Quality statement 3 - Risk–benefit analysis

If you have acute pain and might benefit from an opioid analgesic medicine, your clinician will ask questions to consider the benefits for you and to check your risk of harm from using these medicines. They will ask what pain medicines you are already taking or have used before. Sometimes an opioid analgesic may not be prescribed, because it is not the best medicine to treat your acute pain or there is a possibility of serious harm from the medicine. Opioid-related harm ranges from less serious effects such as nausea and vomiting, itchiness and constipation, through to severe problems such as an inability to stay awake or difficulty in breathing, which may be life-threatening. Long-term harms include dependence and addiction.

Before a surgical procedure, your clinician will ask you questions to determine your risk of harm if opioid analgesics are prescribed after your surgery. Some medicines increase the risk of side effects of opioid analgesics. It may be necessary for you and your clinician to consider reducing or stopping these medicines if opioid analgesics may be required.

If your surgery is planned (elective) and you are already taking opioid analgesics, your clinician may advise reducing your opioid analgesic dose in the lead up to the surgery. This can improve your recovery and increase the options available for managing your pain after surgery.

Identify and document avoidable, modifiable risks of harm if opioid analgesics are prescribed for a patient with acute pain, using appropriate assessment tools where possible.

Patients from some vulnerable groups may be at increased risk of opioid analgesic-related harm. These include older people, infants and children, pregnant and breastfeeding patients, patients with a disability, patients with unstable adverse social circumstances, patients with psychological comorbidities, and patients with substance use disorders.

Patients cannot be reliably assessed for risk of respiratory depression (OIVI). Older age is one risk factor commonly reported as being associated with an increased risk of respiratory depression (OIVI). Follow best practice recommendations for appropriate doses of immediate-release opioid analgesics in older people, such as Therapeutic Guidelines and Acute Pain Management: Scientific evidence.

Other risk factors include chronic opioid analgesic use, chronic sleep-disordered breathing, chronic obstructive pulmonary disease, diabetes, hypertension, hepatic or renal impairment, neurological diseases and obesity.

Modifiable, avoidable risk factors for sedation and respiratory depression (OIVI) include:

• Use of more than one opioid analgesic at a time
• Use of modified-release oral and transdermal opioid analgesics
• Use of continuous opioid analgesic infusions
• Continued administration of opioid analgesics to treat pain that is not responding to opioid analgesics
• Co-administration of central nervous system (CNS) depressants such as benzodiazepines and other sedative hypnotics, barbiturates, gabapentinoids, alcohol and recreational drugs.

Establish the patient’s opioid status and existing opioid analgesics in their possession before prescribing opioid analgesics for acute pain. Access Real Time Prescription Monitoring tools or the Prescription Shopping Program to obtain information on use of other medicines that cause sedation and respiratory depression (OIVI), to inform shared decision making before giving or prescribing opioid analgesics.

For non-opioid naïve patients taking opioid analgesics prior to a planned or elective surgery or procedure, if time allows, slowly reduce opioid analgesics according to recommendations outlined in the current best practice guidelines. For patients identified to be at increased risk of opioid-related nausea and vomiting after surgery, consider opioid-sparing treatments or alternatives to opioid analgesics to manage their acute pain.

Ensure systems are in place for clinicians to assess and document avoidable, modifiable risk factors before a decision is made to prescribe an opioid analgesic.

Ensure systems are in place for clinicians to establish a patient’s opioid status before prescribing opioid analgesics to treat the patient’s acute pain.

Ensure policies and processes are in place to provide clinicians with access to appropriate tools, such as a real time prescription monitoring system (where available) or the Prescription Shopping Program, to identify and assess patients at risk of harm from CNS depressants before opioid analgesics are given or prescribed to treat the patient’s acute pain.

Real time prescription monitoring systems:

• QScript (Queensland)
• SafeScript NSW (New South Wales)
• SafeScript (Victoria)
• Canberra Script (Australian Capital Territory)
• DORA (Tasmania)
• ScriptCheck (South Australia)
• Electronic Recording and Reporting of Controlled Drugs (Western Australia).

The system of Real Time Prescription Monitoring (RTPM), on which the state and territory systems are based, is designed to monitor the prescribing and dispensing of controlled medicines with the aim of reducing their misuse in Australia.

Services Australia: Prescription Shopping Program