Opioid Harm Reduction Strategies

The opioid crisis describes the significant ↑ in opioid-related morbidity and mortality across Western nations, driven by:

This section covers harms of opioid medication. Administration of IV and PO opioids for analgesia are discussed separately under Opioid Harm Reduction Strategies, and intrathecal administration is covered under Intrathecal Analgesia.

• Development of new opioid preparations, including oral slow-release formulations
• Expansion of opioids to manage cancer pain, and then chronic non-malignant pain
• Dramatic ↑ in the use of opioids for post-operative analgesia

Epidemiology and Risk Factors

Perioperative:

• Opioid prescriptions on discharge and following surgical procedures are identified as independent risk factors
• Surgery is a potential gateway to longterm opioid use
• Significant excess of discharge opioid
  
  • 70% of patients have opioids remaining
  • Only 5% of them dispose of it correctly

Prevention

Harm reduction strategies can be divided into:

• Upstream Pharmaceutical and government interventions.
• Midstream Hospital interventions.
• Downstream Community, GP, and pharmacy interventions.

Upstream

Include:

• Legislative changes
  • Up-scheduling
    Requiring more drugs to be prescription.
  • Use of prescription trackers to identify doctor shopping
    e.g. SafeScript.
• Pharmaceutical changes
  • Formulation of abuse-deterrent preparations
    Addition of naloxone to oral opioids.

Midstream

↓ Prescription of opioids by:

• Identify patients at risk of chronic post-surgical pain
• Opioid stewardship programs
  
• Education of patients for realistic expectations for analgesia and harms of over-prescribing
• Opioid prescribing guidelines
• Changing default opioid prescription doses in EMR systems

Optimise acute pain management:

• Early multi-modal therapy
• Regular dosing
• Titrate opioids carefully
• Dose reduction plan on discharge

Downstream

Key principles:

• Education:
  • Prescribers
    • HMOs
    • Senior registrars and consultants
  • Dispensers
    • Pharmacy
  • Patients
  • Community
    • GP
• Opioid return programs
  • Pharmacies

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References

1. Schug SA, Palmer GM, Scott DA, Alcock M, Halliwell R, Mott JF; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2020), Acute Pain Management: Scientific Evidence (5th edition), ANZCA & FPM, Melbourne.
2. Toon, M. Opioid harm reduction strategies - stemming the tide. Australian Anaesthesia. 2019.