Why focus on analgesic stewardship?

Analgesics (including opioids and non-opioids) are the most commonly prescribed medicines in hospitals. The harms of opioids are well known, but there is also concern around the inappropriate use of non-opioid analgesics.¹ Opioid use often starts in hospital after surgery,² and can lead to long-term use in some patients.³ Long-term use of opioids for chronic non-cancer pain has limited benefit and is associated with significant unintended harms.^{4, 5}

Alfred Health’s Director of Pharmacy recognised that the hospital’s established Antimicrobial Stewardship Program could be used as a model to improve the use of analgesics.

Professor Michael Dooley, Director of Pharmacy at Alfred Health, Professor of Clinical Pharmacy, Centre for Medicine Use and Safety at Monash University

“The medication safety and antimicrobial stewardship approach has been successful from an organisational perspective, so I wanted to apply the same approaches to other high-risk and commonly used medications – analgesics and anticoagulants. We call it the AAA stewardship program.”

Following a successful stewardship model

The hospital formed a multidisciplinary committee with representatives from medical, pharmacy and nursing staff in specialty areas that commonly use analgesics, as well as staff from emergency, rehabilitation and GP liaison. The clinicians wanted to be involved because of their own experience or awareness of local and external data showing increasing use of, and harm from, analgesics, particularly opioids.

At the time (2016), there was no clinical care standard for analgesics, so the committee used the Antimicrobial Stewardship Program framework to develop the analgesic program and determine what data were needed. The core elements applied from the Antimicrobial Stewardship Program were:⁶

1. Structure and governance, with multidisciplinary, hospital-wide stakeholder engagement
2. Clinician education
3. Monitoring of stewardship outcomes, supported by access to data and feedback to prescribing clinicians
4. Implementation of quality improvement activities and initiatives
5. Involvement of the lead pharmacist in patient-centred clinical care.

The team conducted an initial point-prevalence audit of analgesic use across the organisation to understand trends and identify areas for improvement.

Key measures were:

• The proportion of patients using analgesics before admission, during their stay and at discharge
• The proportion of opioid-naïve patients who were discharged on opioid analgesics, including modified-release opioids (opioid-naïve patients were those who had no opioids dispensed in the preceding 30 days or did not have opioids listed as a home medicine)
• Inclusion of an analgesic weaning plan on discharge
• Quantities of opioids supplied on discharge
• The type of non-opioid analgesics prescribed in hospital and at discharge.

Thuy Bui, Analgesic Stewardship Pharmacist and Lead Pharmacist for Perioperative Services

“The collaborative, multidisciplinary committee reports back to the hospital executive, signalling importance and relevance and creating impetus to make change in the hospital system.”

Drilling down into the data

The initial audit of analgesic use found that:⁶

• About half of all inpatients took analgesics before admission. Paracetamol (95%) and opioids (80%) were the two most commonly prescribed analgesics.
• Three-quarters of opioid-naïve patients were discharged from hospital with opioids, with most also prescribed paracetamol.
• Opioid-naïve patients were most commonly prescribed opioids for inpatient and discharge use.
• Most patients discharged on an opioid received less than 20 tablets of immediate-release opioid.

Following the audit, areas identified for improvement included the need to:

• Improve analgesic use in surgical patients
• Increase use of analgesic weaning plans at discharge
• Decrease concurrent prescribing of two or more regular modified-release opioids
• Increase use of an anti-inflammatory as part of the multi-modal analgesic regimen.

Looking for underlying causes

The multidisciplinary committee discussed challenges around analgesic prescribing across the hospital. Each clinical area was asked to provide insights into those challenges. There was also feedback from the acute pain service and hospital pharmacists.

The team found that barriers to appropriate prescribing included:

• Clinicians (doctors, pharmacists and nurses) had different levels of knowledge about analgesic options to manage pain.
• There was a lack of focused education around appropriate use of analgesics at initiation and discharge.
• Opioid weaning was a low priority due to competing priorities.

Putting the changes in place

The Analgesic Stewardship Program aimed to improve patient outcomes, reduce analgesic-related harm and ensure cost-effective use of analgesics to provide optimal pain management.

While surgical patients were identified as a priority because they made up a significant proportion of opioid-naïve patients discharged on opioids, the principles were applied across the hospital.

Elements of the Analgesic Stewardship Program include:⁶

• Multidisciplinary, hospital-wide stakeholder engagement through an analgesic stewardship committee that reports back to the hospital executive
• Involvement of the lead Analgesic Stewardship Pharmacist in patient-centred care with support from a medical champion
• Clinician and patient education, including guidelines and tailored resources
• Monitoring and reporting, including regular audits, incident review and key performance indicators
• Quality improvement initiatives, including point-of-care interventions, process and outcome measures, and involvement in research.

Appropriate communication with GPs was one of the early aims of the Analgesic Stewardship Program. Although the hospital had already worked to improve timely and quality discharge communications to GPs, the committee added extra detail to the medical discharge summary, including why the patient was on the opioid analgesic, the weaning regimen for the opioid analgesic and quantity supplied at discharge.

Looking at the impact – building on success

The program has achieved:

• Lower quantities of opioids supplied at discharge⁶
• Increased weaning of modified-release opioids if used during the inpatient stay⁷
• Increased inclusion of weaning and cessation plans for modified-release opioids and other analgesics in the medical discharge summaries.⁶

The odds of slow-release opioids being prescribed on discharge after surgery in opioid-naïve patients was halved after the Analgesic Stewardship Pharmacist delivered a brief education session to junior clinicians and pharmacists.⁸ This education is routinely delivered to new intakes of clinicians.

Other outcomes included:

• Better quality discharge information provided to GPs – audit data showed the number of medical discharge summaries that included an analgesic weaning plan increased from 15% in 2016 to 56% in 2017.
• More than three quarters (78%, 152/195) of patients discharged from any surgical unit were at least satisfied with their pain control after one week and 90% (133/148) were satisfied with their pain control four weeks after discharge, according to a patient survey in August 2021.
  
  (A small discharge audit before the Analgesic Stewardship Program found that 93% of 28 patients were at least satisfied with their pain control one week after discharge.)
• Around one in 20 (4.6%) opioid-naïve patients were still on opioids after one month, lower than other studies, which found that 3.9% to 10.5% were still on opioids between 2 and 4 months after discharge.⁹

System benefits

Safer Care Victoria worked with Alfred Health to implement analgesic stewardship programs across the state. Six Victorian health services were allocated a pharmacist to implement an analgesic stewardship program for surgical patients. The program was based on the key elements of the Alfred Health program. Sites tested an analgesic stewardship toolkit, which aligns with the Australian Commission on Safety and Quality in Health Care's Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard.¹⁰

Thuy Bui, Analgesic Stewardship Pharmacist and Lead Pharmacist for Perioperative Services

“The Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard provides the framework for implementing analgesic stewardship in your daily practice. Health services can look at our example to implement the standard. You can start small, at an individual or team level, and progress to an organisation level with support from your executive committees to introduce a program with impacts across the hospital.”