off without being properly managed. That’s one of the issues that happened in the United States. They switched a lot of people off without individualised planning and care management.”
Anaesthetists do prescribe immediate post-op analgesia, but ongoing analgesic requirements vary significantly between patients and are best titrated following regular review on the ward, then again prior to discharge. Thus, unless the anaesthetist is reviewing the patient regularly on the ward with respect to their post-operative analgesia, they cannot provide a discharge plan. In public hospitals, anaesthetists do not have capacity to do this; however, there is usually an Acute Pain Service (APS, consisting of anaesthetists, among others) that takes on this role, i.e. review patients of a higher complexity (or upon request by surgical teams) regularly on the ward until discharge, or until analgesic requirements are simplified.
Patients who do not require APS input have their discharge medications prescribed by the team who reviews them regularly until discharge, i.e. the home team. By definition these patients should not be requiring high doses of opioids or for long durations.
Medications, in general, should always be reviewed by doctors who continue them, not only by doctors who initiate them. Indications and dosage requirements may change over time, and doctors who continue medications in the absence of continuing indications should rightly be questioned as to whether they are appropriately discharging their duty to the patient.
Post operative analgesics are initiated by anaesthesists not junior doctors.
Any opioids (including intermediate or long acting formulation, and combination drugs like oxycodone with naloxone) as well as gabapentinoids what are prescribed by anaesthesists as part of post procedural management, whether the patient is naive to it or not, should have been clearly managed by the anaesthetic team including clearly written discharge plan; it should not be left to be managed by JMOs.
While the Alfred Hospital experience may empower junior doctors on surgical team to be more involved with detailed personalised planning with de-escalation of opioid use, this should not necessary mean the responsibility of managing opioid treatment initiated by anaesthesists can or should be delegated to junior doctors not under their regular supervision. Neither should it be expected that primary care providers be burdened with similar responsibility.
Opioid prescription without clear exit plan is not the only drug problem relating to inadequate handover of responsibilities and boundaries; other issues including initiation of anticoagulation treatment have similar risks of poor outcome when continuity of care fails as many medico-legal cautionary tales have shown.
By making it clear that the doctors who initiated the treatment are also responsible for prescribing (and communicating) the plan to de-escalate the dosing regimen, then more careful considerations are made by the original prescriber including appropriateness of duration, thereby reducing medication misadventures and drug dependence as practical as possible.