What is opioid stewardship?

In this article, Dr Nicholas Levy, Consultant in Anaesthesia and Acute Pain at West Suffolk Hospital, and Dr Anna Simpson, Consultant in Anaesthesia at Gloucestershire Hospitals NHS Foundation Trust, outline the individual components of opioid stewardship, which we will examine in more detail throughout this week.

Opioid stewardship has been defined as a set of ‘co-ordinated interventions designed to improve, monitor, and evaluate the use of opioids in order to support and protect human health’ [1]. It is more than simply avoiding the use of opioids, but rather aims to find the balance between excessive and insufficient use, which is also associated with harm.

Because the use of opioids in patient care takes place across many different specialties and settings, it is important that efforts to improve practice are coordinated at an institutional and national level, rather than relying solely on education and changes in individual practice.

Opioid stewardship programmes, modelled on the successes of antimicrobial stewardship programmes, have gained increasing acceptance. They include a number of assessments and interventions which are relevant to the whole multidisciplinary team in the phases of care before, during and after surgery. It is imperative that all healthcare professionals involved in a patient’s surgical journey work collaboratively to ensure robust opioid stewardship [1].

What are the opioid-related risk factors which can be addressed by opioid stewardship?

Over the course of Weeks 1 and 2 we have learnt about the many risk factors associated with opioid-related harm in the community.

These are:

Drug-related risk factors

• Addictive properties of opioids: although some specific opioids and formulations have more misuse potential than others, all opioids can lead to the development of opioid use disorder.
• Modified-release preparations: contrary to claims made when they were initially marketed, these do not provide better postoperative analgesia than immediate-release formulations, and they are associated with a greater risk of PPOU. We will cover why this is the case in Step 3.11.
• Use of compound analgesics: these preparations do not allow easy cessation of opioid use as postoperative pain resolves, also increasing the risk of PPOU. We will explore this in greater detail in Step 3.12.

Patient-related risk factors

• Presence of other drug and alcohol use disorders: these are associated with an increased risk of PPOU.
• Anxiety, depression and catastrophic thinking: these are risk factors for persistent postoperative pain and PPOU. We will take a closer look at why this is and at ways in which these risk factors may be addressed in Step 3.6.
• Pre-existing persistent pain: this is another risk factor of PPOU. We will explore why this is in Step 3.5.

Healthcare system-related risk factors

• Excess prescription medication: this is associated with PPOU, opioid misuse and diversion.
• Lack of deprescribing advice
• Lack of storage and disposal advice
• Over-reliance on unidimensional pain scores: this increases the total amount of opioid used without improving pain scores and increases the risk of OIVI and PPOU.
• Failure to recognise the emergence of chronic pain states: opioids are not indicated in the continued management of most chronic pain states.

What are the components of opioid stewardship?

The components of opioid stewardship address these drivers of negative opioid-related outcomes. These are summarised in the table below. There are several assessments and interventions which are relevant to all healthcare practitioners throughout a patient’s surgical journey – from the decision to proceed to surgery, through the hospital admission, to discharge and beyond.

Components of the opioid stewardship surgical care pathway

Adapted from Simpson et al (BJA Ed 2023)

BEFORE ADMISSION	Identify patients on high dose opioids Identify patients at risk of PPOU Consider supervised weaning Utilise transitional pain services Set expectations
DURING SURGERY	Give non-opioid (over the counter) analgesics where safe Procedure-specific strategies (appropriate regional techniques) to promote return of function Adjunct analgesics (eg lidocaine, ketamine, magnesium) ‘Opioid-sparing’ anaesthesia
WARD CARE	Use oral route whenever possible Give regular non-opioid analgesics where safe Use ‘as required’ age-related doses of immediate-release (IR) opioids Titrate opioids to promote function Adjust opioid doses for renal function Sedation scoring to identify impending OIVI Avoid co-sedatives (eg gabapentinoids)
PREPARING FOR DISCHARGE	Identify patients that require additional opioid weaning support (eg critical care admission, pre-existing high-dose opioids) Provide written and verbal management on safe analgesic management Provide appropriate discharge analgesia: – Regular non-opioid analgesics where safe – Short course IR opioid tablets (<7 days) – Use of surgery specific opioid doses – No compound analgesic preparations – No modified-release (MR) preparations
AFTER DISCHARGE	Give non-opioid analgesics where safe Use opioids to facilitate function Wean opioids with reverse pain ladder Promote mobilisation and opioid tapering Refer to pain team and/or consider referral to surgical team if still requiring opioids at 3 months, and probably before Undertake safe opioid storage & disposal Avoid drug driving & opioid diversion

 We will take a closer look at the recommendations and examples of best practice during the rest of this week. 

References

_{1. Simpson AK, Levy N, Mariano ER. Opioid stewardship. BJA Ed 2023;23:389–97.}