Faculty of Pain Medicine, ANZCA
Recommendations from the Faculty of Pain Medicine, ANZCA on chronic pain, neuropathic pain and low back pain. The Faculty of Pain Medicine is a faculty of the Australian and New Zealand College of Anaesthetists and is the professional organisation for specialist pain medicine physicians (Fellows) and specialist pain medicine physicians in training (trainees). The Faculty is responsible for the training, examination and specialist accreditation of specialist pain medicine physicians and for the standards of clinical practice for pain medicine in Australia and New Zealand. Formed in 1998, the Faculty is the first multidisciplinary medical academy in the world to be devoted to education and training in pain medicine.
7.
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
Recommendation 1-5
The Faculty of Pain Medicine (FPM), ANZCA established a working group to develop a preliminary list of pain medicine related practices that were identified, using current clinical evidence, as having possible limited benefit, no benefit or which may potentially cause harm to patients. An online survey tool was used to survey all FPM fellows and trainees inviting them to rank these recommendations and to provide any comment related to them. This engagement facilitated consensus and informed the Fellows and trainees about FPM’s involvement with the Choosing Wisely campaign.
FPM's final list of 5 Choosing Wisely recommendations reflects those that were the most broadly supported by the clinicians and which were considered to be the most relevant to community practice.
Recommendation 6
FPM Board directed that a poll of the fellowship be conducted to assess support for a sixth Choosing Wisely recommendation regarding the role of medicinal cannabis in chronic non-cancer pain treatment. The survey question was very similar to the final wording of the recommendation, and was supported by 79% of the fellows who responded (more than 25% of the active fellowship).
The final draft wording of the recommendation, explanation and list of key references was then approved by the Board and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the following Board meeting before some minor amendments were made to clarify the explanation section of the recommendation.
Recommendation 7
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.
- 1 Avoid prescribing opioids (particularly long-acting opioids) as first-line or monotherapy for chronic non-cancer pain (CNCP).
- 2 Do not continue opioid prescription for chronic non-cancer pain (CNCP) without ongoing demonstration of functional benefit, periodic attempts at dose reduction and screening for long-term harms.
- 3 Avoid prescribing pregabalin and gabapentin for pain which does not fulfil the criteria for neuropathic pain
- 4 Do not prescribe benzodiazepines for low back pain.
- 5 Do not refer axial lower lumbar back pain for spinal fusion surgery.
- 6 Do not prescribe currently available medicinal cannabis products to treat chronic non-cancer pain (CNCP) unless part of a registered clinical trial.
- 7 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