Dr. Brian Rotenberg, MD MPH FRCSC
Catherine Joyes, HBA, MLIS, MBA
Dr. Davy Cheng, MD MSc FRCPC FCAHS CCPE

Schulich School of Medicine and Dentistry
Western University
London, ON

The use of opioids to manage acute pain has increased substantially, with serious consequences. The total amount of opioid tablets prescribed to patients in acute pain settings has increased over time, with Ontario having the highest rate of opioid dispensing, and opioid-related morbidity and mortality is making routine headline news in all forms of media.

A Canadian population-based study examining elderly patients undergoing low-pain short-stay surgery found that an alarming 10% became long-term opioid users at one year. Other studies have reported similar growing long-term opioid use in a proportion of patients after day-surgery or from acute pain settings.

This excessive prescribing of opioids in the postoperative acute pain setting has numerous negative effects. It is both contributing to long-term use and creating a problem with unused opioids as they are rarely disposed of in an appropriate manner.

Addressing the opioid issue is complex, and requires multiple strategies, but an important component is more judicious prescribing in the acute pain setting. St Joseph’s Health Care London and London Health Sciences Centre are regional and provincial leaders in patient care, and as a result, our hospitals have a prominent responsibility to urgently address the local crisis.

Consequently, in November 2017 the hospitals created an Opioid Stewardship Council (OSC) tasked with addressing this challenge. Since its inception, the OSC has reviewed the available evidence-based literature on prescribing for acute pain and synthesized this in conjunction with a snapshot of the challenges facing the London region. We have also deliberately kept the scope of this project focussed on acute pain management, since that is the point of entry for many new diagnoses of opioid use disorder. Chronic pain is a different matter.

The OSC has initiated several key strategies intended to change prescribing behavior within both organizations.

• Tamper-resistant prescriptions have been developed and will be used for any opioid prescription at either site.
• The Institute of Safe Medical Practices has developed a stakeholder education sheet that will be provided to patients with any opioid prescription. Physicians and nurses are required to review this document with patients at the point of prescription to help patients understand what to expect.
• With any new opioid prescription, the new default duration of prescription would become 3 days maximum, based on evidence-based guidelines that consider this duration to be sufficient for most types of acute pain management.

In concert with the above, we have also asked the regional hospitals with whom we share patients to completely align with these changes. As a result, an incredible 14 hospitals in Southwestern Ontario are now all working together with the same strategy to ensure that the risk of excessive opioid use is being minimized in our patient population.

We are also gathering metrics related to Health Quality Ontario’s standards to assess the effectiveness of the intervention, with data to follow in the coming months.

Together, these changes are an example of how policy that is based on good health research and evidence can help to tackle the complex problem of Canada’s opioid crisis.