Episode 46: The safe use of opioids in acute pain

Welcome to the NPS MedicineWires podcast, helping health professionals stay up to date with the latest news and evidence about medicines and medical tests. Hello, I'm Dr Kate Ania, I'm a GP and I'm also a medical advisor for NPS MedicineWires. Thanks for joining us on this podcast. Now today we are revisiting the important topic of opioid analgesic prescribing, this time with a slightly different focus and that is the acute pain setting. Opioids have established efficacy in treating acute pain but they also come with significant risk of harms. A particular concern is the rate at which short-term use results in persistent and long-term problematic use. Now I'm joined by Professor Pamela McIntyre, who is an emeritus specialist pain medicine physician and consultant anaethodistate role at Adelaide Hospital and a clinical professor at the University of Adelaide. Prior to her retirement in 2020 she was the director of the acute pain service at the Royal Adelaide Hospital, the first in Australasia. Professor McIntyre's co-authored a book on acute pain management which is currently in its fifth edition. Throughout her career she is advocated for better and safer acute pain management and her more recent work has examined the role of acute pain medicine in the opioid epidemic, including prescribing of opioids after discharge from hospital. Now there have been no conflicts of interest declared for this podcast. So welcome Pam and thanks for joining me today. So if we could start by setting the scene here, could you take us through this important crossroad where a patient has found themselves in the emergency department with acute pain, say they have acute abdominal pain or they are having a surgical procedure done? How do opioid prescribing practices in this acute setting potentially impact on the long-term outcomes for some of these patients? Not firstly, I think it's important to say upfront that this severe acute pain needs to be treated properly in the first instance. And I know anecdotally that concerns about the opioid epidemic are sometimes now leading to under-dosing of opioids in the acute setting where they are really needed. So you mentioned trajectory and I think the key is to track the patient's progress, look at the trajectories of pain scores, look at trajectories of opioid requirements over the next few days and there should be decreasing. And as we'll probably talk about later trajectories that are not decreasing can mean there's an increased risk of opioid use for longer than is desirable which you've already mentioned as one of the issues with longer-term acute pain management. So one really alarming statistic that I came across was from a recent Australian study in 2019 that found that initiating opioid analgesia after surgery leads to ongoing use in about 4% of people. So if we look at the frequency of surgical procedures carried out in this country each year, this equates to over 100,000 people that are at risk of persistent use of opioids. So that's quite alarming isn't it? It is alarming and 4% I think was from the Australian data, it's even higher in some American studies and it's higher after some kinds of surgery. Sometimes I think we might we'll probably mention later it's because slow-release opioids were used rather than immediate release but it is alarming and it is in most instances I think preventable. Yeah. So why is long-term opioid use such an issue and something that we as health professionals need to try and prevent? Look there's many reasons why long-term opioid use can be a problem and firstly we know and the therapeutic goods administration was keen to emphasise we know that opioids are not the best way to manage chronic pain in most patients and after three months of pain we will consider that chronic pain. But there are other effects related to opioids that I think we need to be aware of. Most doctors would know about problems that might be related to tolerance dependence or in a small percentage of patients addiction they can become an issue. Most all have heard of opioid induced hyperalgesia where quite counterintuitively a reduction in opioid dose can improve pain relief or if you look at the other way giving more opioid can make pain worse but there's there's more and more recent evidence probably only the last decade or less shows that long-term opioid use is associated with an increase risk of infections so there is some degree of immunosuppression this might be infections in the community like pneumonia it can be hospital acquired pneumonia or infections that occur after sometimes some types of surgery and we also know that endocrine function can be affected I think many doctors are aware that sex hormone levels can be suppressed but probably fewer are aware that patients may have the secondary renal insufficiency so a dream of function can also be suppressed in very rare instances addisonin crises have even been reported there's also effects on bone metabolism so there's a high risk of osteoporosis and fractures and in the acute pain setting which is my area and was my area of practice it's been a huge increase in the number of papers published really just the last five to seven years show that patients who are taking opioids in the long-term and then undergo surgery have a much higher risk of poorer post-operative outcomes so for example one of the biggest study groups is patients having hip and knee replacement and we know from those data and it's usually big data from big data so we can't prove causality but preoperative opioid uses associated with an increased risk after hip and knee replacement of wound infection of periprostatic joint infection which is a terrible outcome and these patients are likely to spend not going hospital they're more likely to require a revision of their joint replacement and they may have higher admission rates re-admission rates so all of this is not good either for the patient in particular but it also will lead to high health care costs there is early good evidence or the good news is there's early evidence to suggest that weaning opioid doses ideally back to zero but even weaning the doses some months out from surgery may be able to reduce these risks back down to baseline levels it's not an easy thing to do but it may be worth trying yeah that's interesting so long-term opioid use can really lead to a multitude of damaging effects on the body in addition to potential issues with tolerance and addiction and I think that GPs can use these points to talk to their patients when having those risk-benefit conversations about opioid use in that acute pain setting now as a GP I'm aware of quite a few recent changes in the regulation space around the issue of opioid prescribing for acute pain could you walk me through the important recommendations of the opioid analgesic stewardship in acute pain clinical care standard that was recently published by the Australian Commission on Safety and Quality in Healthcare well yes the new clinical care standards built on really changes that were introduced by the therapeutic school to the Ministry or in part built on them that were introduced by the TJ back in July 2020 where they made quite significant changes to approved indications for the use of opioids prescription of opioids particularly slow release opioids they also made changes to pack size so that fewer than 20 tablets could be dispensed so this will make it easier for the standards the information suggests in the standards to be followed I think the looking at the standards they firstly and I think importantly right up front emphasize the importance of giving the patient and their care is appropriate information about both non-pharmacological and pharmacological options for managing acute pain yes they then look at how we should best assess the patient with pain because surprisingly that's not done as well as it it should be it says that we should be thinking about risk benefit whenever prescribing an opioid but I suspect that applies to prescribing any medication for a patient there's some good information about appropriate analgesic prescribing because I think this isn't done well still and they absolutely promote the idea that acute pain management only immediate release opioid should be used unless there are exceptional circumstances and the TGA actually says exceptional circumstances so this they're indicating the need for a shift away from what has become reasonably common practice of prescribing slow release opioids for the management of acute pain they also look briefly at how to monitor the patient given an opioid you'd think that is common knowledge again it's not unpleasant some care is also need to know a little bit about this because if a patient is given an opioid to take home they and their family need to know about some of the adverse effects and what to do and the status then finally and most importantly and things I think we don't do particularly well cover the things that are needed for a proper transfer of care to the patient's general practitioner yeah that's alright and I'll just mention there too that NPS medicine wise is also released to educational PDFs for using the emergency and the post-operative setting and that's intended as supportive resources for that clinical care standard and and thanks Pam for your work in assisting us in creating those resources oh that was good that was fun so how important is individualising the approach to acute pain management so for example should the prescriber's approach be different for a young fit healthy person as opposed to an older and more frail person absolutely and even regardless of age the key to safe effective management of acute pain really is to tailor the measurement to suit each patient every time especially when it comes to opioid doses and you mentioned older frailer patient we actually know as patients get older there is a steady decrease in the amount of opioid a patient needs to get good pain relief so initial doses firstly should be based on the age of a patient but it's not just that doses need to suddenly be lower in elderly or frail patients as you sometimes read in product information sheets but the dose requirements actually decrease at a steady state over all age groups and we give information to our junior doctors but the information is also in been incorporated into therapeutic guidelines and Australian medicines handbook about different suggested initial doses for severe pain but also moderate acute pain that divide the patients into different age brackets and give suggested starting doses once you've given the dose then you need to tailor that dose to suit each patient either increase or decrease yeah so that's interesting so it's a lot of individual variability there isn't there in what patients will require and obviously what what type of surgery they're having will also have an impact on it yes when we looked at this way back we published the bad age based dosing back in 1996 um the type of surgery we were looking at patients who were using patient controlled analgesia so by definition these would be major surgery the type of surgery and patient weight really didn't figure in the calculations the big the big differences the big predictor was patient age and I don't think people realize or we certainly didn't realize that even in each each age group there was an 8 to 10 fold variation in first 24 hour opioid requirements so there's a massive interpatient difference that most guidelines certainly when you looked at the product information sheets that accompany the medications they just don't take into account yeah that's interesting now the clinical care stand is also referred to the use of functional assessment tools to evaluate a monitor acute pain why the shift in focus to assessing function and how important is monitoring that trajectory of pain and function scores in in your individual patient well as as I said before monitoring um the the key is individual titration to each patient and monitoring is absolutely key to this to make it safe we know that pain scores pants very enormously between patients there are some recognized predictors of high pain scores after surgery including pre-existing chronic pain um patients who've been taking on opioid prior to surgery and those with psychological comorbidities maybe especially anxiety depression or those who exhibit catastrophic thinking the introduction of pain scores started with the pain is the fifth vital sign which was developed by the American pain society in the USA back in the mid 90s and it encouraged staff and I think quite appropriately encouraged staff to assess pain in all patients on a regular basis and try to improve the management of their pain they were encouraging really quite aggressive management of pain as they were in that time for chronic pain which we know was slightly now unsightly misguided but in the US the requirement for pain scoring in particular became part of accreditation requirements and it meant that um many centers in many centers staff were encouraged to give patients enough opioid to keep their pain scores below an arbitrarily acceptable level often a pain score of four and I remember thinking when this um campaign was announced that pain should be the fifth vital sign thinking my gosh we need to make sedation and we'll come to sedation later I think in monitoring and we need to make sedation scores six vital signs because if we push opioids the pain scores only there are going to be problems and then later one study by Violet Alback in 2005 showed that this approach of trying to lower patients pain scores ideally below four absolutely improve patient satisfaction and pain relief but it had the unfortunate effect of doubling the incidence of respiratory depression so it clearly shows that titration of opioids to pain scores alone wasn't safe right so around about 12 years ago 10 to 12 years I can't remember it was suggested that a patient's functions should be assessed as well I think this is something we'd all done clinically but colleagues of mine in Melbourne colleague mine in Melbourne David Scott together a very simple three-point function activity scored so it was assessing a patient's function relative to their surgery or injury for example if that had abdominal surgery it was their ability to take a deep breath and cough and there's an example of this or this function activity scale is actually outlined both in the standards document and in the NPS acute pain management document that you've just mentioned so if it meant that if a patient has high pain scores and there may be many reasons for it but if they have good function activity then more opioids are not indicated at that time at least if our very anxious they may benefit from someone sitting down and chatting to them about what's been happening how they're going and what's going to be happening over the next day or two so we need to listen to their concerns but it just reinforces I think that not all high pain scores need patients with high pain scores don't always need more opioid function activities the key and it's functional pain related movement related pain that is the pain that's going to inhibit their good recovery after surgery or trauma so we've switched to doing both function activity really to help titration of opioids pain scores I don't think we should abandon them but they're more useful as you've mentioned to track a patient's progress over time so look at their trajectory rather than an individual pain score that's right and then that functional score is just so important isn't it for the for the recovery so I'm monitoring someone's ability to you know to progress through to that recovery yeah absolutely it's the key yeah now I'm interested to in your experience as a clinician how open did you find patients where to the use of non-opioid analgesics or other opioid-sparing strategies to manage their pain and how effective can some of those strategies be look I think many of them were receptive I think ideally the time to talk about this is not when the patient is into the pain yes certainly for elective surgery the time to give appropriate information about all of this from pre-admission to after discharge is when the patient is seen before their surgery and their patient care is can be given some information about it and there are simple things there are obviously some more you know some of the non-pharmacological techniques could be quite advanced there would need a psychologist but simple things like distraction watching television playing computer games and sometimes the nurses will be able to get warm towels or warm blankets to put over their abdomen I think most of them are very receptive to it it's just that it's often not explained to them that's right so it's it's about you know making sure that they fully understand what how it can be helpful and and what the options are is absolutely yeah we often find patients say their pain is worse at night time and we used to say that's because this it's the whole ward is quiet you're not watching television people pain does get worse at night whereas when we can be distracted during the day it's not as bad often that's right and encouraging mobility rather than that than rest or that gradual return to normal activities is especially important isn't it it's absolutely it's especially important and that's another reason I think immediate release opioids are good because we can explain to the patient activity based analogies or is what we're after not to sit and watch television and if you take an immediate release opioid and then wait about an hour it will be having its peak effect and that's when you could get up and walk or do physio or any other activity that's right it also gives the patient some control over what they're doing yeah now you mentioned earlier that there's been that shift away from the use of modified and slow release preparations of opioids in the acute setting could we chat a bit more about why immediate release preparations are preferred now yes the practice of slow release opioids um became embedded in many institutional acute pain management protocols very quickly after slow release oxycodone was released in the US for the management of chronic non-cancer pain so I'm talking about oxycodone at that stage um there was the the US had less tight restrictions on the use of slow release opioids at that time it was basically for any pain that might last more than a couple of days but it rapidly became embedded in in that seced institutional pain protocols in early enhanced recovery after surgery protocols surprisingly there there was and still is no good evidence of benefit with slow release opioids when in fact the opposite I need to go back there was one particularly um influential study I think published in 1999 so three years after the release of oxycontin that did show of slow release oxycodone to be much much better than immediate release oxycodone in terms of pain relief in terms of patient sleep in terms of activity and I suspect it likely influenced clinical practice for a while because it was published in a prestigious journal um it probably had some influence until it was retracted ten years later because of scientific fraud right none of the other papers that I could find when I looked showed any benefit so it kind of they slipped in under the radar and really it was to part of the um information that was given about why it might be good for patients with acute pain is as with chronic pain the slow release formulations would provide constant plasma concentration so about 12 hours so the patients would get constant pain relief and that would be easier not just for the patients but twice daily dosing is obviously easier for nursing staff there were two major problems with this for a starter acute pain isn't constant and you've already mentioned that movement of oat pain is the problem inhibiting function activity is the problem and we know that movement of oat pain can be significantly higher than pain at rest there was a study a decade ago that showed the difference between movement of oat pain and pain at rest maybe as much as 200 percent there are any analgesic protocol needs to take this into account slow release opioids with a slow onset and slow offset mean it is just absolutely impossible to titrate appropriate opioid doses to the patient's requirement particularly pain and with movement we also know um that the information that was given out about um plasma concentrations being relatively constant over 12 hours actually wasn't true the initial graphs of plasma concentration that were used in the oxycontin product information sheet for example appeared to show relatively constant levels but they'd used a logarithmic scale on the vertical axis so um which blurred the differences when they plotted on a linear axis this quite a significant decrease over 12 hours so even if acute pain was constant which is not the plasma concentration to work constant so it's no it's no surprise really that more recent publications particularly a couple of really good ones that uh Jenny Steven's a colleague of mine in at St Vincent St Sydney has been involved in have shown that immediate release opioids result in better pain relief yeah also this increasing leverage evidence that um when slow release opioids we use not only was analgesia no better but it increased the risk of harms and particular respiratory depression related to opioids and in particular persistent postoperative or post discharge opioid use which you've already mentioned has been an issue right so there's lots of reasons there that that explain that shift and look if we just talk a little bit more about the respiratory depression issue yeah um how important is monitoring and managing adverse effects such as sedation and respiratory depression um in in that acute pain setting again key you can't safely titrate opioids to affect without good monitoring respiratory depression is an interesting one because um we know the only true measure of respiratory depression is obviously if we can measure a patient's blood carbon dioxide levels but this isn't possible even on a routine basis that will certainly would never be available for every patient uh given an opioid in hospital and we also need to think about how we monitor when a patient goes home the one thing unfortunately that is still not well recognised even though it's a problem that's been known probably for 25 30 years is that measurement of respiratory rate is a hugely unreliable indicator of respiratory depression and you will but we will still see studies published in papers to this day that to say the patients that they use a cutoff respiratory rate of less than eight or less than 10 minutes to say whether or not a patient had respiratory depression we know we've known for a long time as I said that patients can have very severe respiratory depression and yet have a respiratory rate that is considered to be within normal limits sedation seems to be the best indicator clinical indicator we have at the moment of respiratory depression so the nurses need to assess the patient's sedation on a regular basis and that basis should be tied to the root of the administration so if a patient is given an oral immediately opioid for example we would like them to add the nurses in our hospital and our local health network would do sedation scoring at the time of administration but then just pop back in our later when we expect the peak effect to be seen of the opioid they'll pop back and check on sedation scores the patient's sedation scores then because that's the time to work out whether also you've given enough opioid or whether that was an inadequate dose for the patient and having said that there needs to be written instructions for the actions to be taken interventions to be taken should the patient become oversadated the loop needs to be closed so if a patient has a sedation score of two or more and the sedation score systems we use are outlined in both the new standards and the MPS document the nurses need to know for example if the sedation score is two not to give any more opioid to the patients more awake and then regardless of pain scores to use a lower dose next time if sedation score is three two is the patient is easy to hours but has difficulty staying awake if the patient's difficult to hours are unconscious the nurses need to be able to straight away give no lock zone call medical emergency response team and absolutely if if patients need opioids and later on when all this has been sorted the dose must be lower again regardless of pain scores that's right so look if we shift now just to talking a little bit about discharge planning and communications now if a patient is prescribed an opioid when they're discharged from hospital for example after a surgical procedure what considerations should the prescriber make in determining the strengths and quantity of opioids to give a patient on discharge and what sort of information should be given to the GP the main consideration when it comes to prescribing opioids on discharge is not to prescribe excessive doses at that time and not to prescribe them for too long in Australia with PBS prescribing too long would mean that they needed to be repeat prescriptions because of the limitations to the the number of tablets in each box that you can prescribe unless you get permission in the United States they had no limitation on how many tablets patients could go home with and I know I've seen studies where patients went home with two or three hundred oxycodone tablets which is silly but I know so Australia we could do things a lot better we've not had the same problems with the opioid epidemic that they have in the states not in that problem because we've had the PC PBS limitations on prescribing amounts and the fact that you can't repress you can't give repeats so there's been many studies from the states now anyway looking at prescribing after different types of surgery and it was quite clear and some studies in Australia have shown the same that the opioid prescription hasn't always been appropriate in terms of the anticipated pain severity I know in one study or there's a second one just come out recently where patients were given an opioid after cataract surgery which is not appropriate so there's the prescription we know is not always appropriate in terms of how much pain we think the patient's likely to have or how long we think they're likely to have that pain for and if you prescribe very large amounts of opioids that are not needed it means there's a large amount available of unused opioids available which poses risks not just to the patient but also risks to family and there's been reports of children and pets coming to harm for example especially if the left over opioid or opioid even when it's been used he's not stored securely and there's risk to others in the community we know that about 50% of patients and this is information from Australia and the US about 50% of patients who of people who misuse opioids source them from family and friends so we need to make sure that when we send a patient home with oxicodeon that we're not unwittingly adding to this community pool we also know that prescribing too much again increases the risk of persistent postoperative opioid use the more you send a patient home with the longer they're likely to use it for and after a stage they end up taking an opioid for a pain that's no longer acute so it's not appropriate treatment anyway so many publications used to suggest particularly from the US that we base the discharge amount on the type of surgery the patients have but this isn't individualizing patient care and we know now it's much better and these standards recommend this to base the discharge dose on the amount of opioid the patient is shown they need in hospital before they go home so no just in case prescribing yeah that's true so where it's possible obviously with day surgery that's not not possible but we need to look better at individualizing discharge opioid prescribing just as we need to better individualize it in hospital that's right my understanding too is that the duration or the number of days of the first opioid analgesic prescription rather than the actual dose that's more strongly related to that misuse in the early postoperative period without the correct there's certainly shown the number of days is a problem and will lead to long-term opioid use so the patients and the patients general practitioner so they both need to be the general practitioner needs to know what our patients have been told and that's that they should decrease their dose a little each day or two as they recover not necessarily as pain schools go down but as they recover functionally they shouldn't have any alcohol when they go home if they're acquiring opioids they shouldn't take sedatives if they do become sedated they the patient won't notice but their family will so again we need to outline the intervention the family should take if their family member is is over sedated sedation scored two or three and it's reasonably easy to teach that then they need to be able to call an ambulance straight away we need to remind them that they shouldn't be driving while they're taking the opioid that was prescribed for acute pain we need to remind them as I said before about safe storage and disposal and as you've mentioned again they need to be reminded that pain relief is for activity rather than yes so they should use that to improve their recovery and so you know they're more information that you give patients I guess about all of those important points it just empowers them doesn't it and I think it in we need to help the general practitioners because we're not particularly good at giving good information to the general practitioner the standards are suggesting or we should say how long we think the patient will need opioids for for example but that's not always easy to tell the standards do suggest you should give less than seven days supply of opioids which A) might be not that easy in hospitals like ours that use PBS prescribing but some patients may need more than seven days but the general practitioner needs to know what we have told the patient and so patients can't say but there's been teaching hospital said I needed to continue oxycodone for example the GP needs to know that yes we did prescribe oxycodone on discharge but that after recovery is after discharge as well as in hospital dose trajectories need to be going downwards some patients it'll be slower than others but otherwise the trajectories should be downwards and the patient should be off all opioids as soon as feasible yeah so what does the GP do when they find themselves with a patient who is sent home from hospital with a short supply of opioids who then comes in presenting requesting more saying that their pain isn't well enough controlled and they need a longer supply what sort of things should the GP be on the lookout for in that scenario well as I said there are there are going to be patients who do need more opioid than they send home with particularly in where hospitals can't give a seven day supply and as I said even if we do limit it to seven days that can be difficult we if we do give an indication of how long we think opioids are needed that estimate can be quite inaccurate again um mentioning my colleague Jenny Stevens Dr. Jenny Stevens back that's in Vincent and Sydney they they were had been prescribing slow release opioids routinely for patients having hip and knee surgery knee replacement they changed to immediate release opioids and many patients now are not needing any opioid to go home but whereas some would have been using it for maybe a couple of months after surgery they aren't now so and we need to give better information it's not unreasonable for some patients to need more and I think the thing again I would be looking at is the opioid dose trajectory yes as I said some patients will decrease a little bit more slowly than others but as long as it's decreasing I'd be a little bit I'd be less concerned it doesn't mean it should decrease over weeks though weeks and weeks it should be over days if the trajectories are not decreasing all the pains persisting again we need to think about um and I've I she hadn't mentioned these before when trajectories either opioid dose trajectories or pain score trajectories are not decreasing firstly we need to think about non opioid responsive pain um and we know after some types of surgery that patients will have a mixed no-susceptive neuropathic pain pain opioids will be good for than the no-susceptive pain but not the neuropathic pain amputation phantom pain after amputation would probably be the key example of neuropathic pain after surgery but a significant proportion of patients for example after thoracotomy or breast surgery will have neuropathic pain so it's important to look at that see whether the pain that the patient has has a non opioid response is non opioid responsive pain or a mix because if we are treating neuropathic pain that's a different set of medications we also need to look at whether both in hospital and once the patient's gone home whether they're developing any post-operative or post-traumatic complications for example as I said you know um periprostatic joint infection after hip or knee surgery and again we need to take into account the patient's psychological comorbidities because we know the trajectories that are not decreasing are predicted by one of the predictors or his patients who have anxiety or depression or exhibit catastrophic thinking this is not for one minute saying these patients shouldn't be given an opioid but when they leave hospital but they just may need closer watching or more frequent review to make sure the dose trajectory is down that's right but it's looking at the whole patient really isn't it absolutely yeah yeah I look just one final question to Pam the clinical care standard talks about opioid analgesic stewardship as a shared responsibility how important is the role of other healthcare professionals in this whole process absolutely crucial it's just not going to work without in the hospital setting the nurses can be very helpful particularly again if they recognise that those trajectories aren't going down sometimes those trajectories I forgot to mention sometimes the reason for not decreasing is actually very benign the nurse might have seen that the previous two doses of opioid the patient given work well say three tablets and they might give another three tablets of oxycodone or the patients might say look three tablets worked really well can I have three tablets again and the nurses in a really good position to say you're you're recovering really well you've got in late terms you've got good functional activity how about we tried two tablets this time because if they're not enough after an hour we can probably give you a bit more so they're in a position to help with that the ward pharmacists are also I think often underused in hospitals again when they review the patients they will be able to look at the dose trajectories in particular and they're also crucial when it comes to the time of discharge because they're the ones that usually get to give the patients the information about their endogenic medications and they can run through the things I've mentioned about storage about adverse effects and also about how to decrease and cease them and there are some places now developing information sheets that will for example the ward pharmacist can help fill in as well as the ward doctors are obviously key to this as well they should be keeping in our own dose and pain trajectories but there are some information sheets now given to patients that will actually say to them how to decrease opioid and if they're prescribed multi-modal analgesia needs to continue after discharge but they still need to be told they should continue regular paracetamol continued regular non-steroidal anti-inflammatory drugs if not contrary indicated and they should continue those on a regular basis until the opioid dose has been tapered and then ceased and I think certainly our ward pharmacists were absolutely key to helping provide this information it's then up to the ward doctors to try and provide better information I think the patient's general practitioners so it's really a team effort isn't it we all need to be on that same page it has to be and I I should have you know the patient and their carers are obviously part of 13 that's great look there's obviously a lot more we could talk about here on this important topic but I wanted to thank you professor Pamela McIntyre for taking the time to talk to me today about opioid stewardship in the acute pain setting it's a really topical issue where we're seeing a lot of changes at the moment and hopefully we'll start to see some improved outcomes for patients as a result of these changes so for those of you who are listening who'd like more information you can go to our website nps.org.au where you'll find the resources that NPS medicine-wise has developed to support the safe use of opioids for patients presenting with acute pain within the emergency department and in the post operative period you can also visit the Australian Commission on Safety and Quality in Healthcare's website for the opioid allergies stewardship in acute pain clinical care standard gps can also go to our website for more information on CPG points related to this podcast so thanks for joining us and bye for now for more information about the safe and wise use of medicines visit the nps medicine-wise website at nbs.org.au