For complex problems, there are rarely simple solutions, but many pieces of an important puzzle.

Abstract

In our article [1], we presented original research with 120,000 Australian patients that specifically examined how discharge opioid type can influence rates of persistent postoperative opioid use, after considering and controlling for a range of other well established, and important, risk factors. We welcome the editorial by Bicket et al. [2] written to accompany our article. We believe some excellent points were raised and wholeheartedly agree that for complex problems, such as persistent opioid use, there are rarely simple solutions. We do not believe that opioid choice alone is the solution to persistent opioid use. Instead, our view is that, in order to address the wide range of risk factors relevant to this condition, we must have multimodal and comprehensive strategies. We certainly do not recommend “prescribe tapentadol and call it a day”, but propose that anaesthetists and pain management specialists, who are ideally positioned to make a positive impact on opioid prescribing, consider new evidence on the impact of opioid type on persistent opioid use after surgery. As we identified, the greatest risk factors for persistence included the use of medications such as opioids and psychotropic drugs in the period before surgery. However, for hospital-based prescribers, these are largely non-modifiable factors as they are already present at the time of admission. So, although many of the main risk factors for persistent postoperative opioid use are not modifiable, our study demonstrates that opioid type can be one modifiable factor that ought to be considered alongside all the other evidence-based strategies to reduce persistent postoperative opioid use, as outlined in various opioid stewardship programmes. Similar to UK guidelines [3] and the USA initiative [4] described in the editorial, in Australia there is a national opioid stewardship standard for hospital settings [5]. This was prepared by the government, endorsed by all the major medical and nursing colleges, and is intended as guidance so that all patients receive the same level of evidence-based, safe and effective opioid prescribing. There are nine quality statements, and statement five on “Appropriate opioid analgesic prescribing” recommends simple analgesics such as paracetamol and anti-inflammatory medications, as well as non-medication techniques as first-line analgesia, with judicious use of opioids reserved for more severe pain. This includes consideration of the quantity prescribed on hospital discharge, non-routine use of modified-release opioid formulations, duration of therapy post discharge and de-escalation plans as part of the hospital discharge summary. Further, the Australian and New Zealand College of Anaesthetists' position statement on acute pain management already describes a lower risk of adverse effects, such as ventilatory impairment, misuse and diversion with the use of the atypical opioids tramadol, tapentadol and buprenorphine (patches only) [6]. We wholeheartedly support the comprehensive nature of these opioid stewardship standards, and consider our specific work on opioid type to be but one of the many considerations that inform clinical decision-making. Lastly, with respect to the study limitations outlined in the editorial, we direct those who are interested back to our original article for a discussion on these aspects, and comments on future study designs which may address them.