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Prescribing slow-release opioids can be fatal, leading college warns

Doctors have been warned about the risks in prescribing commonly used opioids such as fentanyl patches or slow-release opioid tablets for relief of acute pain in patients not used to them or with conditions including obesity and sleep apnoea, and those taking sedatives because of the risk of respiratory failure and accidental death.   Anaesthetists and pain specialists say the risk of harm without carefully adjusting doses is particularly high in people sensitive to, or not already taking slow release opioids such as oxycodone.
 
The Australian and New Zealand College of Anaesthetists has written to 34 of Australia and New Zealand’s leading medical colleges and associations including the Royal Australian College of General Practitioners, the Royal Australasian College of Physicians, the Royal Australasian College of Surgeons and the Australian Medical Association as part of an opioid information campaign.
 
The college is also advising its specialists to reassess opioid prescription on discharge from hospital in response to growing concerns, supported by clinical evidence, about their use, toxicity and safety.
 
“Slow-release opioids are not recommended for use in the management of patients with acute pain,” says the position statement released by the Australian and New Zealand College of Anaesthetists (ANZCA) and its Faculty of Pain Medicine.
 
The use of slow-release opioids for the treatment of acute pain can be associated with a significant risk of respiratory depression, resulting in severe adverse events and deaths, the statement says.
 
“There are many effective alternatives to opioids for acute pain, but if opioids are needed and used then there are other options that are safer than slow-release opioids, and the duration of any opioid treatment should be limited,” said ANZCA President, Professor David A Scott.
 
“We know of cases where relatively fit patients have gone into hospital to have routine surgery to repair, for example, a knee or shoulder injury and have been prescribed slow-release opioids to manage their pain,” said Professor Scott.
 
“They have subsequently become drowsy and difficult to wake. There can be fatal consequences in extreme cases.
 
“Unfortunately, these risks are not widely appreciated in the medical community which is why we have commenced this education campaign with our colleagues.”
 
For many patients their first exposure to opioids occurs in hospital after an operation or when being treated for an injury.
 
Those at high risk from slow-release opioids include patients on benzodiazepines, some antihistamines, anti-depressant or anti-psychotic medication and patients with obesity and/or chronic sleep apnoea because the treatment can suppress their breathing, sometimes with fatal consequences.
 
Patients who have not been taking opioids prior to their surgery or acute injury are also sensitive to their effects and so if using opioids, doctors need to adjust doses accordingly and use immediate-release preparations. Elderly patients are also more sensitive to opioids.
 
Risks of slow-release opioids include:
  • Accidental deaths.
  • Adverse effects.
  • Interactions with other medications such as benzodiazepines and alcohol.
  • Increased risk of falls.
  • Impaired driving judgement.
Professor Scott said the use of slow-release opioids in the management of acute pain in Australia and New Zealand had become commonplace despite overseas guidelines cautioning against the practice.
“Anaesthetists and specialist pain medicine physicians are ideally placed to show leadership by working with GPs and other medical specialists to encourage management of acute pain with limited or no opioid therapy wherever possible,” Professor Scott said.
 
Professor Scott said it was important to be aware that not all acute pain was responsive to opioid treatment, for example, patients with inflammatory conditions or injuries involving nerve damage.
 
“Acute pain associated with trauma or surgery can fluctuate significantly within short time periods and often decreases rapidly after the initial onset,” he explained. “Slow-release opioids don’t allow us to adjust pain treatment to address these changes.”
 
Professor Scott said the prescribing of slow-release opioids in the initial treatment of pain was   associated with an increased risk of long-term opioid use, especially if patients are discharged with more tablets than likely to be needed.
 
”Long-term opioid use often begins with treatment of acute pain and it is known that many patients prescribed an opioid for management of their acute pain will still be taking an opioid more than six months after discharge from hospital unless a limited duration of treatment is planned at the time,” he said.
 
Professor Scott said many doctors, including anaesthetists and specialist pain medicine physicians, were already changing their clinical practices to minimise the dangers and risks of opioid use for their patients.
 
The college hopes the latest recommendations will encourage better understanding and communication in hospitals and with medical staff about the importance of reducing the amount of opioids prescribed to patients especially on discharge.
 
Patients should be reassured that acute pain can be treated effectively without the need for slow-release opioids.
 
 
 
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