Hopefully this reflects better-educated prescribing, rather than fear of mass addiction, says one pain expert.
Rates of opioid initiation post-hospital and subsequent long-term use are falling slowly but steadily, declining by 16% and 29% between 2014 and 2020, a NSW study has found.
A study published in the British Journal of Pharmacology found that, of 16 million ED and hospital admissions in that time, 8.2% resulted in an opioid initiation, declining over the study term from 8.7% in 2014 to 7.2% in 2020.
Of the 1.3 million initiations 1.1% proceeded to long-term use, declining from 1.3% in 2014 to 0.8% in 2020.
Researchers used NSW’s MedIntel platform – which links hospital and emergency department records, PBS dispensings, deaths data and cancer registry records – to match admissions of opioid-naïve adults with prescribing and dispensing over seven years.
Associate Professor Michael Vagg, past dean and now director of professional affairs at the Faculty of Pain Medicine at the Australian and New Zealand College of Anaesthetists, said the overall decline might be less important than the types of patients who were no longer leaving hospital on opioids.
While some amount of long-term opioid use was inevitable, especially following trauma, Professor Vagg said the study showed even those cases were declining, while in people with more minor problems the drop had been larger.
“There’s signs of a definite movement in the right direction insofar as it probably reflects an increase in higher-value prescribing and a reduction in lower-value, thoughtless prescribing,” he told TMR.
“I suspect that, rather than people being scared to prescribe them, it may be that there is more educated prescribing.
“We don’t want to go back to the bad old days where there was an enormous unmet need of pain management.”
Efforts such as ANZCA’s Resources for Opioid Stewardship Implementation (ROSI) initiative had probably contributed to the drop, Professor Vagg said.
It would be “sad” if fear of addiction was the only factor behind it, since that was a lot less common than generally assumed.
ROSI provides hospitals with templates for handover to general practice, including a planned trajectory for weaning.
“The new standard prescribing in hospital is: if they didn’t come in on an opioid, they shouldn’t go home on one, and if they do, it should be communicated clearly to the patient and to the GP what the expectation is regarding how long [they should take it for],” Professor Vagg said.
The next step, he said, was to develop transitional pain clinics – sub-acute clinics that look after people within two or three months from discharge who are having trouble getting off their opioids or antineuropathic drugs.
“We don’t have the full system that we need yet, and so if it’s not carefully thought out, and there’s not good opioid stewardship in place, then there’s a perception that hospitals are creating issues and just walking away from them and leaving them for GPs [to deal with],” he said.
Trauma admissions had the highest rate of initiations (25.4%), followed by obstetric with surgical intervention (19.8%) and surgery (12%) and lowest in obstetric admissions without surgery (1%).
Rates were higher in private vs public hospitals (13.4%, 6.8%), in direct hospital admissions vs admissions via ED (10%, 8.3%), and in planned vs unplanned admissions (10.2%, 7.8%).
Initiation was higher for younger patients 18-54 (9-10%) than the oldest bracket of 85-plus (5.3%). It was slightly higher for men than women (8.5% to 8%) and for the highest-SES patients vs the lowest (8.9% to 8.5%). It was most common in cities, declining with remoteness.
Codeine combinations were the most prescribed opioids (42.6%) followed by oxycodone (37.5%), oxycodone with naloxone (5.3%) and tramadol (4.3%).
Professor Vagg said this continued dominance of codeine was disappointing, and peculiarly Australian.
“Codeine is a drug that a lot of people are comfortable with, but it’s essentially a strong opioid that is regulated as a weak opioid,” he said.
“Unlike tramadol or tapentadol, which are non-strong opioids that actually mostly behave like non-strong opioids, codeine is only weak at the mu opioid receptor and strong at the other three receptors, and it just behaves like a strong opioid. It creates dependency, it causes withdrawal, it dose-escalates, it pain-sensitises and causes opioid hyperalgesia.
“It does all the things a strong opioid does except pain relief.
“So it’s not a great drug, and it’s got historical use in Australia, which is a hangover that has not occurred in other parts of the world, where they got rid of codeine from their formularies long ago because of its unreliability.”
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The upscheduling of codeine had been “one of the most successful regulations ever, because it wasn’t driven by politics”, but was done in spite of opposition from the Pharmacy Guild.
The study found the highest rates of long-term use (defined as 90 consecutive days of opioid exposure between 90 and 270 days post-initiation – one of two definitions used) were among ED admissions (3.5%) and trauma patients (2.3%). All the other higher/lower patterns seen in initiations were reversed.
Long-term use was highest with buprenorphine (20.7%), fentanyl (15.6%) and morphine (11.5%), and lowest with codeine alone (1.6%), tramadol (0.9%), oxycodone alone (0.9%) and codeine combinations (0.5%).
In the separate realm of GP prescribing, Professor Vagg said the “blunt instrument” of nudge letters to GPs who prescribed opioids above the norm was unfortunate as it emphasised addiction potential over quality of prescribing.
“There is a good story to be told about some more sophisticated opioid prescribing, where you’re choosing the right opioid for the right patient at the right time,” he said.
“I see it every week in my practice as a pain specialist: somebody’s GP is away, and other GPs just refuse to help them, and would be happier leaving that person to withdraw in agony than even give them a script until their colleague gets back.
“So I think there needs to be nuance introduced into the discussion about opioids in general practice.”
