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
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
- 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.