Table 2 Results of the Delphi survey. Statements are in their final version
From: System-level policies on appropriate opioid use, a multi-stakeholder consensus
Statements | Agreement on the final version | Changes | Agreement on prioritisation | Changes |
|---|---|---|---|---|
Governance policies | ||||
The presence of a Pain Management, Analgesia or Opioid Stewardship Steering Committee, with multidisciplinary representation from Key Stakeholders is a priority in the context of acute pain, especially in the hospital. Key goals of this committee will be to inform, coordinate and action tasks and projects which support comprehensive Stewardship, supported by local data. | 91% | + 11% | 96% | + 1% |
The health system should have policies in place which outline the safe and accountable use (closed-loop) of drugs which could lead to dependence and/or unnecessary morbidities or mortalities, such as opioids, combined or not with gabapentinoids, cannabinoids. This includes policies and practices around storage (including strategies to avoid selection error), order, transfer, administration (including comprehensive independent second checks) and disposal of controlled drugs within the hospital, management and return of patient’s controlled drugs, and strategies to identify and address diversion. This should be context and country sensitive. | 100% | + 5% | 96% | + 11% |
Pain Management policies | ||||
Research and policies should be developed to have a better understanding and vision of who are the prescriber and what are the determinants of the prescribing practices, not only about opioids but also about non-opioid and non-pharmacological pain management strategies. This could include research about local strategies, development of specific pain management guidelines, educational programmes, agreement to the use of Therapeutic Guidelines, additional structure around referral criteria (‘Traffic Light’ System as often used for Antimicrobial Prescribing), analgesia de-escalation guidelines, discharge prescribing guidelines. | 100% | + 5% | 91% | + 6% |
Policies should be developed providing guidelines on maximum doses and duration of treatment for high-risk medications such as opioids and high-risk combinations. While most opioid medications will not necessarily have a ‘maximum’ licenced dose, it should be agreed the dose and duration at which senior or specialist review or approval is required. | 86% | + 1% | 76% | −6% |
Processes and guidelines should be prioritised regarding the quality of the follow-up and the referral on high-risk patients. This may include referral pathways in pre-admission clinics for patients on > 50 mg oral morphine equivalent daily dose (OMEDD). Doses of these high-risk medications should always be confirmed with prescriber or dispensing pharmacy. | 87% | + 2% | 78% | + 3% |
Every hospital should have a programme for identifying the places where opioids are used systematically and identifying whether any regular re-assessment based on relevant outcomes occur. This would aim to identify, and sensitize the prescribers, when opioids are systematically used without any relevant evidence, before surgery, during the perioperative period or prescribed systematically at the hospital discharge. | 96% | + 1% | 91% | + 6% |
There is a specific hazard with adding new constraints on opioid prescribing that should be specifically addressed to prevent the risk of leading to the pendulum swinging too far in the other direction, with the risk of patients suffering unnecessarily pain possibly responsive to opioids. The place of opioid should be determined, i.e. where and when they are/will be identified as highly effective and without better alternative so as not to create counterproductive measures. | 100% | 0% | 96% | + 4% |
Patient Care and Consumer Engagement | ||||
Processes should be developed to facilitate and monitor the return any unused or expired analgesic medications or promote the nearest pharmacy which will accept returns. This may include promotion in patient counselling materials, in pharmacy signage, or in local publications such as newspapers, websites or social media accounts. | 91% | + 6% | 52% | −3% |
Every system should develop mechanisms to regularly audit to monitor, disseminate, and benchmark indicators of the quantity and appropriateness of opioid use and quality of pain management. This may include a real-time monitoring, specific to acute and/or postoperative pain, including the analysis of combination with other hypnotics like gabapentinoids, cannabinoids or benzodiazepines. | 100% | + 10% | 96% | + 1% |
Public opinion and societal attitudes should be explored on the implications of ‘Pain relief as a human right’. | 86% | + 21% | 59% | + 4% |
Secondary care practitioners should identify and provide opportunities to interact with General Practitioners and other community providers in promoting pain management and opioid/gabapentinoid/benzodiazepines stewardship after prescription for acute pain. Secondary care may provide guidance on duration of analgesia prescriptions and there should also be opportunities for primary care to feedback on the suitability of guidance. This may include invitations to relevant Grand Rounds presentations, or organising forums with local community providers to discuss pain management and opioid stewardship, Q & A evenings, seeking feedback regarding discharge handover, engagement through GP Liaison Officers. | 100% | + 10% | 96% | + 6% |
Support and access to primary or secondary care deaddiction services should be available to patients who develop substance use disorder as a result of prescribed analgesia. This may include the development of multidisciplinary ‘Pain and Dependency’ services integrating psychosocial and medical care. | 96% | + 1% | 100% | 0% |
Information from drug intelligence and law enforcement agencies as well as from overdoses and deaths related to prescribed drugs should be fed back to prescribers. | 87% | NA | 65% | 0% |