Opioids, when to prescribe
The primary medical use of opioids is in the treatment of severe pain.
- Opioids should be initiated and continued with extreme caution to avoid the unnecessary development of dependence and the potential diversion of opioids to the ‘black market’. There is increasing abuse of pharmaceutical opioids, rather than heroin, and increasingly opioids involved in fatal overdose cases have been pharmaceutical opioids obtained from the 'black market'.
- Before opioids are prescribed, give consideration to the use of non-opioid analgesics and non-pharmacological approaches to pain management (eg physical therapies as well as non-opioid medications) as alternatives or adjuncts to medication.
- When opioids are required, long-acting opioids are preferred over short-acting and injectable forms. See the Analgesia guideline (PDF 137KB) for medical recommendations and clinical notes.
- For ongoing opioid prescribing, it is recommended that a written agreement such as the Consent to opioid therapy (PDF 79KB) exist between prescriber and patient covering expectations of both parties with agreed outcomes should these not be met. In South Australia an Application for authority (PDF 154KB) must be completed and authority needs to be granted before drugs of dependence can be supplied for longer than two months.
Appropriate times to prescribe
It is appropriate to prescribe opioids for:
- short-term acute pain in known patients with clear pathology
- chronic malignant pain
- chronic non-malignant opioid-responsive pain where relevant specialist assistance has been sought and there is ongoing authority and review (use long-acting forms)
- opioid dependence under an authority from the Drugs of Dependence Unit
Medical practitioners can prescribe the buprenorphine-naloxone combination product (Suboxone®) for up to five patients without being specifically trained and accredited through the Suboxone® Opioid Substitution Program (SOSP). Prescribers of methadone or for more than five Suboxone® patients or for pregnant patients the mono-preparation of buprenorphine (Subutex®) for dependence need to be trained and accredited.
Be alert for
- Requests for repeat prescriptions beyond the timeframe expected for the pathology
- reports of lost/stolen scripts
- evidence of injecting drug use
- requests for other drugs (eg benzodiazepines)
- requests for injectable and/or short-acting preparations
- signs of intoxication
- The page called Recognising and handling drug dependent patients provides information about the typical characteristics and tactics of dependent patients, and recommended actions for dealing with someone suspected of being dependent.
- For information about responsibilities and legal obligations regarding the possession, supply, prescribing and administering of drugs of dependence, visit the page called Information on legal control over medicines.
Avoid even short-term prescribing of opioids outside of hospital/specialist setting, other than for immediate pain relief with obvious cause prior to hospital transfer (for example for fractures) if the patient:
- is young with absent pathology
- is psychologically unstable
- has a history of previous or continuing drug dependence
- has a history of previous problems with opioids
- is yourself or a colleague.
If refusal to prescribe will result in an unacceptable risk to personal safety (and/or the safety of others) and no other reasonable alternative exists, provide minimum possible opioids and advise the police.
Pain in opioid-maintained patients
Patients who have been using opioids for long periods of time (such as in opioid substitution treatment) will have a high levels of tolerance to opioids and may have a lowered pain threshold. The following is recommended to achieve adequate management of acute pain in this group:
- always consult with the usual prescribing doctor
- consider use of non-opioid medications including paracetamol and/or NSAIDs
- consider non-pharmacological options (eg physical treatments)
- increase the dose of maintenance opioid medication (following consultation with usual prescriber)
- if additional opioids are required, longer-acting agents are preferred and higher doses will be needed. The prescriber should liaise with authorised prescriber and Drugs of Dependence Unit as an amendment to the prescription authority will be required
- for hospitalised patients unable to take oral medication, maintenance opioid dose plus analgesic requirements should be prescribed (Patient Controlled Analgesia may be a useful option).
Further information and advice
- Alcohol and Drug Information Service (ADIS) 1300 13 1340
- Drug and Alcohol Clinical Advisory Service (DACAS)
Telephone: 7087 1742.
Provides general practitioners and other health professionals, who are seeking advice in managing drug and/or alcohol affected patients, with direct telephone access to a specialist drug and alcohol medical officer. 24-hour service.