A Choosing Wisely approach to improve opioid prescribing
Opioids continue to be the primary drug associated with drug-related deaths in Australia with prescription opioids constituting the majority of unintentional deaths due to opioids since 2004. The Sunshine Coast Hospital and Health Service has applied a Choosing Wisely approach in the Emergency Department to address the problem.
An opioid-naïve person may be at risk of becoming a chronic user when prescribed an opioid, with the risk increasing with the length of the initial use. With around 80% of people using opioids for longer than 3 months experiencing at least one adverse effect from the medicine, ranging from mild to severe and even fatal, it is important to reduce the risk of chronic use.
Patients discharged from our Emergency Department are sometimes prescribed an opioid to manage acute pain – often immediate release oxycodone. A review pointed to Choosing Wisely principles that we could apply to the Emergency Department and we created a program with ambitious targets to educate prescribers, improve clinical handover and educate patients to improve opioid stewardship at our health service.
- Educate prescribers: 90% of immediate release oxycodone scripts supplied at discharge should be for 10 or fewer tablets. Many prescriptions supplied at discharge were for 20 tablets which is much more than needed in most cases. Tablets that are prescribed and not used directly after discharge pose a risk as they could be redirected to inappropriate use.
- Improve clinical handover: 90% of clinical handover letters to GPs should contain information about the opioid prescribed. Many clinical handover letters did not provide any information or only indicated ‘analgesia provided’. The GP needs to have comprehensive information as they will be the one caring for the patient going forward. Best practice clinical handover should also include the number of tablets to be taken and the timeframe, as well as detailing the de-escalation plan.
- Educate patients: 90% of patients should be provided an education handout. This will trigger an informed discussion aligned with Choosing Wisely principles about the risks as well as potential benefits of opioids for acute pain, and set patient expectations around pain relief, possible side effects and that the opioid should only be used for a short period of time.
Consumers are always involved in the process of designing our programs and developing our resources, making sure we are asking the right questions and creating programs that meet their needs. As part of our opioid stewardship program, to support prescriber education we created a video to inform staff about the program and incorporated it into medical officer orientation training. We created a template for the discharge letter to the GP to support clinical handover, and we created a patient education pamphlet . These resources could be valuable for other organisations for their work around opioids.
We set challenging goals, and we are proud to say that we beat them! We now regularly have weeks with over 90% of prescriptions for 10 or fewer tablets, representing a statistically significant improvement. While we have reduced the total amount of immediate release oxycodone prescribed by decreasing the amount per prescription, we did not see a decrease in the number of prescriptions. Clinicians are still prescribing immediate release oxycodone when required, but are matching the number of tablets they prescribe with the number needed.
The program is in mid-flight, and we are working to see improvements towards the other program goals of improving clinical handover and patient education. Although we have yet to see improvements in the information provided in clinical handover letters, we expect this to improve once we make the template letters easily accessible in our clinical information system. We have only just finalised our patient education handout and expect this will support us having important conversations with our patients.
The Sunshine Coast Hospital and Health Service is excited to continue its Choosing Wisely journey and is working hard to roll out more initiatives reducing low-value care.
The NPS MedicineWise educational program Opioids, chronic pain and the bigger picture provides important information and resources for health professionals and consumers on the role of opioids in the management of chronic non-cancer pain, including information on the tapering of opioids and on having conversations with patients about opioids. The Choosing Wisely 5 questions have been adapted for people prescribed with opioids in the hospital and for people using opioids for back pain or osteoarthritis. For more information, see Opioids, chronic pain and the bigger picture on the NPS MedicineWise website.
Related resource: Managing your acute pain
Information about your pain medications and how to use them safely.
2021 Choosing Wisely National Meeting: Lightning talk on opioid prescribing
Dr Andrew Clawson of Sunshine Coast University Hospital presents on opioid prescribing in Sunshine Coast University Hospital Emergency Department at the 2021 Choosing Wisely Australia National Meeting - Empowering Consumers to Choose Wisely
Stewardship toolkit for clinical educators
The Health Resource Stewardship for Clinical educators contains educational material about the Choosing Wisely initiative for use in universities, hospitals and health professional colleges
5 questions to ask your doctor or other healthcare provider to make sure you end up with the right amount of care.