Articles and Case Studies

Oxycodone in the Community

15 Aug 2017

Dr Andrew Miller author

by Dr Andrew Miller

Row of pills

Patients are increasingly being sent home post-surgery while still requiring strong analgesia. This has the advantage of making more efficient use of hospitals and reducing exposure to nosocomial pathogens.

Anaesthetists and surgeons are thus faced with logistic and pharmacological challenges in providing acute post-operative pain control in the early discharge setting. Many of us now need to prescribe opiates for home use, and provide repeats direct to pharmacies for patients who have been discharged to remote locations. Australia is now ranked third in the world for oxycodone prescription.1 

The use of opioids at home has always brought with it some risk, but with the increased use of oxycodone in the community the incidence of serious complications has risen. In the decade ending 2009 oxycodone supply increased nine fold, while there was a twenty fold increase in deaths in Victoria related to oxycodone use.2 Most of these were ruled unintentional. There is evidence of an illicit trade in oxycodone tablets in Australia. 

What responsibility does the prescribing anaesthetist have in this context?

If sending a patient home with this drug, it would be prudent to provide information to explain the potency, the interactions, and the need to avoid overdosage. In particular the use of oxycodone with alcohol, benzodiazepines and illicit drugs should be highlighted as dangerous. We cannot force patients to follow our instructions but we should at least offer the advice where the risk is obvious. 

What alternatives are there? 

The apparent better community safety profile of codeine may be due to its lower efficacy. There is a significant group who have allergy or prior adverse reaction sufficient to make prescription relatively contraindicated. Morphine in pure form is unlikely to be safer or less addictive than oxycodone, and the abuse potential is high. Dextropropoxyphene has been withdrawn from the market. Tramadol is less efficacious and has a relatively high incidence of side effects. Buprenorphine patches are a helpful addition and as a partial agonist are safer. 

Diversion for intravenous abuse is not a problem with the patches. Pregabalin is useful in some types of surgery but can be expensive. Paracetamol is a good foundation drug but insufficient on its own in many post-operative scenarios. Non-steroidal anti-inflammatories can be likewise a useful addition but have a proportion of adverse effects.

How could the system be improved? 

The expansion of “hospital in the home” initiatives have led to extensive nursing being provided in the community. Consideration could be given to extending an acute pain service beyond the hospitals to improve provision and safety of analgesia. Dedicated contact or chat lines could also provide and centralise advice. Pharmacy level controls on prescriptions have been helpful but need to be improved to be “real time”, in order to reduce inappropriate prescription, abuse and diversion of the opioids.3 

The problem of disposal of excess medication has not been satisfactorily addressed in many jurisdictions, such that many patients end up with a store of opioids that are no longer required. Such a stockpile can present a risk in future if used to treat other problems or people. 

For anaesthetists the production of standardised information for patients that explains the risks and appropriate usage of these drugs would be helpful.

References

  1. Roxburgh A, Bruno R, Larance B, Burns L. Prescription of opioid analgesics and related harms in Australia. Med J Aust 2011;195(5):280-284. 
  2. Rintoul AC, Dobbin MD, Drummer OH, Ozanne-Smith J. Increasing deaths involving oxycodone. Victoria. Australia, 2000-09.Inj Prev 2011 Aug;17(4):254-9.Epub 2010 Dec 16. 
  3. Hall WD, Farrell MP. Minimising the misuse of oxycodone and other pharmaceutical opioids in Australia. Med J Aust 2011;195(5):248-249

Article originally published in Anaesthesia Update 2012

Clinical, Anaesthesia
 

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