Quality statement 9 - Transfer of care

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.

Plan for appropriate opioid analgesic use at the transfer of care when a patient is first prescribed, supplied or administered an opioid analgesic for acute pain during their hospital visit/stay. Follow an opioid analgesic weaning and cessation protocol to start weaning and cessation of opioid analgesics during their hospital stay/visit guided by assessing the patient’s functional activity and pain scores. As part of the medication management plan provided to the patient, their carer and the patient’s general practitioner on discharge, the weaning and cessation plan for opioid analgesics should include:

• The appropriate formulation of an opioid analgesic to provide or prescribe
• The appropriate oral morphine-equivalent daily dose (oMEDD) on discharge, which is based on the total oMEDD given in the last 24 hours before discharge
• For patients discharged from day surgery, the appropriate opioid analgesic number of days’ supply based on the expected trajectory of the patient’s condition
• The appropriate opioid analgesic number of days’ supply, considering the day of discharge and when the patient can reasonably be expected to access primary care and other healthcare services post-discharge
• Identification of the patient who already has opioid analgesics in their possession that may adequately treat their acute pain and does not require additional prescription on hospital discharge, and advice on the appropriate use of those opioid analgesics
• Identification of the patient’s general practitioner who will continue the patient’s care after leaving hospital. If this is not possible, develop a plan to assist the patient access health care after discharge.

Provide the patient with written information on discharge that addresses:

• How many times a day to take, use or apply the opioid analgesic, and if it should be taken with food
• Whether the opioid analgesic will affect other medicines they use
• What the adverse effects are and how to manage them
• When to seek urgent care for adverse effects of the opioid analgesic or lack of pain relief
• How to reduce the opioid analgesic, to allow the patient to stop taking the opioid analgesic (weaning and cessation plan)
• How to safely store and dispose of the opioid analgesic.

If a patient is discharged from ED with an opioid analgesic, the quantity supplied may be for up to a maximum of three days’ treatment.

If a hospital inpatient is discharged with an opioid analgesic, the quantity may be for up to a maximum of seven days’ treatment to reduce and stop the medicine.

For patients who live in locations with limited access to prescribers and pharmacies, consider their individual circumstances and expected course of their condition, and provide an appropriate quantity of opioid analgesics that provides analgesia and mitigates the risk of opioid-related harm after discharge.

Ensure a locally approved policy is in place to support transfer of care of patients discharged from hospital with a supply or prescription for opioid analgesics.

Ensure an opioid analgesic discharge weaning and cessation protocol is available to clinicians and used for patients who are prescribed, supplied or administered an opioid analgesic for acute pain during their hospital stay. The protocol should address the cessation or weaning of opioid analgesics started in hospital and provided or prescribed over more than 24 hours. On hospital discharge, the protocol should outline the elements of a weaning and cessation plan that includes:

• The selection of an appropriate formulation of an opioid analgesic
• For patients in hospital for more than a day, the selection of an opioid analgesic dose on discharge that is based on use in the last 24 hours before discharge, using an oMEDD
• For patients discharged from day surgery, the selection of an appropriate opioid analgesic appropriate dose based on the expected trajectory of the patient’s condition
• An appropriate supply of opioids, considering the day of discharge and when the patient can reasonably be expected to access primary care and other healthcare services post-discharge
• Processes to identify patients who already have opioid analgesics in their possession that may adequately treat their acute pain and do not require an additional prescription on hospital discharge, and to advise them on the appropriate use of those analgesics
• Prompt communication of a clinical handover summary to the patient’s general practitioner that includes
  • the cause of the pain for which the opioid analgesic was prescribed
  • the opioid analgesic dose prescribed or recommended on discharge (which will differ to the inpatient dose)
  • a medication management plan that includes recommendations for reducing and ceasing the opioid analgesic where appropriate
• Provision of written patient information that addresses
  • how many times a day to take, use or apply the medicine, and if the medicine should be taken with food
  • whether the medicine may affect other medicines
  • what the potential adverse effects are and how to manage them
  • when to seek urgent care for adverse effects of the medicine or lack of pain relief
  • details of how to reduce the medicine and stop the medicine (weaning and cessation plan)
  • how to safely store and dispose of the medicine.

Ensure processes are in place to identify the patient’s general practitioner who will continue the patient’s care after leaving hospital. If this is not possible, ensure processes are in place to assist the patient access health care after discharge.

Ensure processes are in place to reduce and stop the opioid analgesic by allowing up to a maximum of:

• Three days’ opioid analgesic supply to patients discharged from the ED
• Seven days’ opioid analgesic supply for patients discharged following a hospital stay.

These processes should allow for exceptions such as the patient’s ability to access services in the community and comorbidities.

Clinician resources

• SA Health. Clinical Guideline for Prescribing Opioids on Discharge
• WA Health. Recommendations for Prescribing Analgesia on Discharge Following Surgery or Acute Injury: Information for health practitioners preparing the patient for discharge
• Society of Hospital Pharmacists of Australia. Take-Home Naloxone in Australian Hospitals

Consumer resources

• Clinical Excellence Commission NSW. Managing Side Effects of Opioid Medicines in Hospital: Information for patients, families and carers
• Choosing Wisely. Patient Guide to Managing Pain and Opioid Medicines
• Alfred Health. Managing Your Pain After Leaving Hospital
• SA Health. Oxycodone For Short-Term Management of Acute Pain
• SA Health. Information for Paediatric Patients, and Their Carer, Given Opioids for Short-Term Treatment of Acute Pain
• SA Health. Going Home After Having Been Given a Medicine That Can Make You Sleepy
• WA Health. Pain Relief Medications Following Surgery and Injury: Information for patients preparing for discharge
• TGA. Return Your Unused Opioids – Resource Kit
• Pharmaceutical Society of Australia. Opioid Medicines Fact Sheet for Patients, Families and Carers