Climate-aware prescription of inhalation medication

The most commonly used, high-acting opioids are morphine, fentanyl, oxycodone, and buprenorphine (1). In 2024, more than 1.1 million people received an opioid through the public pharmacy (2). Although the total number of benefits in kind fell slightly compared to 2023, the number of prescriptions from the hospital actually increased slightly (3). A first dose of a high-acting opioid included an average of 9 days of medication in 2024 (3), while acute pain due to trauma or surgery often requires only 48 hours of strong opioid pain relief (4). Prescribing opioids for too long increases the risk of dependence and also leads to unnecessary environmental impact.

Research shows that the amount of opioids that patients receive at discharge influences their actual use (5). As recovery progresses, the need for opioids decreases rapidly; four days are sufficient for most patients. This is in line with international recommendations that recommend a duration of 3 - 7 days (6-8). The guideline of the Dutch Association of Anesthesiology (NVA) also recommends appropriate use of opioids through restrictive prescribing (up to 7 days) tailored to the pain experienced (9).

Another bottleneck is that the intended treatment duration and indication of opioids at discharge or outpatient dispensing are not always explicitly stated or shared with patients and primary care providers. As a result, GPs and pharmacists often lack crucial information to continue treatment responsibly or to phase it out in time. This increases the risk of unnecessarily long use, and thus unnecessary environmental impact and risk of dependency.

Based on a recent opinion article This intervention has been selected in the NTvG by Kaal et al. This article recommends that there is more room for oral antibiotic initiation, but does not describe clinically tested interventions. This intervention will therefore be further developed on the basis of available scientific literature and will follow at a later date.

Antiemetics, such as 5HT3 antagonists (e.g. ondansetron and granisetron) and dopamine antagonists (e.g. metoclopramide), are widely used in clinical care to prevent and treat nausea and vomiting, for example postoperatively or during chemotherapy. Research shows that antiemetics administered enterally (e.g., orally or rectally) at an equivalent dose usually have a similar effectiveness and safety to those administered intravenously (IV) (1-2).

The oral/rectal route contributes to greater comfort and autonomy. In addition, the use of oral/rectal medication is more cost-effective and sustainable, because fewer disposable materials are required than intravenous administration (3). In situations where oral administration is not feasible, such as severe nausea or vomiting, rectal administration may sometimes still be chosen. IV administration is only eligible if this is not possible. This is further detailed in the NVZA monographs (4-6).

The prescription of multiple anticoagulant therapy (e.g. double or triple therapy with anticoagulants and antiplatelet agents) is complex and associated with an increased risk of bleeding. Patients often use these combinations temporarily, for example after acute coronary syndrome, percutaneous coronary intervention, or concomitant atrial fibrillation and stent implantation (1). European and Dutch guidelines therefore emphasize that double or triple therapy is never indicated for life, but always has a limited treatment period, depending on the clinical situation and the individual balance between the risk of bleeding or an ischemic event (1).

In practice, however, it appears that these drugs are regularly used for too long or are continued without a current indication, which significantly increases the risk of serious, preventable bleeding. For example, research in Dutch pharmacies showed that 14— 23% of patients who used dual anticoagulation no longer had a valid indication (2). During hospitalization, it was found that more than 40% of patients with multiple anticoagulant therapies used these combinations incorrectly (3). This risks bleeding complications, and thus unnecessary hospital admissions (4), but also contributes to unnecessary costs and environmental impact.

To prevent this, clear communication during dismissal and transfer is crucial. Explicitly sharing the indication and the intended treatment duration with primary care (general practitioner and pharmacist) enables follow-up care providers to continue treatment responsibly or to stop it in time. This contributes to medication safety, reduces the risk of complications and prevents unnecessary drug use.