Background & Aims
Opioids are the mainstay drugs for pain relief after Surgery, but it has contributed towards an overall increase in opioid prescriptions. The guidance on prescribing them has been missing until recently when the Royal College of Anaesthesia (RCoA) published Surgery and Opioids- Best Practice Guidelines in 2021. A recent study concluded that there is a 50% increase in opioid-related admissions to hospitals in England. In the 2019 audit of primary care providers of Leicester, Northampton and Lincoln, high opioid users (>120mg) prevalence was found to be 0.07%, 0.07% and 0.16%, respectively. Opioid stewardship is an integrated way of addressing the problem of opioid overprescription.
We started a quality improvement project at the Division of Surgery and Anaesthesia at University Hospitals Leicester NHS Trust (UHL) in Dec 2022 with the primary aim of introducing opioid stewardship and the secondary aim of improving perioperative pain management in adult postoperative patients.
Methods
We formed a multidisciplinary team, including a chronic pain consultant, pharmacist, and acute pain team, to write the guidelines for perioperative pain management of adult patients and opioid stewardship. Its highlights include
•preoperative alert for high-dose opioids (> 120 mg) morphine milligram equivalent dose (MME) users,
•opioid-sparing analgesic protocols like ketamine, lignocaine, magnesium and clonidine infusions.
•functional pain assessment scale in the post-anaesthesia care unit.
•opioid agreement discharge letter.
•limiting the supply of opioids at discharge to 7 days.
An opioid management subgroup was formed in Leicester, Leicestershire and Rutland Integrated Care Board (LLRICB) with a chronic pain consultant, primary care representative and pharmacists to monitor opioid prescriptions in the region on high (120mg MME) dose, produce a guideline for opioid prescription in primary care, review and improve referral pathway of opioid clinic.
Results
In the quality and safety board meeting at the Division of Anaesthesia and Surgery of UHL, we presented our final perioperative pain management guideline for adult patients. This was very well received and subsequently ratified. One of the key outcomes of the Opioid management subgroup was the first six-monthly report (Jan to July 23). It showed a log of 668 patients on 120-200mg, 249 on 200-300mg, 131 on 300-500 mg and 62 on > 500 mg MME opioid prescriptions in LLRICB, totalling 1111 patients, although it did not specify postoperative patients.
Conclusions
Higher than 120 mg MME is likely to increase the risk of opioid-related hospital admission and increase the burden on the already stretched National Health Service (NHS). With our experience on this project, we believe that an integrated pathway between primary and secondary care is essential for opioid stewardship. The introduction of perioperative pain management guidelines for adult patients after Surgery has been well received and incorporated.
References
1.Surgery and opioids – Best practice guideline 2021 Royal college of anaesthesia.
2.Elisabeth Mahase Opioid related hospital admissions in England increased by nearly 50% in 10 years BMJ 2022;376:o299
3.S Ramaswamy, J Wilson, L Colvin Non-Opioid based adjuvant analgesia in perioperative care. Continuing Education in Anaesthesia Critical Care & Pain, Volume 13, Issue 5, October 2013, Pages 152–157
Presenting Author
Vitul Manhas
Poster Authors
Topics
- Evidence, Clinical Trials, Systematic Review, Guidelines, and Implementation Science