Clinical coordination needs to occur whenever care is to be delivered by different providers. Poor transfer of care risks patient safety and is a common cause of serious adverse outcomes. Inadequate handover can also lead to medication errors, wasted resources and unnecessary repetition of tests, delayed treatment or follow-up of significant test results, and increased risk of medico-legal action. 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.
GPs also work with a range of care facilities and other professionals who prescribe drugs of dependence, and may work as part of a wider organisation or in a multidisciplinary team. It is important to be aware of accepted bestpractice protocols used in each setting and work in accordance with these.
It is usually good practice to ensure that clinical practices are standardised through local area policies and protocols.
Managing patients prescribed opioid therapy who see multiple providers
Occasionally, some complex patients are managed by several practitioners working in collaboration. It is important to determine and agree on a primary medication provider to avoid medication adverse events.
The doctor writing the prescription ultimately assumes responsibility for the prescription and its compliance with legislation. This is irrespective of whether another doctor at the practice primarily prescribes or a specialist has recommended the treatment.
When a GP does not feel happy to provide a prescription, they should not feel pressured to do so. The ideal situation is to have an independent drug and alcohol specialist review the case. Alternatively, referral back to the original provider for scripts may be warranted.
Referral of patients prescribed long-term opioid therapy
Inter-practice referral of patients prescribed long-term opioid therapy
Patients will travel within Australia and appropriate handover of care to another practice or practitioner is often necessary. For patients who are prescribed opioid therapy this can be complicated. Referral of patients should be both written to Australian Commission for Safety and Quality in Health Care (ACSQHC) handover standards, and assisted by GP-to-GP communication or practice-to-practice communication prior to the arrival of the patient at the new destination.
GPs at the new practice have an obligation to reassess the clinical context and prescribing appropriateness Prescribing drugs of dependence in general practice, Part C2: The role of opioids in general practice – Section 1.5.5 The inherited patient – Continuation of long-term opioid management plans initiated by other healthcare providers). All referrals should contain relevant information pertaining to short-term and long-term pain management including:
- a summary of biopsychosocial assessment and pain history
- a pain diagnosis, and the rationale and plan for pain management
- a medical summary including medications and known adverse reactions
- relevant specialists involved in care
- a copy of relevant state permits.
Deciding when to seek advice or consider referral to a specialist
Patients who are at higher risk for dependence or have more complex issues need to be jointly managed between primary care and specialised drug and alcohol addiction services. They also may also require the input of mental health and/or pain specialists.
The ongoing treatment of pain, addiction and mental illness comorbidities is a complex undertaking. Initial referral may be needed to obtain a comprehensive evaluation or to clarify the optimal therapeutic strategies.
Referral is typically considered for patients who are at higher risk, who have more complex needs or for patients at risk of adverse events. This includes patients who:56
- are relatively young (<35 years)
- have a comorbid psychiatric or psychological disorder
- have previous or current opioid (or other) SUDs
- have indeterminate pathology.
Once an optimal regimen and monitoring approach has been implemented, referral may be warranted in the case of:56
- unexpected drug dose escalation
- ceiling drug dosages reached
- suspected abuse or misuse
- risk category change
- high levels of patient distress
- unusual opioid requirements or suspicions of drug diversion
- poorly controlled comorbid psychiatric or psychological disorder.
Deciding when to refer a patient for hospital admission (through emergency departments)
Patients may need referral to hospital if they are at risk to themselves, pose risks to others or are at risk of harm by others. Typically, these situations are sensitive, and contact with state or territory helplines and accident and emergency staff may be appropriate.
Identifying patient risk
Hospital staff often find it difficult to manage referred patients with chronic pain on long-term treatment even when admission is not related to opioid use. Without the relevant information and a clear understanding of the patient’s pain management, the patient’s treatment may be stopped or altered, which may affect other treatment and outcomes and impact on morbidity, mortality, length of stay and discharge.
All referrals, whether for pain, trauma, injury or other reasons, should contain the relevant information pertaining to short-term and long-term pain management, including:
- medications and known adverse reactions
- diagnosis including reason for requiring inpatient pain management
- relevant specialists involved in care
- duration of treatment
- a summary of biopsychosocial assessment and forensic history.
Providing this information assists hospital teams to seek appropriate consults relevant to the patient’s care and optimises outcomes and discharge. Patients with chronic pain may benefit from a chronic pain service consult while in hospital, and linking in with the service if required. The chronic pain service may request follow-up by a community-based chronic pain service on discharge.
Clinical handover of patients using opioid therapy to general practice
Clinical handover needs to occur whenever care is to be delivered by different providers.
Inadequate transfer of care is a major risk to patient safety and may result in delays in treatment or follow-up, medication errors and unnecessary repetition of tests. It also increases the risk of medico-legal action.
Patients on opioid therapy – handover from hospital clinics to general practice
An effective and efficient health system relies on high standards of care, particularly where handover of care from hospital to community is involved. General practices and GPs should 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.
A practice or GP may not accept the ongoing management of a high-risk patient referred from a public sector facility, unless there is:
- a medical summary
- a clear management plan, particularly with ongoing drugs of dependence including opioids
- 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.
These requirements should be supported by practice policies and communicated to referral agencies if information does not meet required standards. It might also be useful to document non-attendance by patients.
Refer to Appendix C: Preliminary RACGP position statements regarding health services integration.
ACSQHC handover standards are available for reading.
Patients on opioid therapy – handover from emergency departments to general practice
An effective and efficient health system relies on high standards of care, particularly where handover of care from hospital to community is involved. It is vital that hospitals make clear plans for analgesia reduction after discharge and have reliable systems for communication with usual treating practitioners.57–59
Problematic opioid use often has its origins in the acute pain setting.15,60,61 Therefore, before prescribing opioids at discharge, possible adverse effects of opioids should be considered. These include potential risks of longterm opioid use, injury, drug diversion, misuse, abuse, and death from accidental overdose.62 Three days or less of opioid therapy will often be sufficient for acute analgesia; more than seven days will rarely be needed.15 The number of doses dispensed should be no more than the number needed. This prescription should be based on the expected duration of pain that is severe enough to justify prescribing opioids for that condition.47
Additionally, patients discharged from emergency departments (EDs) with opioids may not safely store and dispose of their medications.63 One study found that after receiving opioid prescriptions for an acute episode, 64% of patients kept unused opioids and 34% shared them with others.64 Patients should be advised of the risks associated with these behaviours and what they should do with unused opioids (ie return them to a pharmacy).62
When patients present for acute exacerbation of chronic pain, it is important to identify the source of the pain rather than just treating for acute pain, since treatment for the chronic pain patient can be significantly different. Clinicians should:
- consult the patient’s pain care plan prior to prescribing any medications
- confer with the clinician managing the patient’s chronic pain, their interdisciplinary team or available resources to provide appropriate chronic pain management
- avoid prescribing increased dosage or additional opioids
- manage exacerbations of pain with non-opioid therapy65
- check state-based prescription monitoring services for history of opioid prescriptions
- assess the patient’s mental health status and social situation to determine if additional resources may be appropriate.
Patients on opioid therapy – handover from hospital surgical and rehabilitation units
An effective and efficient health system relies on high standards of care, particularly where handover of care from hospital to community is involved. Over-prescription of opioids has been noted for surgical discharges.66–68 For example, 19% of postoperative patients were prescribed oxycodone upon discharge from a large Australian teaching hospital even though they had not needed any opioid treatment in the 24 hours prior to discharge.69
In part due to the increase in the number of patients and procedures considered suitable for short stay or early discharge, the number of patients discharged from hospital or rehabilitation units with opioid medication is rising.62 There is an association between long-term use of analgesics and early discharge after day-stay surgery with a prescription of opioids, with up to 8% of patients continuing to use opioid medication for months or even years after surgery.70–72
In a population of almost 400,000 opioid-naïve patients over 65 years of age who underwent short-stay surgery, the patients who received an opioid prescription within seven days after surgery were more likely to become long-term opioid users within one year, in comparison to those without a prescription.70 In another study of 39,000 opioid-naïve patients having major elective surgery, 3.1% showed prolonged opioid use after discharge.72
In the majority of cases, opioid therapy can be stopped within one week of surgery or injury.73 With more complex cases, opioids should be weaned and ceased within three months at the most.73
A clear plan for analgesia reduction after discharge and good communication with usual treating practitioners will assist in avoiding long-term treatment and unintended dose escalation.57–59
Patients on opioid therapy – handover after admission with intentional nonfatal overdose of opioids
Patients who have had a presentation or admission for opioid overdose are at significant risk for another overdose and further harms.74
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%, 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 SUDs, as patients often have both pain and substance abuse issues.
Alternatively, naloxone distribution programs are firmly rooted in the principles of harm reduction. Naloxone is safe, effective, inexpensive, and relatively easy to administer via intramuscular (IM) injection.75 Please refer to ‘Naloxone therapy’ in Part C2: The role of opioids in pain management for further information.
All patients presenting to hospital EDs with non-fatal opioid overdose should undergo a full pain and psychiatric evaluation, including consideration of opioid cessation or naloxone therapy. A clear plan for opioid safety after discharge and communication with the patient’s usual treating GP in the community is essential.
Box 3. Summary of requirements for effective handover from hospital to general practice
- Hospitals should develop robust communication systems for transfer of care to usual treating practitioners in the community consistent with ACSQHC standards for handover
- Patients discharged from hospitals (including EDs, rehabilitation units and 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 hospitals (including EDs, rehabilitation units and 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 plan for dose reduction
- Patients commenced on long-term opioids in hospital for chronic (cancer or non-cancer) pain should contain detailed documentary support justifying continued 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
- Prescriptions of opioids on discharge should, in most cases, not exceed seven days’ supply (or until earliest office opening and follow-up from the patient’s usual GP)
- If a patient with a history of chronic pain is admitted to a hospital for non-fatal overdose:
- the patient should have a full pain and psychiatric evaluation, and consideration of opioid cessation or provision of naloxone therapy for peer or family administration in situations of overdose – the patient’s usual GP or care team should be notified.