As a medical health professional, patients look to you as a key influence in their pain management. The strategies you equip your patients with, and the medication you prescribe, should always be clinically appropriate and tailored to their personal needs. There are a number of tools and resources you can access to help maximise patient benefits and minimise the potential harms associated with prescription opioids.
Know the Risk – Daily Oral Morphine Equivalent
Patients can be on a combination of prescription opioids or at doses which place them at risk. The Faculty of Pain Medicine’s opioid calculator is an essential clinical tool, designed to simplify the calculation of equianalgesic dose by expressing it as total oral Morphine Equivalent Daily Dose (oMEDD). It uses a “traffic light” dose warning system as a clear, simple way to indicate the risk of dose-related harm.
HealthPathways SA is a free online portal that provides GPs and other health professionals with easy access to comprehensive, evidence-based assessment, management and local SA referral pathways for specific health conditions. HealthPathways SA is developed locally by South Australian GPs, specialists, nurses and other health professionals to improve patient access to the right care at the right time in the right place.
Pathways to support patient care include:
- Chronic Non-cancer Pain in Adults
- Medications in Chronic Non-cancer Pain
- Self-management Support for Chronic Pain
Prescribing In The Community
Most acute pain conditions presenting in general practice can be treated with non-opioid analgesia, with the RACGP specifically advising against prescription opioids for:¹
- Uncomplicated back and neck pain
- Uncomplicated musculoskeletal pain (i.e. shoulder pain)
- Uncomplicated headache or migraine
- Non-traumatic dental pain
- Acute exacerbation of chronic non-cancer pain (CNCP)
- Irritable bowel syndrome
If you do make the decision to prescribe opioids, this should be a conscious decision and made in partnership with the patient. Consideration should be made for the length of trial, discussion of potential side effects, additional supporting self-management strategies and review criteria. This is to reduce the risk of “drifting” into long-term opioid use, a common situation after an acute presentation or post-surgery.
Opioid therapy is not indicated in chronic non-cancer pain, with no evidence for improving chronic pain and functional outcomes in this cohort.² Population studies show that people maintained on long term opioid therapy for CNCP describe more troublesome pain and greater functional interference than people not on opioids.
To find out more on prescribing best practice, visit:
- The Royal Australian College of General Practitioners (RACGP) – guidelines for prescribing drugs of dependence
- Faculty of Pain Medicine ANZCA – recommendations regarding the use of Opioid Analgesics in patients with CNCP
- Faculty of Pain Medicine ANZCA – quick reference recommendations for conduct of an opioid trial in patients with CNCP
The Routine Opioid Outcomes Monitoring (ROOM) Tool is a screening tool for prescription opioid dependence, developed specifically to use in primary care settings.³
Click here to download.
Opioids and Their Impact on Surgery
Research is identifying the use of opioids pre-surgery, and the significant impacts on surgical outcomes it brings, including an association with increased postoperative complications.⁴ Reducing the use of opioids before surgery can result in improved clinical outcomes for your patients, comparable to those who use no opioids at all.⁵
The role of opioids in post-surgery management is also a focus in Australia. Recent research has identified in many Australian hospitals, prescription opioids are a standard discharge prescription post-surgery.⁶ In April 2019, the Lancet revealed a major contributor to the opioid issue is the inappropriate management of post-surgery pain that becomes chronic and long-lasting.⁷
For more information, explore the work being undertaken by Dr Jennifer Stevens, anaesthetist and pain specialist at St Vincent’s public and private hospitals in Sydney and acting chair of ScriptWise.
De-Prescribing Prescription Opioids
Prescription opioids should always be prescribed with a plan for reduction and cessation in place. Patient education is essential to successfully tapering opioids, with success more likely when the person is aware of the issues with long term use.
Tolerance to the analgesic effects of opioids develops in almost all people with long term use, with decreased benefits in long term prescription opioid use, defined as over eight weeks.²
It is recommended that patients with chronic non-cancer pain taking 100mg oral morphine equivalent or more should have their opioids decreased. Patients who are taking between 50-100mg oMEDD should be considered for opioid dose reduction or cessation².
The Guide to Deprescribing: Opioids is an outline of recommended deprescribing where ongoing use is not appropriate.
The Faculty of Pain Medicine (FPM) has developed recommendations about how to cease opioids after prescribing them to a patient. It sets out specific weaning strategies in the context of transition to self-management. Click here to view the FPM recommendations in entirety.
A summary of considerations is offered below²:
- Utilise a motivation approach, discuss the risks vs benefits of long-term opiates with consideration to the ‘stages of change’.
- Discuss side effects and dependence using the ROOM tool.
- Consider other methods of pain relief in collaboration with the patient.
- If on multiple opiates, convert to one medication using the Opioid Calculator.
- Tailor the reduction to the needs of the patient, decreasing at a rate that allows the patient to manage withdrawal symptoms.
- Discuss the risk of overdose if the patient returns quickly to a previous high dose of opiates.
- Offer psychological support to deal with anxiety or depression.
- If tapering quickly, watch for opiate withdrawal side effects such as flushing, disturbed sleep, muscle cramps, nausea and tremor.
- Use of short term supplementary medications, such as benzodiazepines for sleep disturbance and anxiety, anti-emetics, antidiarrheals, muscle relaxants and non-opioid analgesics may be helpful to alleviate withdrawal symptoms.
- Offer clear and regular support and encouragement and help the patient build a team of others who can also support and encourage them if necessary.
NCETA have a short resource developed to address several key issues related to pharmaceutical opioids. It is available here.
For information on the use of Naloxone in opioid overdose prevention and response in South Australia, please refer to SA Health’s website
 Royal Australian College of General Practitioners (2017), Prescribing drugs of dependence in general practice – Part C1: Opioids.
 Primary Health Tasmania and Consultant Pharmacy Services (2019). ‘A guide to deprescribing: Opioids’. Available from https://www.primaryhealthtas.com.au/resources/deprescribing-resources/
 Nielsen S, Picco L, Middleton M, Kowalski M & Bruno R, Validation of the Routine Opioid Outcome Monitoring (ROOM) Screening tool in patients prescribed opioids for chronic pain. National Institute on Drug Abuse (NIDA) International Forum, San Antonia, Texas, USA. June 17, 2019 (Poster presentation)
 Cozowicz C, et al. (2017), ‘Opioid prescription levels and postoperative outcomes in orthopaedic surgery’ in Pain, 158(12): 2422-2430.
 Nguyen LCL, et al. (2016), ‘Preoperative reduction of opioid use before total joint arthroscopy’ in Journal of Arthroplasty, 31(9): 282-287.
 The Society of Hospital Pharmacists of Australia (2018), Reducing opioid-related harm: a hospital pharmacy landscape paper.
 Monash University (2019), ‘Landmark Lancet series reveals poor management of surgery pain key contributor to global opioid crisis’.