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Prescribing drugs of dependence in general practice

Part C1 - Opioids

Appendix C

Last revised: 04 Mar 2020

Preliminary RACGP position statements regarding health services integration

Purpose

To ensure high-quality continuity of care for patients who require drugs of dependence by complying with the Australian Commission on Safety and Quality in Health Care’s (ACSQHC’s) handover standards.

Example policy

[Insert practice name]

Date effective:

Review date:

HANDOVER POLICY

Background

Clinical handover needs to occur whenever care is to be delivered by different providers. Within general practices there should be an effective handover system that ensures safe and continuing healthcare delivery for patients in the event of staff absences.

Failure of transfer of care, or inadequate transfer of care is a major risk to patient safety and a common cause of serious adverse patient outcomes. Inadequate handover can also lead to wasted resources, delayed treatment, delayed follow-up of significant test results, unnecessary repetition of tests, medication errors and increased risk of medico-legal action.20

It is recommended that general practices and GPs insist on high standards for referral letters for clinical handover or shared-care arrangements from secondary care before accepting the ongoing care of a patient. This facilitates the continuity of care and transfer back to higher levels of care if the need arises.

Handover within the general practice

Practice standards are required to ensure the ongoing provision of care in the event of the absence of the patient’s usual doctor. These standards include:

  • having an effective handover system to ensure safe and continuing healthcare delivery for patients (eg a buddy system for continued care in the usual GP’s absence)
  • ensuring each patient’s medical records contain up-to-date healthcare notes (that allow continuity of care in the usual GP’s absence).

Handover from external healthcare facilities (hospitals, rehabilitation units, specialist outpatients)

With respect to new patients presenting to the practice, or being referred by other agencies, it is our practice policy that:

  • the practice reserves the right not to accept these patients if either the practice or the practitioner is of the view that the current treatment plan is inconsistent with evidence-based guidelines, and the level of complexity exceeds the practice’s capacity to manage the patient
  • if a doctor feels that a referral letter from an external agency does not meet handover standards, then communication should be sent to the original referrer seeking additional information.

A practice or GP should not accept the ongoing management of a high-risk patient referred from a public sector facility, unless the referral includes:

  • a medical summary
  • a clear management plan
  • patient-specific instructions, including specific clinical issues that would prompt referral back to secondary care
  • contact details of a case manager and a clinically responsible person
  • documentation that details mechanisms for rapid transfer back to specialty care if deterioration occurs.

This requirement should be supported by practice policies and communicated to referral agencies if information does not meet required standards.

Handover to external healthcare centres (specialist outpatients)

It is our practice policy that all patients regularly using drugs of dependence have their problems and needs assessed based on levels of complexity (ie low, medium or high). Patients in medium-complexity or high-complexity groups should have an appropriate specialist review.

Practice policy requires that patients with medium-complexity or high-complexity problems are managed in a manner consistent with the universal precautions of pain medicine. That is:

  • a clear diagnosis and reasons for prescription are documented
  • a full psychosocial assessment is conducted, including risk of addictive disorders
  • informed consent for treatment plans is used
  • pre-intervention and post-intervention assessments of pain level and function are undertaken
  • opioid therapy with or without adjunctive medication is commenced on a trial basis
  • levels of pain and function are constantly assessed
  • the ‘5As’ of pain medicine (analgesia, activity, adverse effects, aberrant behaviour, affect) are constantly assessed
  • the diagnosis is periodically reviewed and comorbidities are managed appropriately
  • the level of documentation standard is high.

The ACSQHC handover standards are available here.

 


Background

An effective and efficient health system relies on high standards of care, particularly where handover of care from hospital to community is involved.

Before prescribing opioids as a discharge medication, consideration needs to be given to possible opioid adverse effects, which include the potential risks of long-term opioid use, drug diversion, misuse/abuse and death from accidental overdose.62 The risk of falls should also be considered: the overall risk is greatest in the first week following the initial prescription, and decreases over time.190

A small pilot study has shown that patients discharged from emergency departments (EDs) with opioid medication do not safely store and dispose of these medicines.63 After receiving opioid prescriptions for an acute episode, 64% of patients kept unused opioids and 34% shared them with others.64 Patients should be educated about not compiling or distributing medications and also of the safe way to dispose of unused opioid medicines, which, in Australia, is to return them to a pharmacy.62

A clear plan for analgesia reduction after discharge and robust systems for communication with usual treating practitioners in the community are essential and will assist in avoiding unintended dose escalation.57-59

Evidence statements

  • The efficacy of opioid therapy in acute pain is supported by strong evidence from randomised controlled trials.48,52
  • Long-term opioid use often begins with treatment of acute pain.15 When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.15

RACGP requests of hospital accident and EDs

  • A clear plan for analgesia reduction after discharge and robust systems for communication with usual treating practitioners in the community are essential.57-59
  • Patients presenting with an acute exacerbation of existing chronic pain should be assessed with caution and usually by or in conjunction with their usual doctor or healthcare team.
  • A prescription for three days or less will often be sufficient; more than seven days will rarely be needed.15

Acute exacerbation of existing chronic pain

It is important to identify the source of pain rather than just treating for acute pain, since treatment for the chronic pain patient can be significantly different. Because of potential risks and adverse effects, clinicians are encouraged to avoid prescribing increased dosage or additional opioids. Assess the patient’s mental health status and social situation to determine if additional resources may be appropriate.

Consult the patient’s pain care plan prior to prescribing any medications:

  • Exacerbations of pain should be managed with non-opioid therapy 65
  • Confer with the clinician managing the patient’s chronic pain, their interdisciplinary team or available resources to provide appropriate chronic pain management
  • Check state-based prescription monitoring services for history of opioid prescriptions

Background

The number of patients discharged from hospital or rehabilitation units with opioid medication is rising because the range of patients and procedures considered suitable for short stay or early discharge are increasing.62

Before prescribing opioids as a discharge medication, consideration needs to be given to possible opioid adverse effects, which include the potential risks of long-term opioid use, drug diversion, misuse/abuse and death from accidental overdose.62

Postoperative opioids

Opioid therapy can usually be ceased within one week of surgery or injury. In more complex cases opioids should be weaned and ceased within 90 days at most. However, following postoperative initiation, up to 8% of patients continue to use opioid medication for months or even years.70–72

Early discharge after day surgery with a prescription of opioids or non-steroidal anti-inflammatory drugs (NSAIDs) carries an increased risk of subsequent long-term use of these analgesics. In a population of 391,139 opioid-naïve patients over 65 years of age who underwent short-stay surgery, patients who received an opioid prescription within the seven-day period after surgery were more likely to become long-term opioid users within one year in comparison to those without a prescription.70

Of 39,000 opioid-naïve patients having major elective surgery, 3.1% showed prolonged opioid use after discharge.72

Additionally, after receiving opioid prescriptions for an acute episode, 64% of patients kept unused opioids and 34% shared them with others.64

This rate of ‘over-prescription’ has been noted for surgical discharges.66–68 Indeed, it is often completely unnecessary: 19% of postoperative patients prescribed oxycodone upon discharge from a large Australian teaching hospital had not needed any opioid in the 24 hours prior to discharge.69

A clear plan for analgesia reduction after discharge and robust systems for communication with usual treating practitioners in the community are essential and will assist in avoiding unintended dose escalation.57–59

Evidence statements

  • The efficacy of opioid therapy in acute pain is supported by strong evidence from randomised controlled trials.48,52
  • Long-term opioid use often begins with treatment of acute pain.15 When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.15

RACGP requests to hospitals regarding handover on patient discharge

  • Hospitals and rehabilitation units should develop robust communication systems for transfer of care to usual treating practitioners in the community consistent with the ACSQHC’s standards for handover.
  • Patients discharged from hospital or day care facilities on opioids should be educated regarding the safe and optimal use of the pain medications that have been prescribed.
  • Patients discharged from hospital or day care facilities on opioids should have a clear plan of pain management to facilitate handover of care.
  • A post-surgery discharge letter must accurately reflect information on opioid dose frequency and suggested duration of treatment, including a plan for dose reduction.
  • Patients commenced on long-term opioids in hospital for chronic (cancer or non-cancer) pain should receive a detailed discharge summary justifying opioid use.
  • Psychiatric patients, or patients who were admitted with opioid overdose, should have clear justifications for opioid use and clear plans for future monitoring.
  • Discharge prescriptions for opioids should:
    • (in most cases) not exceed seven days’ supply (or until earliest office opening and follow-up from the patient’s usual GP)
    • be communicated to the patient’s usual GP or care team.
  • If a patient with a history of chronic pain is admitted for non-fatal overdose:
    • hospital staff should conduct a full pain and psychiatric evaluation, and consider opioid cessation or naloxone therapy. These deliberations should be documented on the discharge summaries to GPs
    • the usual GP or care team should be notified.


Patients who have had a presentation or admission for opioid overdose are at significant risk for another overdose and further harms.74 Almost all patients continue to receive prescription opioids after an overdose.

At two years, the cumulative incidence of repeated overdose was:74

  • 17% (95% confidence interval [CI]: 14%, 20%) for patients receiving high dosages of opioids after the index overdose
  • 15% (CI: 10%, 21%) for those receiving moderate dosages
  • 9% (CI: 6%, 14%) for those receiving low dosages
  • 8% (CI, 6% to 11%) for those receiving no opioids.

Opioid discontinuation after overdose is associated with lower risk for repeated overdose.74

Non-fatal opioid overdose is an opportunity to identify and treat substance use disorders, as patients often have both pain and substance abuse issues.

The use of naloxone falls within harm reduction strategies and patient-centred care. It is safe, effective, inexpensive, and relatively easy to administer via intramuscular (IM) injection.75

The RACGP requests that for all patients presenting to hospital EDs with non-fatal opioid overdose, hospital staff conduct full pain and psychiatric evaluations, and consider opioid cessation or naloxone therapy. It is essential for practitioners in the ED to develop a clear plan for opioid safety after discharge and to communicate with the patient’s usual treating practitioners in the community.

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