Information for health service organisations - Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard

What the standard says

The nonpharmacological and pharmacological options for managing acute pain are discussed with a patient and their carer in a way that they can understand, and that leads to a shared understanding of the decision to use an opioid analgesic or other treatment(s).

What the quality statement means for health service organisations

Ensure systems are in place for clinicians to provide patients, and their family or carers, with culturally appropriate information and advice on acute pain treatment options.

Provide high-quality written patient materials and resources for use by clinicians and patients that have been developed in partnership with consumers, and meet the diverse needs of people who access your services.

Ensure processes are in place so that information is communicated to the patient about their treatment options and medication management or pain management plan, including at transitions of care (such as on transfer in, or discharge from, hospital).

Where opioid analgesics are prescribed, ensure systems are in place so that clinicians discuss with patients and their family or carers the need to take the medicine as prescribed, the expected duration of treatment, any potential adverse effects and interactions with existing medicines, and when their treatment requires review. Ensure systems are in place so that, on discharge, clinicians discuss with patients and their family or carers the possibility of harm if they give opioid analgesics to other people, and the safe storage and disposal of opioid analgesics.

Monitor patient understanding of information provided for acute pain treatment and evidence of shared decision making – for example, through patient surveys, patient-reported experience measures and patient-reported outcome measures.

Related resources

• Clinical Excellence Commission NSW. Managing Side Effects of Opioid Medicines in Hospital: Information for patients, families and carers
• SA Health. Oxycodone for Short-Term Management of Acute Pain
• SA Health. Information for Paediatric Patients, and Their Carer, Given Opioids for Short-Term Treatment of Acute Pain
• SA Health. Going Home After Having Been Given a Medicine That Can Make You Sleepy
• WA Health. Pain Relief Medications Following Surgery and Injury: Information for patients preparing for discharge
• TGA. Return Your Unused Opioids – Resource Kit
• Return Unwanted Medicines
• Pharmaceutical Society of Australia. Opioid Medicines Fact Sheet for Patients, Families and Carers

What the standard says

Analgesic prescribing for a patient with acute pain is guided by its expected severity and assessment of patient-reported pain intensity and the impact of pain on the patient’s function.

What the quality statement means for health service organisations

Ensure appropriate evidence-based tools to assess patient function and pain are available, and that processes and policies support their use to assess and document acute pain before clinicians prescribe appropriate analgesia.

Related resources

Several evidence-based tools for assessing pain and function are available.

Functional Activity Scale

A No limitation: the patient can undertake the activity without limitation due to pain (pain-intensity score is typically zero to three)

B Mild limitation: the patient can undertake the activity, but experiences moderate to severe pain (pain-intensity score is typically four to ten)

C Significant limitation: the patient cannot complete the activity due to pain or pain treatment-related adverse effects independent of pain-intensity scores.

• Wong-Baker FACES Pain Rating Scale and Multi-Language Wong-Baker FACES Pain Rating Scale
• Multi-language International Association for the Study of Pain Faces Pain Scale Revised

---

Pain scoring systems for paediatric patients

A summary of validated tools for measuring pain in paediatric patients is in Acute Pain Management: Scientific evidence, 5th edition (2020).

• Table 10.1 Acute pain-intensity measurement tools – neonates
• Table 10.2 Composite scales for infants and children
• Table 10.3 Self-report tools for children
• Table 10.4 Sample of observational pain assessment scales for intellectually disabled children.

---

Pain scoring systems for cognitively impaired patients

A summary of tools for measuring pain in patients with dementia can be found in Acute Pain Management: Scientific evidence, 5th edition (2020), including:

• Faces Pain Scale
• Abbey Pain Scale
• Pain Assessment in Advanced Dementia (PAINAD)
• Pain Assessment Checklist for Seniors with Limited Ability to Communicate
• Mobilization–Observation–Behaviour–Intensity–Dementia Pain Scale (MOBID).

Other resources include:

• Doloplus-2, which is a behavioural pain assessment scale for older people who present with verbal communication disorders
• Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)
• Royal Children’s Hospital, Melbourne, Clinical Guidelines (Nursing). Pain Assessment and Measurement.

What the standard says

Whenever an opioid analgesic is considered for a patient with acute pain, their risk of opioid-related harm is assessed. An opioid analgesic may be prescribed when other analgesics are not clinically feasible or sufficient, and the potential benefits outweigh the potential harms.

What the quality statement means for health service organisations

Ensure systems are in place for clinicians to assess and document avoidable, modifiable risk factors before a decision is made to prescribe an opioid analgesic.

Ensure systems are in place for clinicians to establish a patient’s opioid status before prescribing opioid analgesics to treat the patient’s acute pain.

Ensure policies and processes are in place to provide clinicians with access to appropriate tools, such as a real time prescription monitoring system (where available) or the Prescription Shopping Program, to identify and assess patients at risk of harm from CNS depressants before opioid analgesics are given or prescribed to treat the patient’s acute pain.

Related resources

Real time prescription monitoring systems:

• QScript (Queensland)
• SafeScript NSW (New South Wales)
• SafeScript (Victoria)
• Canberra Script (Australian Capital Territory)
• DORA (Tasmania)
• ScriptCheck (South Australia)
• Electronic Recording and Reporting of Controlled Drugs (Western Australia).

The system of Real Time Prescription Monitoring (RTPM), on which the state and territory systems are based, is designed to monitor the prescribing and dispensing of controlled medicines with the aim of reducing their misuse in Australia.

Services Australia provides a Prescription Shopping Program for prescribers of PBS medicines to make informed decisions for patients who may get more PBS subsidised medicines than they need.

What the standard says

A patient with acute pain prescribed an opioid analgesic who is at increased risk of opioid-related harm is appropriately managed in conjunction with a locally approved pathway to mitigate the potential for harm.

What the quality statement means for health service organisations

Ensure there is a locally approved policy that defines the clinical pathways for hospitalised patients who are identified to be at increased risk of opioid-related harm. The pathways should enable clinicians to refer and escalate care of patients at increased risk of opioid-related harm to access support services, including specialist services for paediatrics, pain management, drug and alcohol, clinical pharmacy and allied health.

Ensure systems are in place to inform patients why they are being referred to a pathway and the plan for their ongoing clinical management.

Ensure clinicians are trained on how to access the pathways and that workforce proficiency is maintained.

Related resources

Drug and alcohol services

• Drug and Alcohol Specialist Advisory Service for New South Wales and ACT health professionals
• Drug and Alcohol Clinical Advisory Services (DACAS) for Victoria, Tasmania and Northern Territory health professionals
• Drug and Alcohol Clinical Advisory Services (DACAS) for South Australia health professionals

What the standard says

If an opioid analgesic is considered appropriate for an opioid-naïve patient with acute pain, use an immediate-release formulation at the lowest appropriate dose, for a limited duration, and prescribe in line with best practice guidelines. Modified-release opioid analgesics cannot be safely or rapidly titrated and their use in acute pain should be exceptional and not routine. The patient is supported to cease any opioid analgesic use as their function and pain improve.

What the quality statement means for health service organisations

Ensure systems are in place for clinicians to be able to access best practice guidelines for appropriate prescribing of opioid analgesics for acute pain.

Ensure processes and systems are in place to alert clinicians to limit the duration of therapy for opioid analgesics and plan to reduce their use.

Ensure policies, procedures and systems are in place for clinicians to supply or prescribe paracetamol and anti-inflammatories alongside opioid analgesics.

Ensure policy and procedures are in place to prevent the prescribing of modified-release opioid analgesics for routine management of acute pain.

Related resources

• WHO Analgesic Ladder (revised) (2020)
• Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists. Opioid Dose Equivalence Calculation Table.
• Acute Pain Management: Scientific evidence, 5th edition
• Therapeutic Guidelines: Pain and analgesia
• ANZCA Guideline on Acute Pain Management
• ANZCA Position Statement on the Use of Slow-Release Opioid Preparations in the Treatment of Acute Pain
• PROSPECT. Better Postoperative Pain Management Guidelines

---

Paediatric guidelines

• Children’s Hospital Westmead. Pain Management – CHW: Practice guideline
• Royal Children’s Hospital, Melbourne, Clinical Guidelines (Nursing). Pain Assessment and Measurement
• Royal Children’s Hospital, Melbourne, Clinical Guidelines (Nursing). Management of the Paediatric Patient Receiving Opioids
• South Australian Paediatric Clinical Practice Guidelines. Acute Pain Management and Opioid Safety in Children
• Perth Children’s Hospital. Analgesia (ED guidelines)

---

Reducing guidelines

• Primary Health Tasmania. A Guide to Deprescribing Opioids

What the standard says

When an opioid analgesic is prescribed, supplied or administered for a patient with acute pain, adverse effects are monitored and managed. The patient and carer are made aware of potential adverse effects and signs of overdose, including respiratory depression.

What the quality statement means for health service organisations

Ensure systems and protocols are in place for clinicians to monitor and manage opioid analgesic adverse effects such as nausea, constipation, sedation, and signs of overdose including respiratory depression (OIVI). Ensure monitoring of sedation levels and appropriate action when sedation levels increase. Ensure all clinicians are aware of these systems and protocols.

Ensure protocols are in place to escalate care. Ensure all clinicians are aware of these protocols.

Where electronic healthcare records are in place, consider incorporating PowerPlans, flags and reminders of opioid analgesic adverse effects into the record management system.

Related resources

The Australian and New Zealand College of Anaesthetists Statement on principles foridentifying and preventing opioid-induced ventilatory impairment (OIVI) in the acute pain setting provides one example of a commonly used sedation scoring system:

Sedation scores

• 0 = awake, alert
• 1 = easy to rouse, remains awake
• 2† = easy to rouse, unable to remain awake
• 3 = difficult to rouse

* Note that a sedation score (e.g. ‘sedation score less than 2’) may be specified in the ‘Max dose/24 hrs’ in the PRN section of the national inpatient medication chart to indicate the maximum amount to be administered in 24 hours when prescribing opioids.

† A score of 2 is taken to indicate early respiratory depression (OIVI) and therefore the aim should be to

titrate an opioid so that a patient’s sedation score is always less than 2.

---

Other tools and guidelines

• Faculty of Pain Medicine, Australian & New Zealand College of Anaesthetists. Opioid Dose Equivalence Calculation Table
• South Australian Paediatric Clinical Practice Guidelines. Acute Pain Management and Opioid Safety in Children
• Clinical Excellence Commission NSW. Managing Side Effects of Opioid Medicines in Hospital: Information for patients, families and carers
• Victorian Quality Council, Victorian Department of Human Services. Acute Pain Management Measurement Toolkit,

What the standard says

When a patient with acute pain is prescribed, supplied or administered an opioid analgesic, the intended duration of therapy, and the review and referral plan are documented in the patient’s healthcare record. The cause of the pain for which the opioid analgesic is prescribed is documented, including on the inpatient prescription.

What the quality statement means for health service organisations

Ensure a system is in place for clinicians to document the intended duration (number of days), the weaning and cessation plan, and the review and referral plan for opioid analgesics in the patient’s healthcare record.

Ensure a system is in place for clinicians to document the cause of pain for which the opioid analgesic is prescribed, including on the inpatient prescription.

Where electronic medical records are being used, incorporate flags and reminders into the record management system to support documentation in all relevant fields or consider making them mandatory fields.

What the standard says

During hospital care, a patient prescribed an opioid analgesic for acute pain is assessed regularly to determine their response to therapy and whether an opioid analgesic is effective and appropriate for their stage of care.

What the quality statement means for health service organisations

Ensure systems are in place for clinicians to regularly review the effectiveness, appropriateness and ongoing need for opioid analgesics according to the patient’s stage of care. In hospital, this includes ceasing opioid analgesics when no longer necessary and reviewing regularly from the first prescription. Ensure an oMEDD calculator is available for clinicians to determine the appropriate daily dose of opioid analgesic.

Include systems to ensure that review of opioid analgesics occurs immediately before the patient leaves the hospital.

Ensure referral and escalation of care processes are in place to support clinicians when a patient’s acute pain does not respond to opioid analgesic therapy. This may include referral to other hospital-based support services, including escalation to specialist services for paediatrics, pain management, drug and alcohol, clinical pharmacy and allied health.

Ensure policy, procedures and systems are in place to support clinicians to change from intravenous to oral opioid analgesics in patients with acute pain. This should include incorporating flags in electronic medication management systems where these are in use.

What the standard says

Planning for appropriate analgesic use at the transfer of care begins when a patient is started on an opioid analgesic during their hospital visit, according to an agreed opioid analgesic weaning and cessation protocol. The number of days’ supply of an opioid analgesic on discharge is based on multiple factors, including the expected course of the patient’s condition, appropriate arrangements for follow-up and opioid analgesic use in the last 24 hours before discharge.

What the quality statement means for health service organisations

Ensure a locally approved policy is in place to support transfer of care of patients discharged from hospital with a supply or prescription for opioid analgesics.

Ensure an opioid analgesic discharge weaning and cessation protocol is available to clinicians and used for patients who are prescribed, supplied or administered an opioid analgesic for acute pain during their hospital stay.

The protocol should address the cessation or weaning of opioid analgesics started in hospital and provided or prescribed over more than 24 hours. On hospital discharge, the protocol should outline the elements of a weaning and cessation plan that includes:

• The selection of an appropriate formulation of an opioid analgesic
• For patients in hospital for more than a day, the selection of an opioid analgesic dose on discharge that is based on use in the last 24 hours before discharge, using an oMEDD
• For patients discharged from day surgery, the selection of an appropriate opioid analgesic appropriate dose based on the expected trajectory of the patient’s condition
• An appropriate supply of opioids, considering the day of discharge and when the patient can reasonably be expected to access primary care and other healthcare services post‑discharge
• Processes to identify patients who already have opioid analgesics in their possession that may adequately treat their acute pain and do not require an additional prescription on hospital discharge, and to advise them on the appropriate use of those analgesics
• Prompt communication of a clinical handover summary to the patient’s general practitioner that includes
  • the cause of the pain for which the opioid analgesic was prescribed
  • the opioid analgesic dose prescribed or recommended on discharge(which will differ to the inpatient dose)
  • a medication management plan that includes recommendations for reducing and ceasing the opioid analgesic where appropriate
• Provision of written patient information that addresses
  • how many times a day to take, use or apply the medicine, and if the medicine should be taken with food
  • whether the medicine may affect other medicines
  • what the potential adverse effects are and how to manage them
  • when to seek urgent care for adverse effects of the medicine or lack of pain relief
  • details of how to reduce the medicine and stop the medicine (weaning and cessation plan)
  • how to safely store and dispose of the medicine.

Ensure processes are in place to identify the patient’s general practitioner who will continue the patient’s care after leaving hospital. If this is not possible, ensure processes are in place to assist the patient access health care after discharge.

Ensure processes are in place to reduce and stop the opioid analgesic by allowing up to a maximum of:

• Three days’ opioid analgesic supply to patients discharged from the ED
• Seven days’ opioid analgesic supply for patients discharged following a hospital stay.

These processes should allow for exceptions such as the patient’s ability to access services in the community and comorbidities.

Related resources

Clinician resources

• SA Health. Clinical Guideline for Prescribing Opioids on Discharge
• WA Health. Recommendations for Prescribing Analgesia on Discharge Following Surgery or Acute Injury: Information for health practitioners preparing the patient for discharge
• Society of Hospital Pharmacists of Australia. Take-Home Naloxone in Australian Hospitals

Consumer resources

• Clinical Excellence Commission NSW. Managing Side Effects of Opioid Medicines in Hospital: Information for patients, families and carers
• Alfred Health. Managing Your Pain After Leaving Hospital
• SA Health. Oxycodone For Short-Term Management of Acute Pain
• SA Health. Information for Paediatric Patients, and Their Carer, Given Opioids for Short-Term Treatment of Acute Pain
• SA Health. Going Home After Having Been Given a Medicine That Can Make You Sleepy
• WA Health. Pain Relief Medications Following Surgery and Injury: Information for patients preparing for discharge
• TGA. Return Your Unused Opioids – Resource Kit
• Pharmaceutical Society of Australia. Opioid Medicines Fact Sheet for Patients, Families and Carers