Information for consumers - Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard

What the standard says 

The nonpharmacological and pharmacological options for managing acute pain are discussed with a patient and their carer in a way that they can understand, and that leads to a shared understanding of the decision to use an opioid analgesic or other treatment(s).

What this means for you

Acute pain is pain that lasts for a few moments, days or weeks. If you have acute pain, your clinician will explain your treatment options. These may include medicines and other treatments. The aim of these medicines and other treatments is to reduce your pain levels to allow you to undertake your regular day-to-day activities. They may not take away all your pain.

Your clinician will explain the possible benefits and harms (the good and bad things that might happen) of the different options. This can help you and your clinician decide how to manage your pain.

Opioid analgesic medicines (pain relief medicines commonly known as opioids) are one option, but they can have serious adverse effects. Your clinician may suggest trying other options first. Other options include non-opioid medicines, and other treatments such as heat packs, ice packs, exercise or physiotherapy. You and your clinician might decide that a combination of two or more treatments is best for you.

If you decide on a medicine, your clinician will give you instructions about what you need to do, especially if you will use the medicine after leaving hospital. It is important that you follow these instructions correctly to get the most benefit.

Talk to your clinician if you are not sure what to do, or if you have questions about:

• How many times a day to take the medicine and if the medicine should be taken with food
• Whether the medicine will affect other medicines you use
• What the adverse effects are and how to manage them.

If you are prescribed an opioid, only use the medicine for the reason it is prescribed, and do not give this medicine to other people, such as friends and family. Opioid analgesic medicines can make you sleepy. If you are prescribed an opioid analgesic do not drink alcohol or drive. Check with your clinician about what other medicines you can safely take, including sleep medicines, so you don’t have any negative interactions with the opioid medicine.

What the standard says 

Analgesic prescribing for a patient with acute pain is guided by its expected severity and assessment of patient-reported pain intensity and the impact of pain on the patient’s function.

What this means for you

Being in acute pain can interfere with your ability to participate in your regular day-to-day activities. It is important for your clinician to understand how your acute pain is affecting your ability to function, as well as how much pain you are feeling. This can help them to provide the most appropriate treatment. The treatment may not completely stop your pain. The aim of treatment is to reduce your pain to a level that allows you to return to your regular day-to-day activities.

Your clinician will ask you questions about how your pain is interfering with your ability to function normally and carry out activities. They may also ask you questions about how you are coping with your pain. For example, whether the pain is affecting your sleep, or your ability to carry out regular activities. There are several measurement tools to score your pain and your function, and your clinician will use the ones that best suit your needs when they assess your acute pain.

What the standard says 

Whenever an opioid analgesic is considered for a patient with acute pain, their risk of opioid-related harm is assessed. An opioid analgesic may be prescribed when other analgesics are not clinically feasible or sufficient, and the potential benefits outweigh the potential harms.

What this means for you

If you have acute pain and might benefit from an opioid analgesic medicine, your clinician will ask questions to consider the benefits for you and to check your risk of harm from using these medicines. They will ask what pain medicines you are already taking or have used before. Sometimes an opioid analgesic may not be prescribed, because it is not the best medicine to treat your acute pain or there is a possibility of serious harm from the medicine. Opioid-related harm ranges from less serious effects such as nausea and vomiting, itchiness and constipation, through to severe problems such as an inability to stay awake or difficulty in breathing, which may be life-threatening. Long-term harms include dependence and addiction.

Before a surgical procedure, your clinician will ask you questions to determine your risk of harm if opioid analgesics are prescribed after your surgery. Some medicines increase the risk of side effects of opioid analgesics. It may be necessary for you and your clinician to consider reducing or stopping these medicines if opioid analgesics may be required.

If your surgery is planned (elective) and you are already taking opioid analgesics, your clinician may advise reducing your opioid analgesic dose in the lead up to the surgery. This can improve your recovery and increase the options available for managing your pain after surgery.

What the standard says 

A patient with acute pain prescribed an opioid analgesic who is at increased risk of opioid-related harm is appropriately managed in conjunction with a locally approved pathway to mitigate the potential for harm.

What this means for you

If your clinician has identified you as having an increased risk of harm from opioid analgesics, your clinician may refer you to other hospital-based support services. These may include specialist services for children and adolescents, pain management, drug and alcohol, clinical pharmacy and allied health to help manage your acute pain and the risk of possible harm.

What the standard says 

If an opioid analgesic is considered appropriate for an opioid-naïve patient with acute pain, use an immediate-release formulation at the lowest appropriate dose, for a limited duration, and prescribe in line with best practice guidelines. Modified-release opioid analgesics cannot be safely or rapidly titrated and their use in acute pain should be exceptional and not routine. The patient is supported to cease any opioid analgesic use as their function and pain improve.

What this means for you

If you are prescribed an opioid analgesic medicine for acute pain, your clinician will prescribe the lowest dose needed to reduce your pain. The dose will be in line with accepted guidelines.

Taking opioid analgesic medicines for longer than required to manage your acute pain can lead to the medicine becoming less effective and cause harm. Your clinician will discuss with you how to reduce your use of opioid analgesic medicine. As a first step, this might include reducing the dose while you continue to use other medicines to manage your pain. For example, your clinician might advise taking paracetamol and anti-inflammatories while reducing the dose of the opioid analgesic for acute pain. Treatments such as heat packs, ice packs, exercise and physiotherapy may also be recommended to manage your pain.

As your pain and function improve, it may be appropriate to stop using, or change how you use the opioid analgesic medicine. For example, in hospital, changing from an injection or an infusion into the bloodstream through one of your veins to a medicine you take by mouth, or by reducing the dose and how often you take the medicine. In some cases, you can just stop the medicine as your pain improves. Your clinician will talk to you about how long you will need to take this medicine after you leave hospital.

What the standard says 

When an opioid analgesic is prescribed, supplied or administered for a patient with acute pain, adverse effects are monitored and managed. The patient and carer are made aware of potential adverse effects and signs of overdose, including respiratory depression.

What this means for you

If you are prescribed or given an opioid analgesic for acute pain, your clinician should regularly check for harmful effects and adjust your treatment when necessary. Harmful effects from opioid analgesics include nausea, constipation, itchiness, drowsiness and slowed breathing.

Your clinician will monitor adverse effects by regularly checking your breathing, how drowsy you are and how often you are going to the toilet.

Opioid analgesics can sometimes slow down your breathing to dangerously low levels. Becoming very sleepy after having an opioid analgesic can be a sign your breathing is too slow. When you first start an opioid analgesic, starting with a smaller dose will reduce drowsiness, have less effects on your breathing, and be safer for you. If you do become very sleepy after taking your opioid analgesic medicine, do not take any more opioid analgesics unless you are completely awake. Your clinician will monitor your breathing and adjust your treatment if necessary, such as lowering the dose. Talk to your clinician if you have concerns about sleepiness or your breathing.

Your clinician will prescribe laxatives to prevent or treat constipation. If required your clinician will prescribe appropriate treatments for nausea and vomiting, or itchiness.

What the standard says 

When a patient with acute pain is prescribed, supplied or administered an opioid analgesic, the intended duration of therapy, and the review and referral plan are documented in the patient’s healthcare record. The cause of the pain for which the opioid analgesic is prescribed is documented, including on the inpatient prescription.

What this means for you

Your healthcare record contains information about your opioid analgesic therapy. This includes information on:

• The medicine (active ingredient/s) and dose you have been prescribed
• The cause of the pain for which the opioid analgesic is prescribed
• How long to use them for
• The plan to review your opioid analgesic treatment
• The plan to reduce the opioid analgesic medication, to allow you to stop taking the medicine.

Information in your healthcare record can help different clinicians involved in your care to understand why an opioid analgesic has been prescribed and the plan for your care.

What the standard says 

During hospital care, a patient prescribed an opioid analgesic for acute pain is assessed regularly to determine their response to therapy and whether an opioid analgesic is effective and appropriate for their stage of care.

What this means for you

If you are prescribed an opioid analgesic while in hospital, your clinicians should regularly check that you still need the medicine, that the medicine is helping your pain and that it is the best medicine for you. Your pain and ability to function will be regularly checked, and the amount of opioid analgesic you take will be reduced as your condition improves and your need for pain relief decreases.

If your pain does not improve when you take an opioid analgesic your clinician may change your medicine or refer you to other hospital-based support services. These may include specialist services for children and adolescents, pain management, drug and alcohol, clinical pharmacy, and allied health such as physiotherapy.

What the standard says 

Planning for appropriate analgesic use at the transfer of care begins when a patient is started on an opioid analgesic during their hospital visit, according to an agreed opioid analgesic weaning and cessation protocol. The number of days’ supply of an opioid analgesic on discharge is based on multiple factors, including the expected course of the patient’s condition, appropriate arrangements for follow-up and opioid analgesic use in the last 24 hours before discharge.

What this means for you

It is important that you know how to safely manage your pain when you leave hospital. Not everyone who receives opioid analgesics while in hospital will need to take them when they leave. In some cases, the pain can be managed with other medicines or techniques.

If an opioid analgesic is prescribed for you, the dose will help you to manage your pain and get back to your regular day-to-day activities. The amount you receive will be based on several things. Your clinician will consider your expected recovery along with the amount of pain relief you needed while you were in hospital. You should be advised to reduce your dose of opioid analgesic as your pain and ability to function improve.

The amount of opioid analgesic medicine you receive will be individualised to your needs. To reduce the risk of harm, there are limits on the amounts of opioid analgesics hospitals can provide:

• If you are seen in the emergency department (ED), the most that can be supplied is three days of treatment
• If you have been admitted to hospital, the amount of opioid analgesics you are given will be based on your pain relief needs in the last 24 hours you were in hospital. The most that can be supplied is seven days of treatment.

The aim is to help with your pain and give you time to visit your general practitioner where your care will be reviewed.

If you leave hospital on a weekend, live far from medical support or if your pain is expected to continue for longer, your clinician will talk to you when you are leaving hospital about the appropriate amount of opioid analgesic for your circumstances.

To ensure your care is continued, you will be advised to consult your general practitioner for follow-up after you leave hospital. If you do not have a general practitioner, your clinician will advise you on how to access care after you leave hospital.

You will be given a medication management plan describing why you were prescribed the opioid analgesic and how to reduce and stop taking this medicine. The plan to reduce and stop your opioid analgesic will be provided to your general practitioner. This is to make sure that you use these medicines for as short a time as possible, as long-term use of opioid analgesics can cause serious health and social issues. The medication management plan will include information on:

• How many times a day to take, use or apply the medicine, and if the medicine should be taken with food
• Whether the medicine will affect other medicines you use
• What the potential adverse effects are and how to manage them
• When to seek urgent care for adverse effects of the medicine or if the medicine is not helping with the pain
• How to reduce the medicine, to allow you to stop taking the medicine (weaning and cessation plan)
• How to safely store and dispose of the medicine.

If you already have opioid analgesics at home that can treat your acute pain, you may not be prescribed additional opioid analgesics when you leave hospital.

Your clinician will ask you for the details of your general practitioner to ensure your care is continued when you leave hospital. Information will be provided to them about the care you received in hospital, including the medicines you received in hospital and when you left hospital.