Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard

Discuss the patient’s expected recovery, and the potential benefits and harms of acute pain treatment options, with them or their carer. Tailor the options to the patient’s acute pain in line with a stepwise approach when providing treatment options, which may or may not result in prescribing opioid analgesics. This discussion should consider the patient’s preferences and needs, and any cultural and linguistic matters.

Inform the patient of suitable treatment options to help with symptoms, including paracetamol and non-steroidal anti-inflammatories, and nonpharmacological treatments such as splinting, heat packs, ice packs, physiotherapy and exercise.

If opioid analgesics are considered appropriate, discuss with the patient the importance of using opioid analgesics as prescribed, how to take them and for how long, potential opioid analgesic adverse effects and interactions with existing medicines, and when the treatment will be reviewed.

If opioid analgesics are supplied or prescribed on discharge, discuss how to safely store opioid analgesics and dispose of unused opioid analgesics by returning to the patient’s local community pharmacy.

Provide culturally and linguistically appropriate written information and resources to the patient about their treatment options and their analgesic treatment. When a patient is unable to receive information or participate in treatment decisions, provide information to the patient’s family or carer and offer them the opportunity to participate in decisions, if appropriate.

Document in the patient’s healthcare record what information was conveyed to the patient, including the provision of written information such as a consumer medicines information sheet, the Pharmaceutical Society of Australia’s Opioid Medicines fact sheet, information about safe storage and disposal, and the outcome of the shared decision making process. Outcomes of shared decision making should be documented wherever possible, including in the medication management plan and clinical handover summary.

Ensure systems are in place for clinicians to provide patients, and their family or carers, with culturally appropriate information and advice on acute pain treatment options.

Provide high-quality written patient materials and resources for use by clinicians and patients that have been developed in partnership with consumers, and meet the diverse needs of people who access your services.

Ensure processes are in place so that information is communicated to the patient about their treatment options and medication management or pain management plan, including at transitions of care (such as on transfer in, or discharge from, hospital).

Where opioid analgesics are prescribed, ensure systems are in place so that clinicians discuss with patients and their family or carers the need to take the medicine as prescribed, the expected duration of treatment, any potential adverse effects and interactions with existing medicines, and when their treatment requires review. Ensure systems are in place so that, on discharge, clinicians discuss with patients and their family or carers the possibility of harm if they give opioid analgesics to other people, and the safe storage and disposal of opioid analgesics.

Monitor patient understanding of information provided for acute pain treatment and evidence of shared decision making – for example, through patient surveys, patient-reported experience measures and patient-reported outcome measures.

Acute pain is pain that lasts for a few moments, days or weeks. If you have acute pain, your clinician will explain your treatment options. These may include medicines and other treatments. The aim of these medicines and other treatments is to reduce your pain levels to allow you to undertake your regular day-to-day activities. They may not take away all your pain.

Your clinician will explain the possible benefits and harms (the good and bad things that might happen) of the different options. This can help you and your clinician decide how to manage your pain.

Opioid analgesic medicines (pain relief medicines commonly known as opioids) are one option, but they can have serious adverse effects. Your clinician may suggest trying other options first. Other options include non-opioid medicines, and other treatments such as heat packs, ice packs, exercise or physiotherapy. You and your clinician might decide that a combination of two or more treatments is best for you.

If you decide on a medicine, your clinician will give you instructions about what you need to do, especially if you will use the medicine after leaving hospital. It is important that you follow these instructions correctly to get the most benefit.

Talk to your clinician if you are not sure what to do, or if you have questions about:

• how many times a day to take the medicine and if the medicine should be taken with food
• whether the medicine will affect other medicines you use
• what the adverse effects are and how to manage them.

If you are prescribed an opioid, only use the medicine for the reason it is prescribed, and do not give this medicine to other people, such as friends and family. Opioid analgesic medicines can make you sleepy. If you are prescribed an opioid analgesic do not drink alcohol or drive. Check with your clinician about what other medicines you can safely take, including sleep medicines, so you don’t have any negative interactions with the opioid medicine.

• Clinical Excellence Commission NSW. Managing Side Effects of Opioid Medicines in Hospital: Information for patients, families and carers
• SA Health. Oxycodone for Short-Term Management of Acute Pain
• SA Health. Information for Paediatric Patients, and Their Carer, Given Opioids for Short-Term Treatment of Acute Pain
• SA Health. Going Home After Having Been Given a Medicine That Can Make You Sleepy
• WA Health. Pain Relief Medications Following Surgery and Injury: Information for patients preparing for discharge
• TGA. Return Your Unused Opioids – Resource Kit
• Return Unwanted Medicines

When treating a patient with acute pain, assess the patient’s functional activity using an evidence-based assessment tool before prescribing an opioid analgesic. The results of the functional assessment should be considered together with patient’s pain scores in discussion with the patient to guide appropriate treatment. The outcome of the assessments should be documented in the patient’s medical record.

Consider the clinical context – such as intensive care or ward – and the patient context including developmental, cognitive, emotional, language and cultural factors, to assist in choosing an appropriate pain assessment tool for acute pain. For example, verbal pain descriptors may be a better choice of pain measurement tool than numerical rating scales for some Aboriginal and Torres Strait Islander people.

Validated tools for measuring pain in neonates, infants and children are available, and the appropriate tool should be selected based on the child’s age and developmental stage.

Ensure appropriate evidence-based tools to assess patient function and pain are available, and that processes and policies support their use to assess and document acute pain before clinicians prescribe appropriate analgesia.

Being in acute pain can interfere with your ability to participate in your regular day-to-day activities. It is important for your clinician to understand how your acute pain is affecting your ability to function, as well as how much pain you are feeling. This can help them to provide the most appropriate treatment. The treatment may not completely stop your pain. The aim of treatment is to reduce your pain to a level that allows you to return to your regular day-to-day activities.

Your clinician will ask you questions about how your pain is interfering with your ability to function normally and carry out activities. They may also ask you questions about how you are coping with your pain. For example, whether the pain is affecting your sleep, or your ability to carry out regular activities. There are several measurement tools to score your pain and your function, and your clinician will use the ones that best suit your needs when they assess your acute pain.

Several evidence-based tools for assessing pain and function are available.

Functional Activity Scale

A No limitation: the patient can undertake the activity without limitation due to pain (pain-intensity score is typically zero to three)

B Mild limitation: the patient can undertake the activity, but experiences moderate to severe pain (pain-intensity score is typically four to ten)

C Significant limitation: the patient cannot complete the activity due to pain or pain treatment-related adverse effects independent of pain-intensity scores.

• Wong-Baker FACES Pain Rating Scale and Multi-Language Wong-Baker FACES Pain Rating Scale
• Multi-language International Association for the Study of Pain Faces Pain Scale Revised

Pain scoring systems for paediatric patients

A summary of validated tools for measuring pain in paediatric patients is in Acute Pain Management: Scientific evidence, 5th edition (2020).

• Table 10.1 Acute pain-intensity measurement tools – neonates
• Table 10.2 Composite scales for infants and children
• Table 10.3 Self-report tools for children
• Table 10.4 Sample of observational pain assessment scales for intellectually disabled children.

Pain scoring systems for cognitively impaired patients

A summary of tools for measuring pain in patients with dementia can be found in Acute Pain Management: Scientific evidence, 5th edition (2020)², including:

• Faces Pain Scale
• Abbey Pain Scale
• Pain Assessment in Advanced Dementia (PAINAD)
• Pain Assessment Checklist for Seniors with Limited Ability to Communicate
• Mobilization–Observation–Behaviour–Intensity–Dementia Pain Scale (MOBID).

Other resources include:

• Doloplus-2, which is a behavioural pain assessment scale for older people who present with verbal communication disorders
• Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)
• Royal Children’s Hospital, Melbourne, Clinical Guidelines (Nursing). Pain Assessment and Measurement.

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.

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.

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

Manage and refer patients identified at increased risk of opioid-related harm according to a defined clinical pathway for appropriate support services. This includes escalation of care to specialist services for paediatrics, pain management, drug and alcohol, clinical pharmacy and allied health.

Inform the patient why they are being referred. Provide information about the care to which they are being referred according to the pathway. Advise the patient of your role in the patient’s continuing care.

Ensure there is a locally approved policy that defines the clinical pathways for hospitalised patients who are identified to be at increased risk of opioid-related harm. The pathways should enable clinicians to refer and escalate care of patients at increased risk of opioid-related harm to access support services, including specialist services for paediatrics, pain management, drug and alcohol, clinical pharmacy and allied health.

Ensure systems are in place to inform patients why they are being referred to a pathway and the plan for their ongoing clinical management.

Ensure clinicians are trained on how to access the pathways and that workforce proficiency is maintained.

If your clinician has identified you as having an increased risk of harm from opioid analgesics, your clinician may refer you to other hospital-based support services. These may include specialist services for children and adolescents, pain management, drug and alcohol, clinical pharmacy and allied health to help manage your acute pain and the risk of possible harm.

Drug and alcohol services

• Drug and Alcohol Clinical Advisory Services (DACAS) for Victoria, Tasmania and Northern Territory health professionals
• Drug and Alcohol Clinical Advisory Services (DACAS) for South Australia health professionals

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.

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.

• 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
• ANZCA Guideline on Acute Pain Management
• PROSPECT. Better Postoperative Pain Management Guidelines

Paediatric guidelines

• 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

If opioid analgesics are prescribed, regularly monitor the patient for adverse effects in line with current best practice guidelines. The frequency of patient monitoring will be influenced by the hospital setting, pain severity, age and comorbidities, and the dose and route of administration of the opioid analgesic. Develop appropriate management strategies for the adverse effects, including adjustments to the dose, route of administration, formulation and type of opioid analgesic.

Prescribe appropriate treatments to prevent and manage opioid analgesic–induced adverse effects: laxatives to prevent or treat constipation, and appropriate treatments for nausea and vomiting, and itchiness.

Patient sedation levels should be monitored and the results documented in the monitoring chart in the patient medical record. Excess sedation is a reliable indicator of respiratory depression (OIVI). Patients with excess sedation (such as a score of greater than 1) should be managed by de-escalating the opioid analgesic dose and continued monitoring. Withhold all opioids until the patient is awake. If more analgesia is needed, a smaller dose should be given regardless of pain score. Monitoring sedation should always be paired with appropriate opioid analgesic prescription and dose adjustment. Excess sedation may require escalation of care, according to locally approved protocols. Consider the administration of naloxone to reverse respiratory depression (OIVI), according to a locally approved protocol.

CNS depressants such as benzodiazepines or other sedative hypnotics, barbiturates, and gabapentinoids increase the risk of excess sedation. These medicines should be avoided and patients taking these medicines should be subject to increased monitoring.

Patient cohorts at risk of excess sedation and respiratory depression (OIVI) include people who take opioid analgesics chronically; and patients with sleep-disordered breathing, chronic obstructive pulmonary disease, diabetes, hypertension, hepatic and renal impairment, neurological diseases and obesity. Patients with these comorbidities should be subject to increased monitoring.

Ensure systems and protocols are in place for clinicians to monitor and manage opioid analgesic adverse effects such as nausea, constipation, sedation, and signs of overdose including respiratory depression (OIVI). Ensure monitoring of sedation levels and appropriate action when sedation levels increase. Ensure all clinicians are aware of these systems and protocols.

Ensure protocols are in place to escalate care. Ensure all clinicians are aware of these protocols.

Where electronic healthcare records are in place, consider incorporating PowerPlans, flags and reminders of opioid analgesic adverse effects into the record management system.

If you are prescribed or given an opioid analgesic for acute pain, your clinician should regularly check for harmful effects and adjust your treatment when necessary. Harmful effects from opioid analgesics include nausea, constipation, itchiness, drowsiness and slowed breathing.

Your clinician will monitor adverse effects by regularly checking your breathing, how drowsy you are and how often you are going to the toilet.

Opioid analgesics can sometimes slow down your breathing to dangerously low levels. Becoming very sleepy after having an opioid analgesic can be a sign your breathing is too slow. When you first start an opioid analgesic, starting with a smaller dose will reduce drowsiness, have less effects on your breathing, and be safer for you. If you do become very sleepy after taking your opioid analgesic medicine, do not take any more opioid analgesics unless you are completely awake. Your clinician will monitor your breathing and adjust your treatment if necessary, such as lowering the dose. Talk to your clinician if you have concerns about sleepiness or your breathing.

Your clinician will prescribe laxatives to prevent or treat constipation. If required your clinician will prescribe appropriate treatments for nausea and vomiting, or itchiness.

Sedation scores 

• 0 = awake, alert
• 1 = easy to rouse, remains awake
• 2 = easy to rouse, unable to remain awake
• 3 = difficult to rouse

1. A score of 2 is taken to indicate early respiratory depression (OIVI) and therefore the aim should be to titrate an opioid so that a patient’s sedation score is always less than 2.
2. Note that a sedation score (e.g. ‘sedation score less than 2’) may be specified in the ‘Max dose/24 hrs’ in the PRN section of the national inpatient medication chart to indicate the maximum amount to be administered in 24 hours when prescribing opioids.

Other tools and guidelines

• Faculty of Pain Medicine, Australian & New Zealand College of Anaesthetists. Opioid Dose Equivalence Calculation Table
• South Australian Paediatric Clinical Practice Guidelines. Acute Pain Management and Opioid Safety in Children
• Clinical Excellence Commission NSW. Managing Side Effects of Opioid Medicines in Hospital: Information for patients, families and carers

When prescribing opioid analgesics, document the indication, intended duration (number of days), the review and referral plan, and the weaning and cessation plan in the patient’s healthcare record. This documentation includes the patient’s paper or electronic medical record, the My Health Record system, prescription record, medication chart and medication management plan.

Document the cause of pain for which the opioid analgesic is prescribed, including on the inpatient prescription, to ensure the reason for use of the opioid analgesic is printed on any dispensed opioid analgesic the patient takes with them when they leave hospital.

Document co-prescribed paracetamol, non-steroidal anti-inflammatories or nonpharmacological treatments, in the patient’s healthcare record.

Ensure a system is in place for clinicians to document the intended duration (number of days), the weaning and cessation plan, and the review and referral plan for opioid analgesics in the patient’s healthcare record.

Ensure a system is in place for clinicians to document the cause of pain for which the opioid analgesic is prescribed, including on the inpatient prescription.

Where electronic medical records are being used, incorporate flags and reminders into the record management system to support documentation in all relevant fields or consider making them mandatory fields.

Your healthcare record contains information about your opioid analgesic therapy. This includes information on:

• the medicine (active ingredient/s) and dose you have been prescribed
• the cause of the pain for which the opioid analgesic is prescribed
• how long to use them for
• the plan to review your opioid analgesic treatment
• the plan to reduce the opioid analgesic medication, to allow you to stop taking the medicine.

Information in your healthcare record can help different clinicians involved in your care to understand why an opioid analgesic has been prescribed and the plan for your care.

When opioid analgesics are prescribed, the effectiveness, appropriateness and ongoing need for opioid analgesic therapy should be regularly reviewed according to the patient’s stage of care. If the opioid analgesic is continued, decisions about the appropriate daily dose of opioid analgesic should be based on the oral morphine-equivalent daily dose (oMEDD) given in the past 24 hours.

During their hospital care, a patient prescribed an opioid analgesic for acute pain should have regular assessment of their pain and function. Due to interpatient variability, the timing of regular assessments should be tailored to the needs of the patient considering the patient’s sedation scores, physical state, ability to move and engagement with active interventions such as physiotherapy.

Consider alternative pain management for patients whose acute pain does not respond to opioid analgesics. This may include changing the opioid analgesic to a non-opioid medicine, nonpharmacological management or referral to other hospital-based support services. These may include specialist services for paediatrics, pain management, drug and alcohol services, clinical pharmacy, or allied health.

If opioid analgesics are being administered intravenously, consider switching to oral opioid analgesic options as soon as the oral route is available.

Ensure review of opioid analgesic treatment occurs immediately before the patient leaves the hospital. The aim of opioid analgesic therapy should be to manage the patient’s acute pain with an opioid analgesic for the shortest duration possible.

Ensure systems are in place for clinicians to regularly review the effectiveness, appropriateness and ongoing need for opioid analgesics according to the patient’s stage of care. In hospital, this includes ceasing opioid analgesics when no longer necessary and reviewing regularly from the first prescription. Ensure an oMEDD calculator is available for clinicians to determine the appropriate daily dose of opioid analgesic.

Include systems to ensure that review of opioid analgesics occurs immediately before the patient leaves the hospital.

Ensure referral and escalation of care processes are in place to support clinicians when a patient’s acute pain does not respond to opioid analgesic therapy. This may include referral to other hospital-based support services, including escalation to specialist services for paediatrics, pain management, drug and alcohol, clinical pharmacy and allied health.

Ensure policy, procedures and systems are in place to support clinicians to change from intravenous to oral opioid analgesics in patients with acute pain. This should include incorporating flags in electronic medication management systems where these are in use.

Ensure systems are in place for clinicians to regularly review the effectiveness, appropriateness and ongoing need for opioid analgesics according to the patient’s stage of care. In hospital, this includes ceasing opioid analgesics when no longer necessary and reviewing regularly from the first prescription. Ensure an oMEDD calculator is available for clinicians to determine the appropriate daily dose of opioid analgesic.

Include systems to ensure that review of opioid analgesics occurs immediately before the patient leaves the hospital.

Ensure referral and escalation of care processes are in place to support clinicians when a patient’s acute pain does not respond to opioid analgesic therapy. This may include referral to other hospital-based support services, including escalation to specialist services for paediatrics, pain management, drug and alcohol, clinical pharmacy and allied health.

Ensure policy, procedures and systems are in place to support clinicians to change from intravenous to oral opioid analgesics in patients with acute pain. This should include incorporating flags in electronic medication management systems where these are in use.

Plan for appropriate opioid analgesic use at the transfer of care when a patient is first prescribed, supplied or administered an opioid analgesic for acute pain during their hospital visit/stay. Follow an opioid analgesic weaning and cessation protocol to start weaning and cessation of opioid analgesics during their hospital stay/visit guided by assessing the patient’s functional activity and pain scores. As part of the medication management plan provided to the patient, their carer and the patient’s general practitioner on discharge, the weaning and cessation plan for opioid analgesics should include:

• the appropriate formulation of an opioid analgesic to provide or prescribe
• the appropriate oral morphine-equivalent daily dose (oMEDD) on discharge, which is based on the total oMEDD given in the last 24 hours before discharge
• for patients discharged from day surgery, the appropriate opioid analgesic number of days’ supply based on the expected trajectory of the patient’s condition
• the appropriate opioid analgesic number of days’ supply, considering the day of discharge and when the patient can reasonably be expected to access primary care and other healthcare services post-discharge
• identification of the patient who already has opioid analgesics in their possession that may adequately treat their acute pain and does not require additional prescription on hospital discharge, and advice on the appropriate use of those opioid analgesics
• identification of the patient’s general practitioner who will continue the patient’s care after leaving hospital. If this is not possible, develop a plan to assist the patient access health care after discharge.

Provide the patient with written information on discharge that addresses:

• how many times a day to take, use or apply the opioid analgesic, and if it should be taken with food
• whether the opioid analgesic will affect other medicines they use
• what the adverse effects are and how to manage them
• when to seek urgent care for adverse effects of the opioid analgesic or lack of pain relief
• how to reduce the opioid analgesic, to allow the patient to stop taking the opioid analgesic (weaning and cessation plan)
• how to safely store and dispose of the opioid analgesic.

If a patient is discharged from ED with an opioid analgesic, the quantity supplied may be for up to a maximum of three days’ treatment.

If a hospital inpatient is discharged with an opioid analgesic, the quantity may be for up to a maximum of seven days’ treatment to reduce and stop the medicine.

For patients who live in locations with limited access to prescribers and pharmacies, consider their individual circumstances and expected course of their condition, and provide an appropriate quantity of opioid analgesics that provides analgesia and mitigates the risk of opioid-related harm after discharge.

Ensure a locally approved policy is in place to support transfer of care of patients discharged from hospital with a supply or prescription for opioid analgesics.

Ensure an opioid analgesic discharge weaning and cessation protocol is available to clinicians and used for patients who are prescribed, supplied or administered an opioid analgesic for acute pain during their hospital stay. The protocol should address the cessation or weaning of opioid analgesics started in hospital and provided or prescribed over more than 24 hours. On hospital discharge, the protocol should outline the elements of a weaning and cessation plan that includes:

• the selection of an appropriate formulation of an opioid analgesic
• for patients in hospital for more than a day, the selection of an opioid analgesic dose on discharge that is based on use in the last 24 hours before discharge, using an oMEDD
• for patients discharged from day surgery, the selection of an appropriate opioid analgesic appropriate dose based on the expected trajectory of the patient’s condition
• an appropriate supply of opioids, considering the day of discharge and when the patient can reasonably be expected to access primary care and other healthcare services post-discharge
• processes to identify patients who already have opioid analgesics in their possession that may adequately treat their acute pain and do not require an additional prescription on hospital discharge, and to advise them on the appropriate use of those analgesics
• prompt communication of a clinical handover summary to the patient’s general practitioner that includes:
  • the cause of the pain for which the opioid analgesic was prescribed
  • the opioid analgesic dose prescribed or recommended on discharge (which will differ to the inpatient dose)
  • a medication management plan that includes recommendations for reducing and ceasing the opioid analgesic where appropriate.
• provision of written patient information that addresses:
  • how many times a day to take, use or apply the medicine, and if the medicine should be taken with food
  • whether the medicine may affect other medicines
  • what the potential adverse effects are and how to manage them
  • when to seek urgent care for adverse effects of the medicine or lack of pain relief
  • details of how to reduce the medicine and stop the medicine (weaning and cessation plan)
  • how to safely store and dispose of the medicine.

Ensure processes are in place to identify the patient’s general practitioner who will continue the patient’s care after leaving hospital. If this is not possible, ensure processes are in place to assist the patient access health care after discharge.

Ensure processes are in place to reduce and stop the opioid analgesic by allowing up to a maximum of:

• three days’ opioid analgesic supply to patients discharged from the ED
• seven days’ opioid analgesic supply for patients discharged following a hospital stay.

These processes should allow for exceptions such as the patient’s ability to access services in the community and comorbidities.

It is important that you know how to safely manage your pain when you leave hospital. Not everyone who receives opioid analgesics while in hospital will need to take them when they leave. In some cases, the pain can be managed with other medicines or techniques.

If an opioid analgesic is prescribed for you, the dose will help you to manage your pain and get back to your regular day-to-day activities. The amount you receive will be based on several things. Your clinician will consider your expected recovery along with the amount of pain relief you needed while you were in hospital. You should be advised to reduce your dose of opioid analgesic as your pain and ability to function improve.

The amount of opioid analgesic medicine you receive will be individualised to your needs. To reduce the risk of harm, there are limits on the amounts of opioid analgesics hospitals can provide:

• if you are seen in the emergency department (ED), the most that can be supplied is three days of treatment
• if you have been admitted to hospital, the amount of opioid analgesics you are given will be based on your pain relief needs in the last 24 hours you were in hospital. The most that can be supplied is seven days of treatment.

The aim is to help with your pain and give you time to visit your general practitioner where your care will be reviewed.

If you leave hospital on a weekend, live far from medical support or if your pain is expected to continue for longer, your clinician will talk to you when you are leaving hospital about the appropriate amount of opioid analgesic for your circumstances.

To ensure your care is continued, you will be advised to consult your general practitioner for follow-up after you leave hospital. If you do not have a general practitioner, your clinician will advise you on how to access care after you leave hospital.

You will be given a medication management plan describing why you were prescribed the opioid analgesic and how to reduce and stop taking this medicine. The plan to reduce and stop your opioid analgesic will be provided to your general practitioner. This is to make sure that you use these medicines for as short a time as possible, as long-term use of opioid analgesics can cause serious health and social issues. The medication management plan will include information on:

• how many times a day to take, use or apply the medicine, and if the medicine should be taken with food
• whether the medicine will affect other medicines you use
• what the potential adverse effects are and how to manage them
• when to seek urgent care for adverse effects of the medicine or if the medicine is not helping with the pain
• how to reduce the medicine, to allow you to stop taking the medicine (weaning and cessation plan)
• how to safely store and dispose of the medicine.

If you already have opioid analgesics at home that can treat your acute pain, you may not be prescribed additional opioid analgesics when you leave hospital.

Your clinician will ask you for the details of your general practitioner to ensure your care is continued when you leave hospital. Information will be provided to them about the care you received in hospital, including the medicines you received in hospital and when you left hospital.

Clinician resources

• SA Health. Clinical Guideline for Prescribing Opioids on Discharge

Consumer resources

• Clinical Excellence Commission NSW. Managing Side Effects of Opioid Medicines in Hospital: Information for patients, families and carers
• Alfred Health. Managing Your Pain After Leaving Hospital
• SA Health. Oxycodone For Short-Term Management of Acute Pain
• SA Health. Information for Paediatric Patients, and Their Carer, Given Opioids for Short-Term Treatment of Acute Pain
• SA Health. Going Home After Having Been Given a Medicine That Can Make You Sleepy
• WA Health. Pain Relief Medications Following Surgery and Injury: Information for patients preparing for discharge
• TGA. Return Your Unused Opioids – Resource Kit

Priority actions to reduce medication-related harm from high-risk medicines, including opioid analgesics, were identified in Australia’s response to the World Health Organization Global Patient Safety Challenge – Medication without harm (2020). One of the identified priority actions was developing a national guideline for peri-surgical management of high-risk medicines, including the:

• quantity prescribed on hospital discharge
• duration of therapy post discharge
• introduction of de-escalation plans as part of the hospital discharge summary, where appropriate.

Following a public consultation on prescription opioids in 2018, the Therapeutic Goods Administration (TGA) established the Opioid Regulatory Advisory Group to provide independent, expert advice to review proposed options for a regulatory response to opioid use and misuse in Australia. As a result, several opioid analgesic regulatory changes were implemented in June 2020.

In April 2020, the TGA engaged the Commission to develop a framework for a National Opioid Analgesic Stewardship program, and an accompanying Clinical Care Standard, which together support the opioid analgesic regulatory changes. The aim of the TGA regulatory changes, the National Opioid Analgesics Stewardship program and the accompanying Clinical Care Standard is to minimise the risk of harm associated with opioid analgesic use.

Read more about the scope and goal of this Standard or see further background in the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard. 

This Standard applies to care provided in the following care settings:

• all hospital settings, including public and private hospitals, subacute facilities, and outpatient and day procedure services
• emergency services, including ambulance services.

In the document, the term ‘clinician’ refers to all types of healthcare providers who deliver direct clinical care to patients, including:

• doctors
• dentists
• nurses
• midwives
• pharmacists
• nurse practitioners
• Aboriginal and Torres Strait Islander health workers or practitioners
• podiatrists endorsed for scheduled medicines
• paramedics
• allied health practitioners.

Not all quality statements within this Standard will be applicable to every healthcare service or clinical unit. Healthcare services should consider their individual circumstances in determining how to apply the statement.

Implementation should consider the context in which care is provided, and local variation and the quality improvement priorities of the individual healthcare services. In rural and remote settings, different strategies may be needed to implement the standard, such as hub-and-spoke models integrating larger and smaller health services and using telehealth consultations.

This Standard relates to the care of people of all ages with acute pain for whom opioid analgesics may be considered or prescribed. It covers patients presenting with acute pain to the emergency department (ED) or following surgery, up to and including, discharge from hospital. 

It includes care provided by relevant members of the interdisciplinary team, such as specialist services for paediatrics, acute pain services, drug and alcohol services, clinical pharmacy services and allied health services.

National Safety and Quality Health Service Standards

Monitoring the implementation of Clinical Care Standards helps healthcare services to meet some of the requirements of the:

• National Safety and Quality Health Service Standards (NSQHS Standards) for acute services
• National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) for services that deliver health care in a primary and/or community setting. 

Find out more about how healthcare services are expected to implement the national standards in How to use the Clinical Care Standards.

The Commission is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians. 

Person-centred care recognises and respects differences in individual needs, beliefs, and culture. The Commission: 

• is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians
• acknowledges that discrimination and inequity are significant barriers to achieving high‑quality health outcomes for some patients from culturally and linguistically diverse communities

Culturally safe service provision and environments are those where the places, people, policies and practices foster mutual respect, shared decision making, and an understanding of cultural, linguistic and spiritual perspectives and differences. Cultural safety is supported by organisations and individuals that recognise cultural power imbalances and actively address them by: 

• ensuring access to and use of interpreter services or cultural translators when this will assist the patient and aligns with their wishes
• providing visual or written information in a language that the patient, their family and carers will understand
• providing cultural competency training for all staff
• encouraging clinicians to review their own beliefs and attitudes when treating and communicating with patients
• identifying variation in healthcare provision or outcomes for specific patient populations, including those based on ethnicity, and responding accordingly.

The Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard is endorsed by 12 key organisations, including the Australasian College of Emergency Medicine, the Australian Orthopaedic Association and the Society of Hospital Pharmacists of Australia.

• Australian and New Zealand College of Anaesthetists & Faculty of Pain Medicine
• Australasian College for Emergency Medicine
• Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT)
• Australian College of Nurse Practitioners
• Australian College of Nursing
• Australian Orthopaedic Association
• Children's Healthcare Australasia
• College of Emergency Nursing Australasia Ltd (CENA)
• NPS MedicineWise
• Pharmaceutical Society of Australia
• The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
• The Society of Hospital Pharmacists of Australia (SHPA)

The Commission develops Clinical Care Standards taking into account:

• advice from multidisciplinary topic working groups which include clinicians, consumers, and researchers
• consultation with key stakeholders including consumer bodies, professional organisations, and state and territory health departments. 

The Opioid Analgesic Stewardship program Topic Working Group provided expert advice on the development of a national Opioid Analgesic Stewardship program (the Project). In addition, a public consultation process was conducted with key stakeholders.

Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard - Topic Working Group

The main role of the Topic Working Group is to:

• advise the Commission on the key components of care within the scope of the Project
• advise the Commission on key sources of evidence to inform development of the Project. This may include systematic reviews and meta-analyses, clinical practice guidelines, frameworks for best practice models, and clinical standards
• provide technical and expert advice on the development of an opioid analgesic stewardship program for acute care settings, including implementation and communication strategies
• actively support raising awareness of the Project
• advise the Commission on a review plan for the project, and support any associated revision as required.

From members who are consumers, a key role is to advise the Commission on matters relating their experience – whether as patient or carer – and provide this perspective during the development of the Project.

All members are required to disclose financial, personal and professional interests that could, or could be perceived to, influence a decision made, or advice given to the Commission. Disclosures are updated prior to each meeting and managed in line with the Commission’s Policy on Disclosure of Interests.

The quality statements in the Standard are based on the best available evidence and guideline recommendations at the time of development. 

Key sources that underpin the Standard are current clinical guidelines including:

Therapeutic Guidelines: Pain and analgesia

Acute Pain Management: Scientific evidence 5th edition (2020)