Pain relief without dependence

Much attention has recently focused on the use of opioids, which include morphine and related painkillers such as oxycodone. Though regarded as a blessing for patients suffering from severe and acute pain, they can also be a curse due to their potentially addictive nature and the risk of fatal overdose.

The opioid crisis in the U.S. and Canada, where tens of thousands of people die of overdoses each year, is now casting a shadow over Europe, where the number of prescriptions for opioids such as oxycodone has seen a big jump over the past decade.

Opioids also feature large in the research collaboration between Kantonsspital Baden's hospital pharmacy and the Institute of Pharmaceutical Sciences at ETH Zurich, a project that has been running for more than four years. ETH's participation in this project is led by Professor of Pharmacoepidemiology Andrea Burden. A key role is played by her colleague Dominik Stämpfli, who splits his time between working as a clinical pharmacist at Kantonsspital Baden and as a scientist in Burden's research group at ETH.

Optimal therapy

Both researchers work on a number of topics, including the risks that medication poses to patients and how drug administration can be improved to ensure patients derive the maximum benefits from their course of treatment. Their goal is to minimize the frequency of side-effects, the risk of overdose and the development of drug dependence.

Re-hospitalization also forms part of their research. A key goal of care is to avoid any post-discharge complications that might make it necessary for a patient to be readmitted after leaving hospital. Once again, opioids emerge as a key factor here, as an ETH Master's student was able to show in a data analysis under the supervision of Stämpfli and Burden.

This analysis revealed that patients who were still being prescribed opioid painkillers at the time of discharge from hospital had an increased risk of being re-hospitalized within 30 days. "The results confirmed what we already knew: that we need to take better care of patients that receive opioids," says Stämpfli.

According to an analysis of health insurance data—excluding patients who receive opioids for cancer pain and opioid-dependent patients receiving controlled quantities under medical supervision—around one-third of people in Switzerland who are prescribed opioids by a doctor continue taking the medication for over 12 months. Yet evidence suggests that while opioids are useful for treating acute pain and for palliative care, they should not be taken for longer periods of time to treat chronic pain.

This is because long-term use may increase sensitivity to pain, hinder rehabilitation or lead to opioid use disorder with the risk of overdose. Recommendations on how to make the best use of these drugs in hospitals are therefore vital. At Kantonsspital Baden, a team is now working with resident clinicians, nurses and primary-care practitioners to put together appropriate guidelines. This will also include advice on how doctors and nurses can work together to ensure that patients eventually come off their opioid medication.

Discharge without opioids

"Patients need better support with opioid therapy; we shouldn't be leaving them to deal with this alone," says Burden. This support might include monitoring patients more closely while they are still in hospital, as well as making an earlier start on tapering off the dosage. "Ideally, this tapering process would be completed before the patient leaves hospital, so that they can be discharged without opioids," says Stämpfli.

Meanwhile, patients who still require opioid painkillers after leaving hospital should be given detailed information on how to use their medication properly, either through talking to a clinician or in the form of leaflets. Patients and their primary-care practitioners need to know how quickly they should taper off opioid medication for acute pain. Kantonsspital Baden is therefore working with Burden on a study that will assess the effectiveness of different tapering strategies.

"It's not about withholding opioids from patients, because they have the right to relief from excessive pain," says Burden. "It's more a question of making responsible use of this type of pain-relief medication, which basically means using it for short-term relief from acute, severe pain and combining this with a clear exit strategy."

The collaboration between Kantonsspital Baden and ETH offers benefits for both sides. "ETH Zurich doesn't have a medical faculty; by working with the hospital, we get the opportunity to conduct research using patient data and to carry out clinical studies," says Burden.

The key benefits for her come from the close contact to doctors, nurses and pharmacists who work with patients on a daily basis—in other words, practitioners who have plenty of pressing questions. "Scientists like us have the research expertise and can help them find the answers they need," she says.