ROSI FAQs

Opioid stewardship programs do not require large teams. Any interested pharmacist, senior nurse, or doctor can be an opioid stewardship champion and build an opioid stewardship program.

Do not prescribe any modified-release opioid preparations for opioid naive patients.

The central goal of any opioid stewardship program is safe and effective opioid prescribing. The prescribing guides included in the ROSI are a simple first step that can help initiate and support the introduction of an opioid stewardship program.

Prescribing guidelines ensure prescribers have ready access to best-practice prescribing for simple analgesics and opioid medications. They can help reduce prescriber errors and ensure appropriate medication inclusion and exclusion. Clinical decision support tools have been demonstrated to decrease variability, improve quality, decrease adverse events, and improve efficiency and costs¹.

Adapt the ROSI prescribing guides to suit local context however do not include any modified-release (MR) preparations.

Presentation at grand rounds, morbidity and mortality meetings and department in-service sessions help facilitate stakeholder education and increase clinician engagement with opioid stewardship programs.

Acute pain service teams should be included as a standing item in anaesthetic department M&M meetings. Reports should include rates of respiratory depression, review of adverse events and current prescribing rates.

ROSI guides provide information on compiling reporting rates for all these criteria.

Strong evidence for altering prescribing habits has been demonstrated by providing individualised feedback to prescribers, known as academic detailing².

An informal chat is often the best way to facilitate conversations to address the need for change, challenge long-held beliefs and provide information and evidence on best practice opioid prescribing in acute pain.

Prescribers must be aware that documents, such as the ANZCA Position statement on acute pain management 2023 and the ACSQH Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, are the current best practice reference documents against which clinicians' practice is measured.

These documents would be used as evidence for minimum safety standards in the event of a critical incident review.

• Ensure resources are embedded into all new hospital policy and procedure documents. Where possible, revise existing documents to include resources.
• Ensure unity across all resources, e.g. prescribing protocols are aligned to lanyard cards.
• Create folders in applications such as HosPortal or other mobile apps to facilitate timely and easy access to protocols and other reference documents.
• Distribute lanyards / prescribing cards to all prescribers on commencement of employment or during orientation.
• Be a constant reminder to clinicians of the need for judicious use of opioids when prescribing and for the consideration of the ongoing need for prescribing when preparing discharge medications.
• Always reference local protocols and other documents (for example the FPM position statement/CCS) when providing advice or consultation to raise awareness of best practice evidence and recommendations.

Both the Clinical Care Standards and FPM regard that MR opioids should only be prescribed in exceptional circumstances^3,4. MR opioids should not be initiated within the first 1-2 weeks of the onset of acute pain.

Administration of MR opioids increases the risk of adverse events including increased sedation score, opioid-induced ventilatory impairment (OIVI) and the consequent increased risk of patient harm⁴. The risk of unintentional overdose events has been reported as significantly increased within the first two weeks of initiation of a MR formulation⁵.

Additionally, evidence suggests that the addition of a MR opioid does not improve pain scores or functional ability as significantly lower peak plasma concentrations are achieved with MR medications compared to immediate-release (IR) formulations.⁶

Finally, the risk of persistent post-operative opioid use is increased when patients are commenced on MR opioids. Weaning and ceasing of MR preparations requires increased oversight and monitoring when comparted to IR formulations.⁷

Prescribers in tertiary hospitals, in particular, must be mindful that regional or country patients may not have sufficient or timely access to resources to support opioid use and weaning when they return home. Appropriate oversight may be significantly more challenging in regional and remote locations where timely access to GPs can be difficult. Clear plans and expectations regarding the ongoing need for opioids should be provided to patients prior to discharge. This is much easier to achieve when only immediate-release preparations are prescribed.

A modified-release opioid should not be initiated within the first 1-2 weeks of the onset of acute pain.

In the context of severe and ongoing acute nociception, and in pain that has been demonstrated to be opioid responsive, a time-limited prescription for MR atypical opioids may be warranted. However, this must be regarded as an exception rather than routine practice and prescribing in this case must include a plan for review, weaning and ceasing.

The ROSI includes a guide to assist with preparing an application to the local Drug and Therapeutics Committee to request an expansion to hospital formulary and other local prescribing restrictions. This resource can be adapted for local use.

Opioids should not be supplied "just in case". Most acute pain lasts 7-10 days, and patients are often more comfortable at home than in hospital.

Prior to recommending any opioid medication for discharge:

• Review opioid requirements for the previous 24-48 hours
• Ask patients how many tablets they think they will require (they will often respond with a smaller number than clinicians would otherwise prescribe and be equally satisfied and comfortable).
• If the patient is from an area where timely access to post discharge GP follow up may be delayed, then the amount of opioid provided for discharge should be sufficient to prevent unintended premature cessation of opioid analgesia.

If an opioid is dispensed on discharge, ensure the patient and GP hasve received instructions for weaning and ceasing.

Instructions for expectations regarding the ongoing use of opioids prescribed in the hospital should be included on all discharge summaries. The Pain Medicine Discharge Plan is a simple, effective and timely way to provide information about in-hospital analgesic prescribing and expectations for ongoing analgesic requirements.

Encourage patients to book appointments with GPs prior to hospital discharge.

For individuals identified as high risk, it may be appropriate for a senior clinician to contact the GP to discuss the expected trajectory for recovery and the ongoing need for opioid prescribing.

Pharmacy department (for example opioid stewardship pharmacists) can assist with data collection of local prescribing and dispensing rates.

Quality and risk managers within hospitals can provide information on rates of hospital acquired complication (HAC).

ROSI resources include downloadable quick guides to assist members of the multidisciplinary team to obtain data to provide evidence for the relevant quality statements.