Components of opioid stewardship

Dr Nicholas Levy, consultant anaesthetist at West Suffolk Hospital, has summarised the components of opioid stewardship as follows: 

• Educate prescribers, people with lived experience of pain and their carers
• Manage expectations about the role of opioids in chronic pain
• Consider opioid use for non-cancer-related pain, with an appropriate treatment duration to avoid repeat prescriptions
• Avoid co-administration of other sedating drugs
• Avoid long-term use in order to reduce side effects, tolerance and physical dependence
• Consider the effects of opioids on the person’s ability to drive or perform other skilled tasks
• Review and closely monitor people who are prescribed opioids
• Promote the safe storage and disposal of opioids, making sure to avoid opioid diversion
• Conduct further research into the long-term safety and efficacy of opioids.⁵

Applying opioid stewardship to practice 

When reviewing prescriptions for opioids, pharmacy technicians should consider whether: 

• The opioid is enabling the person to improve their level of function – for example, can they carry out their daily activities? 
• The person has opioid non-responsive pain
• The person is developing tolerance
• The person is developing opioid-related side effects
• There is potential for opioid deprescribing. 

You should also consider whether the opioid may be worsening the person’s pain, causing opioid-induced hyperalgesia. 

Hyperalgesia

Opioid-induced hyperalgesia (OIH) is “a state of nociceptive sensitisation caused by exposure to opioids”.⁶ It is characterised by a counter-intuitive response, where a person receiving opioids for the treatment of pain may become more sensitive to certain painful stimuli.⁶

A person with OIH may report worsening of their original pain, increased sensitivity or the development of pain in a new area. OIH can occur with the use of opioids at any point, but may be more likely to develop when opioids have been used at high doses for long periods of time.⁷ 

Explaining the concept of OIH can be difficult, but it is important to bring it into a conversation around opioid deprescribing.