Opioid deprescribing on discharge: An audit of post-surgery patients

Background

Opioid misuse and deaths have focused attention on opioid availability and oversupply, alongside dependency and personal, social and economic costs. Dorset is an outlier for liquid morphine 10mg/5mL usage, particularly over-labelled packs. High quality patient care requires multimodal analgesia, including opioids, promoting well-managed post-operative pain, speedier recovery and discharge. Good practice for new strong opioids on discharge requires providing advice on deprescribing, specifically not for repeat within community settings.

Analgesia guidelines:

• Paracetamol +/- naproxen (max 7 days) and strong opioid: First line morphine, second line oxycodone (CKD3)
• Proton pump inhibitors (PPI) with NSAID if >65yrs or high-risk factors.

Objectives

To audit discharge analgesia for adult patients undergoing total hip replacement (THR) or total knee replacement (TKR) surgery.

Audit standards (all targets 100%):

1. Opioid analgesia on discharge is PRN 4-6hourly (from 2 hourly as in-patient) maximum 100mL GP to continue “No”.
2. Oxycodone only used if CKD3 (CrCl <59ml/min).
3. NSAID courses limited to 7 days.
4. PPIs prescribed with NSAID if >65yrs or high-risk factors.

Method

All adult patients undergoing THR or TKR from 1 April 2022 to 13 June 2022 were obtained from Clinical Audit. Patients were excluded if they had been prescribed a strong opioid prior to admission, or were admitted as emergency admissions, or had no Dorset Care Record (DCR).

Patient, prescribing and dispensing data were collated from patient and clinical systems using an Excel spreadsheet. Data included age, renal function, length of stay (LOS), pain scores, analgesia for discharge, and gastrointestinal (GI) protection. Strong opioids continued after discharge were identified from DCR. This study did not require ethics approval.

Results

Of 36 eligible patients, 64% (23/36) had TKR. The median age of patients was 71 years (45-85).

Inpatients

• 16% (3/19) prescribed oxycodone had CKD3
• PPIs: 47% (17/36) new, 29% (5/17) <65yrs, 41% (7/17) no NSAID

On discharge

• 66% (23/36) were dispensed a strong opioid
  • 42% morphine, 22% oxycodone
  • all PRN, 4-6 hourly, 100mL
• 61% (22/36) pain score = 0; 59% (13/22) supplied a strong opioid

Discharge letter

• 52% (12/23) of opioids highlighted ‘short term’ by pharmacist
• All opioids stated GP to continue “No”

In primary care

• One new opioid continued as repeat
• One new PPI continued.

Conclusions

All strong opioids were de-escalated and quantities followed guidelines. The opioid continued in primary care had an in-patient pain team review and deprescribing plan in the discharge information.

Strong opioids supplied with pain scores of 0 indicates oversupply, although the known reluctance to document actual pain scores due to increased workload may have underestimated pain. Only three patients were eligible for oxycodone.

Overuse increases drug and staff costs (controlled drug documentation/storage), indicating a potential for cost savings. Overuse of PPIs occurred; one was continued in primary care, indicating that a further review was required. Planned changes include guideline/e-protocol and prescribing prompt review, clarification of renal thresholds and staff education.

Additional authors: L Edwards

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.