We read with great interest the article by Lam et al. [1]. The authors used linked hospital and community pharmacy data for surgical patients and applied mixed-effects logistic regression models to predict persistent opioid use at 90 days after hospital discharge. Among the 122,836 patients included, the odds of persistent opioid use were significantly lower for those who received modified-release tapentadol compared with modified-release oxycodone. However, we wish to re-iterate that the Australian and New Zealand College of Anaesthetists and its Faculty of Pain Medicine has advised against the initiation of modifiedrelease opioids for the management of acute pain due to their limited effectiveness in reducing pain intensity [2] and worse in-hospital clinical outcomes [3] compared with immediate-release opioids. Lam et al. noted that patients prescribed tapentadol had higher baseline comorbidity compared with those prescribed oxycodone.Weare in agreement that prescribers may bemore likely toprescribe tapentadol formore complex patients. In 2022, we collected electronic medical record data from three metropolitan hospitals in Australia on adults who received formulations of tapentadol or oxycodone for analgesic purposes during inpatient stay following a surgical procedure. We used a different method to that used by Lam et al. to classify comorbidity burden. The International Classification of Diseases 10th Edition, Australian Modification diagnosis codes were used to identify comorbidities at baseline and to calculate the Charlson comorbidity index [4].We included 93,650patients, of whom 1671 received tapentadol and 25,168 received oxycodone postoperatively. We identified that patients prescribed tapentadol had a higher mean (SD) Charlson comorbidity index, 1.3 (2.0) vs. 0.8 (1.7), p < 0.001. Our data also highlighted higher proportions prescribed tapentadol compared with oxycodone in those patients receiving cardiac valve interventions and coronary bypass (21.3% vs. 1.6%, p < 0.001) and spinal surgery (5.3% vs. 4.6%, p < 0.001). As demonstrated in a 2022 systematic review, rates of persistent opioid use after surgery in Australia vary widely from 5.3% after joint arthroplasty to 50.1% after spinal surgery [5]. In the study by Lam et al., surgical specialties were not reliably captured due to inconsistent or non-specific data. While a sub-analysis for orthopaedic procedures was conducted, the effect of differences in other surgical procedures, such as cardiac procedures, on the incidence of persistent opioid use remains unclear. In addition, the effect of unmeasured variables, such as peri-operative prescribing practices, on the study outcomes is unknown. For instance, the use of tapentadol may be an indicator of safer opioid prescribing practices over recent decades which may subsequently contribute towards a reduction in persistent opioid use. Randomised trials involving various surgery types investigating the impact of tapentadol, compared with other opioids, on persistent opioid use are, therefore, required to confirm the conclusions reported by Lamet al.

Effect of discharge opioid use on persistent postoperative opioid use

Opioids are commonly prescribed to manage pain after surgery. However, excessive supply on discharge can increase patients’ risk of persistent opioid use and contribute to the reservoir of unused opioids in the community that may be misused. This study aimed to evaluate the use of opioids in Australian surgical patients after discharge and patient satisfaction with the provision of opioid information after discharge. This prospective cohort study was conducted at a tertiary referral and teaching hospital. Surgical patients were called 7–28 days after discharge to identify their opioid use and the information that they received after discharge. In total, 66 patients responded. Most patients underwent orthopaedic surgery (45.5%; 30/66). The median days of opioids supplied on discharge was 5 (IQR 3–5). In total, 40.9% (27/66) of patients had >50% of their opioids remaining. Patients undergoing orthopaedic surgery were less likely to have >50% of their opioids remaining ( P = 0.045), whilst patients undergoing urological or renal surgeries were significantly more likely ( P = 0.009). Most patients recalled receiving information about their opioids (89.4%; 59/66). However, the majority (51.5%; 34/66) did not recall receiving any information about the signs of opioid toxicity and interactions between opioids and alcohol. In conclusion, around 40% of patients had more than half of their opioid supply remaining after they ceased taking their opioid. Although most patients recalled receiving information about their opioids, more than half did not recall receiving any information about the signs of opioid toxicity or interactions between opioids and alcohol.

https://journals.sagepub.com/doi/pdf/10.1177/0310057X231163890

Supply of opioids and information provided to patients after surgery in an Australian hospital: A cross-sectional study

Opioid prescribing requires careful planning to minimise the risk of serious adverse outcomes. However, documentation of discharge opioid plans for patients and their general practitioners (GPs) is inconsistent, particularly when opioids are commenced in the emergency department or after surgery. We describe an initiative to promote consistent discharge opioid plan communication by implementing an opioid management plan (OMP) in our hospital's electronic medical record. Completion of an electronic form by the prescriber generates an OMP note in the medical history, which is used by the pharmacist to provide tailored opioid patient education. The OMP also populates the discharge summary that is sent to the GP and the Australian national digital health record platform, My Health Record. Preliminary evaluation shows incorporating OMP documentation into routine workflows has assisted prescribers to consistently document the plan for supplied opioids, supporting continuity of care. Workflow optimisation is ongoing to further improve discharge summary documentation and provision of patient-friendly written information. This study was conducted as a quality improvement project and audits conducted as part of the project were approved by Austin Health's Office for Research (Project No: LNR/18/Austin/155). Informed patient consent was not required by Austin Health. 

Design and implementation of an electronic opioid management plan to support consistent communication of opioid analgesia prescribing intentions to patients and general practitioners

The Stewardship Framework (Framework) was developed by an expert clinician group and was designed to provide a mechanism for continuous monitoring of improvement in opioid prescribing in acute hospitals. The aim of this study was to modify the Framework into an Opioid Stewardship Self-Assessment Tool (Self-Assessment Tool), and pilot test the acceptability and its use in a variety of acute hospital settings.The Framework was converted into the Self-Assessment Tool to allow hospitals to undertake a gap analysis of their current opioid stewardship activities. To participate hospitals were required to establish a small team and complete the Self-Assessment Tool. Participating sites were recruited using purposive sampling. Responses were tabulated and coded to enable assessment. 'Acceptability' was defined as the completion of the Self-Assessment Tool (response rate, proportion of questions answered) and responder feedback relating to its content. The use of the Tool was categorised based on the level of detail of responses.Nineteen of the 20 facilities approached, agreed to participate. The 16 sites which established a small team to facilitate survey completion are included in the final analysis. The overall response rate was 96 % (413/432) for the (27 survey questions across 16 participating sites), 4 % (19/432) of questions were left unanswered or were not interpretable by the study team. Opportunities were identified to enhance the use of the Self-Assessment Tool, particularly to support its potential to assist reflection and planning of local strategies.This study demonstrated that the Self-Assessment Tool was an acceptable method of assessing a facility's opioid stewardship capabilities in a real-world setting. The next iteration will be modified using the insights on how the Tool was used by study participants. 

Describing the acceptability and use of an opioid stewardship self-assessment tool in real-world settings

The relationship between presurgical opioid type and persistent postoperative opioid use: a retrospective observational linkage study comparing tapentadol and oxycodone.

ObjectiveThis systematic review identified studies that provided an estimate of persistent opioid use following patient discharge from hospital settings in Australia.MethodsA literature search was performed on 5 December 2020, with no date restrictions to identify studies that reported a rate of persistent opioid use following patient discharge from Australian Hospitals. The search strategy combined all terms relating to the themes 'hospital patients', 'prescribing', 'opioids' and 'Australia'. Studies that dealt solely with cancer, palliative care or addiction medicine were excluded. The databases searched in this review were Embase, PubMed, Scopus, CINAHL, and International Pharmaceutical Abstracts. Studies were assessed for bias using the Newcastle-Ottawa Scale and considered against international literature.ResultsIn total, 13 publications are included for final analysis in this review. Of these, 11 articles relate to post-surgical opioid use. With one exception, studies were of a 'good' quality. Methods of data collection in included studies were a mixture of those conducting follow up of patients directly over time and those utilising dispensing databases. Persistent opioid use among surgical patients generally ranged from 3.9 to 10.5% at between 2 and 4 months after discharge.ConclusionsHow rates of persistent opioid use following hospital encounters in Australia are established, and how long after discharge rates are reported, is heterogeneous. Literature primarily relates to post-surgical patients, with very few studies investigating other settings such as encounters with the emergency department.

Persistent opioid use after hospital discharge in Australia: a systematic review.

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Persistent opioid use after hospital discharge in Australia: a systematic review.