Work

Calling time on the use of modified‐release opioids for acute pain

Year: 2024

Type: article

Abstract: PerspectiveCalling time on the use of modified-release opioids for acute pain T he first modified-release (MR) formulation of oxycodone was approved for the management of pain in 1995 and aggressively marketed (with false claims of a low addiction risk) primarily for the management of chronic non-cancer pain. 1 In many high income countries, including Australia, 2 prescription of MR oxycodone for the management of acute pain, especially post-operative pain, then became commonplace.1 This occurred despite no evidence at the time showing that MR oxycodone was betterin terms of analgesia and/or adverse effects -than immediate-release (IR) oxycodone alone (as explained below).1,3,4 A survey of Australian public and private hospital pharmacists showed that MR opioids were commonly prescribed to opioid-naïve patients with acute pain in more than 70% of hospitals -both as an inpatient and at discharge. 2 Guidelines reflecting the current evidence base and aiming to improve the safety of opioid use for acute pain management in Australia have recently been introduced.5,6 These strongly recommend against the initiation of MR opioids for acute pain in opioidnaïve patients.Opioids remain an important part of multimodal acute pain analgesic regimens, with guidelines indicating how to use IR opioids more safely and effectively, while not limiting appropriate access and dosing for patients who require them.Calling time on initiating MR opioids for acute pain is a key recommendation of these guidelines and aims to reduce opioid risk in two key areas: in-hospital morbidity and mortality, and inadvertent persistent post-discharge opioid use (PPOU), which comes with its own list of potential adverse effects.7 Recent changes to opioid-prescribing guidelines in AustraliaIn 2000, regulatory changes made by the Australian Therapeutics Goods Administration were designed to decrease the risk of harm from prescription opioids.8 Included in the changes were that MR opioids should not be used for the management of severe pain unless the pain is opioid-responsive and "requires daily, continuous, long term treatment" (thus excluding acute pain).8 In 2022, the Australian Commission on Safety and Quality in Health Care published their Opioid Analgesic Stewardship in Acute Pain Clinical Care Standards, which advised that MR opioid use for the management of acute pain "should be exceptional and not routine".5 In the same year, a new Choosing Wisely Australia statement said "Avoid routine prescription of slow-release (SR) opioids in the management of acute pain, in hospital and community settings, unless there is a demonstrated need, close monitoring is available, and a cessation plan is in place".9 A 2023 publication from the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine contains similar recommendations, 6 which are consistent with other Australian 10,11 and international guidelines.

Source: The Medical Journal of Australia

DOI: 10.5694/mja2.52417

Authors: Pamela E Macintyre, Melissa A Jamcotchian, Jennifer A Stevens