Jamie Smart
A Consultant in Anaesthesia and Pain Management at UCLH and the National Hospital for Neurology & Neurosurgery. Chair of the Opioid Stewardship Committee at UCLH.
Location London
Activity
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Thank you Dianna. Older patients may require between 50-75% less opioid depending on their age. Using a Functional Pain Scale as part of your pain assessment may be useful to you in these circumstances. Step 3.10
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Jamie Smart replied to dianna taylor
Thank you Dianna, the below article may be of interest to you. It shows that Modified Release Opioids increase the risk of PPOU & ORADE and provide inferior analgesia. Also in the references above you can review further evidence and consensus statements which agree that MR opioids should be avoided post-operatively.
Risks and benefits of oral...
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Jamie Smart replied to Heather S
Thank you Heather, the current evidence available to us shows that the risk of OIVI is almost x3 higher in patients on modified release (MR) opioids than those on immediate release (IR), and post-operative pain and function was also worse in the MR group.
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Thank you Dianna, do you use Functional Pain Scales where you work as part of your pain assessment?
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Thank you Heather, in 2.18 we saw higher doses and longer duration of opioid prescriptions lead to a higher risk of PPOU. While opioid free anesthesia and analgesia may not be feasible for all complex surgery, using an opioid sparing technique will help to mitigate this risk.
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Jamie Smart replied to Heather S
Thank you Heather, opioid free and opioid sparing anesthesia can also be targeted at patients at a higher risk of PPOU undergoing a wide variety of procedures.
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Thank you Niamh. If you are going to try to build a business case to establish a Transitional/Perioperative Pain Clinic then there is a guide on how to do this, available from Toronto General Hospital
https://www.transitionalpainservice.ca/establish-tps -
Jamie Smart replied to Niamh Molloy
Thanks for your comments Niamh. Tramadol does come with an increased risk of sedation, dizziness and nausea & vomiting compared to other step 2 opioids, although some people do tolerate it well.
If you do have limited options in your formulary remember you can also use lower doses of morphine in this context. -
Thank you Sandra. It is true that people become more sensitive to opioids as they age, and that reducing the doses we prescribe accordingly and using a Functional Pain Scale as part of the pain assessment would be sensible. A smaller dose of opioid for your patients over 60 may improve their analgesia and be less likely to cause side effects, so you may find...
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Thank you Niamh. We do discuss setting expectations of post-operative pain with patients later in week 3. Setting expectations has been shown to reduced post-operative opioid intake by up to 1/3. If resources are tight then this can be done in preassessment clinic or with the British Pain Society leaflet on Managing Pain After Surgery...
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Jamie Smart replied to judy phile
Thank you Judy. There is certainly some evidence to support this in the below article which matched patients who weaned their opioids pre-operatively with those who did not. The group who reduced their opioid intake showed reduced pain scores and improved function postoperatively.
Preoperative Reduction of Opioid Use Before Total Joint Arthroplasty. The... -
Jamie Smart replied to judy phile
Thank you Judy. Hopefully you will need less opioid than you think with a multimodal analgesic regime and possibly a regional block.
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We strongly discourage use of MR opioids at UCLH, however they are still available in the formulary at this time.
Even the most worthwhile change in a large hospital can sometimes be slow, but we will continue advancing the agenda we believe in.
I hope you make progress with your transitional pain clinic. The perioperative pain clinic at UCLH has proved... -
Thank you Sandra. 5-7 days of opioid to take home aligns with the Faculty of Pain Medicine guidance (further reading in section 3.9)
https://fpm.ac.uk/sites/fpm/files/documents/2021-03/surgery-and-opioids-2021_4.pdf
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Thank you for your insights Sandra, these are both important points.
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Thank you all for your comments, we will be discussing pain assessment and functional pain scores in week 3 (3.10)
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It is true that improved discharge planning is essential if we are to reduce the risk of PPOU.
All of your suggestions are components of good opioid stewardship. Shorter courses of opioids to take home, better handover to primary care and advice on opioid reduction in the discharge paperwork, and also access to advice for patients who are struggling. Follow... -
Thank you both for your comments, we will be discussing more about expectation management and patient education in week 3
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Thank you Fiona, you have made a very valid point. We will be talking more about post-operative pain measurement including Function Pain Assessment in 3.10
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Jamie Smart replied to Seershitha S
Thanks Seershitha, we also need to be aware that mortality is only one measure of the harms of Opioid Use Disorder which can have health, societal and economic implications.
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Jamie Smart replied to Dan Nguyen
Thank you Dan, we will discuss more about post-op pain measurement and functional pain assessment in 3.10. You are right, this is an essential component in finding the correct balance between opioid efficacy and harm.
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Jamie Smart replied to Steph Smith-Magee
Thank you Steph, we will be discussing pre-operative management in more detail in week 3.
What is happening in your hospital? -
Jamie Smart replied to keith miles
It is true that the crisis has been developing for decades, but the drugs involved have changed over time and the risks and mortality rates have been constantly increasing.
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Jamie Smart replied to Tom Marshall
Thank you Tom, we will be dealing with the practicalities of pain management in week 2 and week 3
