Quality statement 5 - Appropriate opioid analgesic prescribing

If you are prescribed an opioid analgesic medicine for acute pain, your clinician will prescribe the lowest dose needed to reduce your pain. The dose will be in line with accepted guidelines.

Taking opioid analgesic medicines for longer than required to manage your acute pain can lead to the medicine becoming less effective and cause harm. Your clinician will discuss with you how to reduce your use of opioid analgesic medicine. As a first step, this might include reducing the dose while you continue to use other medicines to manage your pain. For example, your clinician might advise taking paracetamol and anti-inflammatories while reducing the dose of the opioid analgesic for acute pain. Treatments such as heat packs, ice packs, exercise and physiotherapy may also be recommended to manage your pain.

As your pain and function improve, it may be appropriate to stop using, or change how you use the opioid analgesic medicine. For example, in hospital, changing from an injection or an infusion into the bloodstream through one of your veins to a medicine you take by mouth, or by reducing the dose and how often you take the medicine. In some cases, you can just stop the medicine as your pain improves. Your clinician will talk to you about how long you will need to take this medicine after you leave hospital.

Consider Pharmaceutical Benefits Scheme requirements for drugs of addiction, state and territory regulations, and best practice guidelines when prescribing opioid analgesics.

If an opioid analgesic is required for acute pain in an opioid-naïve patient, follow best practice guidelines. Use immediate-release formulations at the lowest appropriate dose and for the shortest appropriate duration. Consider strategies to minimise overall opioid analgesic use.

Consider the individual patient’s characteristics such as age, weight, hepatic and renal function, allergies, and other health conditions such as obstructive sleep apnoea. Consider the patient’s opioid status and other medicines prescribed. Use paracetamol and anti-inflammatories to reduce the dose of opioid analgesic for acute pain. Consider whether the patient has a life-limiting illness and whether they are in the care of a palliative care team.

An opioid analgesic weaning and cessation plan is particularly important for patients prescribed opioid analgesics because long-term opioid use often starts with using opioid analgesics for acute pain. Opioid analgesic dose reduction should start as soon as possible, and can usually start one to two days after major surgery or trauma.¹ In general, opioid analgesics should be discontinued before paracetamol and non-steroidal anti-inflammatories are discontinued.

Define an opioid analgesic weaning and cessation plan guided by assessing the patient’s functional activity and pain scores, the amount of opioid analgesic used in each 24-hour period and the duration of therapy. For example, if discontinuing opioid analgesics that were prescribed for a short duration and used for less than 10 days, doses can be reduced quickly. This also applies when discontinuing immediate-release opioids prescribed for acute pain in patients who are also on long-term opioid analgesic therapy. Discuss, and agree to, the weaning and cessation plan with the patient.

There is no evidence to support the use of modified-release opioid analgesics for acute pain. Some emerging evidence shows that their use is problematic. For example, modified-release opioid analgesics following surgery are associated with increased risk of opioid-related harm and complications. The Therapeutic Goods Administration (TGA) states that modified-release products should only be used where the pain is opioid-responsive and the patient requires daily, continuous, long-term treatment. Long-term treatment does not align with the definition of acute pain. The TGA also states that modified-release opioids are not indicated to treat chronic non-cancer pain (other than in exceptional circumstances) or for ‘as-needed’ pain relief.

• Ensure systems are in place for clinicians to be able to access best practice guidelines for appropriate prescribing of opioid analgesics for acute pain.
• Ensure processes and systems are in place to alert clinicians to limit the duration of therapy for opioid analgesics and plan to reduce their use.
• Ensure policies, procedures and systems are in place for clinicians to supply or prescribe paracetamol and anti-inflammatories alongside opioid analgesics.
• Ensure policy and procedures are in place to prevent the prescribing of modified-release opioid analgesics for routine management of acute pain.

• WHO Analgesic Ladder (revised) (2020)
• Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists. Opioid Dose Equivalence Calculation Table.
• Acute Pain Management: Scientific evidence, 5th edition
• Therapeutic Guidelines: Pain and analgesia
• ANZCA Guideline on Acute Pain Management
• ANZCA Position Statement on the Use of Slow-Release Opioid Preparations in the Treatment of Acute Pain
• PROSPECT. Better Postoperative Pain Management Guidelines

Paediatric guidelines

• Children’s Hospital Westmead. Pain Management – CHW: Practice guideline
• Royal Children’s Hospital, Melbourne, Clinical Guidelines (Nursing). Pain Assessment and Measurement
• Royal Children’s Hospital, Melbourne, Clinical Guidelines (Nursing). Management of the Paediatric Patient Receiving Opioids
• South Australian Paediatric Clinical Practice Guidelines. Acute Pain Management and Opioid Safety in Children
• Perth Children’s Hospital. Analgesia (ED guidelines)
• Perth Children’s Hospital. Analgesia Emergency Department Guidelines

Reducing guidelines

• Primary Health Tasmania. A Guide to Deprescribing Opioids