Australian and New Zealand College of Anaesthetists
The Australian and New Zealand College of Anaesthetists (ANZCA) ), including the Faculty of Pain Medicine, is one of Australasia's largest specialist medical colleges and is responsible for the training, examination and specialist accreditation of anaesthetists and pain medicine specialists and for the standards of clinical practice.
6.
Avoid routine prescription of slow-release opioids in the management of acute pain unless there is a demonstrated need, close monitoring is available and a cessation plan is in place
An individual’s experience of pain in response to a noxious stimulus from surgery, trauma or medical illness is variable and typically improves with time. Decisions about acute pain management should be tailored according to individual patient assessment and the care setting. If acute pain is moderate or severe and considered to be opioid-responsive, immediate-release opioids (IR) may be indicated as part of a multimodal analgesic regimen. Ideally, they should be titrated to effect and ceased at the earliest opportunity as functionality returns.
Avoid routine prescription of slow-release (SR) opioids in the management of acute pain, in hospital and community settings, unless there is a demonstrated need, close monitoring is available, and a cessation plan is in place. Their slow onset and offset do not allow rapid and safe titration. Their use in the acute pain setting has been associated with an increased risk of opioid-induced ventilatory impairment (OIVI) – best recognised clinically as increasing patient sedation – and other opioid-related adverse effects; less effective relief of acute pain; and a higher risk of prolonged opioid use. SR opioids act as a constant background dose of opioid, which may be excessive to patient needs or may act as an unpredictable addition to the opioid load if IR opioids are added on an ‘as needed’ (prn) basis. If opioid-related adverse effects are encountered, they will also be sustained.
The 2022 Australian Commission on Safety and Quality in Health Care notes that the use of SR opioids in acute pain ‘should be exceptional and not routine’.
SR opioids are not TGA-approved for the treatment of acute pain and hence such use is ‘off-label’. ‘Off-label’ prescribing requires additional obligations and responsibilities on the prescriber. However, these medications would normally be continued at the pre-existing dose in patients with acute pain who are already taking SR opioids for long-term management of their chronic or cancer pain. Independent verification of drug and dose, for example, via a prescription monitoring program or GP health records, should be sought before the patient’s usual SR opioid is prescribed.
If there is a demonstrated need for an SR opioid, consideration should be given to prescribing opioids with a lower risk of OIVI – for example, the atypical opioids tramadol, tapentadol or buprenorphine (taking into account individual patient risks, vulnerabilities and potential medication interactions).
Supporting evidence
- Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine PS41 Position statement on acute pain management 2022. Available from https://www.anzca.edu.au/getattachment/558316c5-ea93-457c-b51f-d57556b0ffa7/PS41-Guideline-on-acute-pain-management
- Awadalla R, Liu S, Kemp-Casey A, Gnjidic D, Patanwala A, Stevens J, et al. Impact of an Australian/New Zealand organisational position statement on extended-release opioid prescribing among surgical inpatients: a dual centre before-and-after study. Anaesthesia 2021;76(12):1607-1615.
- Australian Commission on Safety and Quality in Health Care. Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard - Acute care edition. 2022. Available from https://www.safetyandquality.gov.au/publications-and-resources/resource-library/opioid-analgesic-stewardship-acute-pain-clinical-care-standard
- Council of Australian Therapeutic Advisory Groups. Rethinking medicines decision-making in Australian Hospitals. Guiding principles for the quality use of off-label medicines. Council of Australian Therapeutic Advisory Groups 2013.
- Kim T, Zhou CE, Sara RA, Lightfoot NJ. The effect of perioperative sustained-release opioid use on long-term opioid dispensing following total knee arthroplasty: a retrospective cohort study. N Z Med J 2021;134(1544):57-68.
- Levy N, Quinlan J, El-Boghdadly K, Fawcett WJ, Agarwal V, Bastable RB, et al. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia 2021;76(4):520-536.
- Schug SA, Palmer GM, Scott DA, Alcock M, Halliwell R, Mott JF; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence 2020 (5th edition), ANZCA & FPM, Melbourne.
- Stevens JA. One quantum of solace for all? Anaesth Intensive Care 2020 Jan;48(1):7-10.
- Tan AC, Bugeja BA, Begley DA, Stevens JA, Khor KE, Penm J. Postoperative use of slow-release opioids: The impact of the Australian and New Zealand College of Anaesthetists/Faculty of Pain Medicine position statement on clinical practice. Anaesth Intensive Care 2020 Nov;48(6):444-453.
How this list was made
ANZCA’s Safety and Quality Committee established a working group that developed a preliminary list of 10 anaesthetic-related practices that, based on clinical evidence, may have possible limited benefit, no benefit or may potentially cause harm to patients. Using an on-line survey tool, all ANZCA Fellows and trainees were invited to rank these recommendations and provide relevant comments. This engagement facilitated consensus and informed Fellows and trainees about ANZCA’s involvement with the Choosing Wisely campaign.
Recommendation 1-5
ANZCA’s final list of 5 Choosing Wisely recommendations deliberately supports the clinician’s judgements and emphasises the importance of considering patient and surgical factors in decision making; in particular, as regards the selection of necessary preoperative testing and appropriate facilities for all patients and the expected outcomes and goals of care for the medically frail.
Recommendation 6
The ANZCA Safety and Quality Committee proposed that the college submit a statement to Choosing Wisely Australia as part of analgesic stewardship.
The committee agreed that the existing document development group (DDG) for ANZCA and FPM professional document PS41(G) Position statement on acute pain management would be well-placed to develop the Choosing Wisely recommendation. It was also agreed that an expert group should be formed comprising members with expertise in obstetric anaesthesia, paediatric anaesthesia, and paediatric pain medicine, to provide input to the Choosing Wisely recommendation.
The draft document was circulated for consultation in February 2022 with the following stakeholders: ANZCA national/regional committees, NZ national committee, FPM committees, Australian Society of Anaesthetists (ASA), New Zealand Society of Anaesthetists (NZSA), ANZCA Special Interest Groups (SIG) including Obstetric SIG and Acute Pain SIG, and Society for Paediatric Anaesthesia in New Zealand and Australia (SPANZA). The one-month consultation period finished in March 2022. After consideration of the feedback received during this period, the DDG made further amendments to the CW recommendation. The ANZCA Safety and Quality Committee approved the post consultation version and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the Board meeting before some minor amendments were made to clarify the explanation section of the recommendation.Download ANZCA Recommendations
- 1 Avoid routinely performing preoperative blood investigations, chest X-ray or spirometry prior to surgery, but instead order in response to patient factors, symptoms and signs, disease, or planned surgery.
- 2 Avoid ordering cardiac stress testing for asymptomatic patients prior to undergoing low to intermediate risk non-cardiac surgery.
- 3 Avoid administering packed red blood cells (blood transfusion) to a young healthy patient with a haemoglobin of ≥70g/L who does not have on-going blood loss, unless the patient is symptomatic or haemodynamically unstable.
- 4 Avoid initiating anaesthesia for patients with limited life expectancy, at high risk of death or severely impaired functional recovery, without discussing expected outcomes and goals of care.
- 5 Avoid initiating anaesthesia for patients with significant co-morbidities without adequate, timely preoperative assessment and postoperative facilities to meet their needs.
- 6 Avoid routine prescription of slow-release opioids in the management of acute pain unless there is a demonstrated need, close monitoring is available and a cessation plan is in place