Atlas Focus Report: Opioid medicines dispensing

The long-term use of opioid medicines for non-cancer pain can lead to physical and psychological harms and dependence.² Legal or prescribed opioids are more likely than illegal opioids such as heroin to be involved in hospitalisations or death.⁴ There was a 25% increase in unnecessary hospitalisations due to poisoning associated with prescribed opioids in Australia between 2007­–08 and 2016­–17.⁴In 2019, prescribed opioids accounted for 429 – or almost half (49%) – of unintentional drug-induced deaths involving opioids.⁷

In recognition of the harms associated with opioid medicines use, in 2020 the Therapeutic Goods Administration (TGA) restricted the registered indications for use of opioid medicines to manage chronic non-cancer pain except in exceptional circumstances and asked sponsors to register additional smaller pack sizes for immediate-release products.¹

Although GPs are the largest group of prescribers of opioid medicines,⁸ opioids use in Australia often starts in the acute care setting.⁹ A survey of hospital pharmacists in Australia found that opioid medicines are frequently supplied for patients to take home after surgery “just in case”.¹⁰

The Third Australian Atlas of Healthcare Variation found a 5% increase in the rate of opioid medicines dispensing between 2013–14 and 2016–17. Almost 15.5 million prescriptions were dispensed through the Pharmaceutical Benefits Scheme (PBS) in 2016–17 compared to nearly 14 million prescriptions in 2013–14.¹¹ In 2020, the overall volume of opioid medicines (defined daily dose) dispensed in Australian adults was 1.6 times the average of the OECD (Organisation for Economic Co-operation and Development) countries. Although this was slightly lower than in 2019, Australia had the third highest defined daily dose per day of OECD countries for both years.¹²

Given the high use of opioid medicines, and continuing concerns about harms, it is time to re-examine trends in opioid use.

This report examines PBS prescriptions dispensing for opioid medicines for all ages, between 2016–17 and 2020–21.

Data are reported according to where people live. The report presents national data, and data by state and territory, Primary Health Network (PHN) and local area (Statistical Area Level 3; SA3).

The report presents interactive data visualisations for:

• Australia and its states and territories
• Remoteness and socioeconomic status levels
• Primary Health Networks (PHNs)
• Local areas (SA3s).

The report, which builds on previous findings from the Australian Atlas of Healthcare Variation Series, covers dispensing rates for all opioid medicines that are PBS-listed for analgesia (including medicines listed on the palliative care schedule). These are medicines that contain buprenorphine, codeine, aspirin and codeine, fentanyl, hydromorphone, methadone, morphine, oxycodone, oxycodone-naloxone, paracetamol and codeine, tramadol and tapentadol. Opioid medicines that are PBS-listed for the treatment of opioid addiction are not included.

The 18% fall in the dispensing rate nationally between 2016–17 and 2020–21 reversed the trend seen in the Third Australian Atlas of Healthcare Variation (Third Atlas), which recorded a 5% increase between 2013–14 and 2016–17.

The data also show a 30% reduction in the overall volume of opioid medicines dispensed on any given day (defined daily dose per 1,000 people per day) compared to Third Atlas data, which showed little change in this measure before 2016–17.

While the dispensing rate is falling nationally and in all states and territories, there has been little change in geographic variation. The data continue to show higher rates of prescribing in regional areas and in areas with the most socioeconomic disadvantage.

Although the relationship between high dispensing rates and areas of greater socioeconomic disadvantage is not clear, factors that may contribute to the higher rates in regional areas and areas with the most socioeconomic disadvantage include:

• Reduced access to multidisciplinary pain services and pain specialists,^{13, 14} although virtual health care has improved access
• Poorer health outcomes, due to illness and injuries that may require use of opioid medicines¹⁵
• Higher hospitalisations for physical injury.¹⁶

While Tasmania had the highest dispensing rate of all states and territories, it recorded a 21% reduction in dispensing between 2016–17 and 2020–21, which was higher than the average reduction across Australia (18%). Factors that may have contributed to higher dispensing rates in Tasmania include socioeconomic disadvantage and the high proportion of regional local areas in the state.

The lower rates of opioid medicines dispensing in the Northern Territory may be because PBS data do not capture medicines that are supplied through remote Aboriginal health services. See the Technical Note.

National strategies

The Australian Government’s first National Strategic Action Plan for Pain Management sets out priority actions to improve access to, and knowledge of, best practice pain management.¹⁷The actions are based around the themes of coordination and leadership; care; implementation; research; prevention and support.

Obesity is often associated with chronic pain.¹⁷ The National Strategic Action Plan for Pain Management includes options for preventing chronic pain, including strategies such as reducing the prevalence of obesity through increased physical activity and recognising the role of nutrition.¹⁷

The National Preventive Health Strategy 2021–2030 also sets out actions to reduce the risks of poor health and disease, including reducing harms related to alcohol and other drugs.¹⁸

The Australian Commission on Safety and Quality in Health Care (the Commission) has had a sustained focus on opioid medicines, including reporting prescription dispensing rates in the Atlas series and recommending a wide range of actions to improve the appropriateness of opioid medicines use.¹¹

Efforts to reduce the inappropriate use of opioid medicines in Australia have included regulatory changes, updated guidelines, safety warnings, education and policy changes.¹¹

It is important to note that codeine-containing products previously available over the counter became available on prescription only in February 2018. The 18% reduction in opioid medicines dispensing occurred despite all codeine-containing products being available only on prescription for more than three years of the time series period.

Changes and initiatives that may have influenced the time series data over the past five years are discussed below.

Government review and reform

Policy changes appear to have had the greatest impact on opioid medicines use. In April 2020, the TGA asked opioid sponsors to register additional smaller pack sizes for immediate-release prescription products³ and there was a complementary PBS change in June 2020.¹ There was a sharp drop in prescription dispensing after these changes.

The TGA and PBS implemented further changes that may have contributed to the reduction in opioid use, including:^1,19

• Additional warning statements in prescribing information
• Updated prescribing indications to encourage more selective use of opioids for chronic non-cancer pain
• Increased quantities/repeats only by authority approval
• Requirement for a second opinion for any patient who is taking, or who is expected to take, opioids for more than a year.

The TGA conducted a communication and education program for consumers and health professionals about the regulation changes that may have contributed to reduced dispensing rates. Consumers viewed or accessed a range of 'safe use of opioids' resources more than 32 million times, while health professionals accessed educational resources and online content about the reforms more than 455,000 times.

Changes in practice

Guidelines that identified a dose of opioids above which adverse events escalate dramatically^20,21 provided a target for de-prescribing and a limit for new prescribing.

Taking opioids before surgery is one of the biggest risk factors for opioid continuation after surgery.^22,23 Research reinforced the lack of benefit of taking opioids compared with non-opioid pain relief.²⁴ It is likely that this research contributed to fewer patients starting opioids before surgery, reducing opioid use after surgery.

Private dispensing

An increase in private market prescriptions may have contributed to the decline in PBS prescribing of opioid medicines. Private market prescriptions provide access to medicines that are approved for use in Australia but not listed on the PBS. A study of opioid prescribing in general practice in Australia between 2013 and 2018 found that private market prescriptions made up just 6% of prescription opioid use in Australia, but that the market share was growing.¹⁴

Multidisciplinary pain services

Timely and coordinated multidisciplinary pain services covering physical, psychological and medicines treatment are best practice for people with persistent pain.¹³ Attendance at multidisciplinary pain services is associated with opioid cessation. An Australian study showed that 27% of patients attending pain services had stopped using opioids and 20% had reduced their dose by at least 50% by the end of their treatment.⁶

An additional 41 pain services were established in Australia between 2008 and 2018, taking the total to 109 and increasing the number of new referrals able to be seen each year by 15%.¹³

However, there is uneven distribution of multidisciplinary pain services across Australia and still not enough to meet demand. For example, there is only one pain service in Tasmania.¹³ Median wait times for pain services in many parts of Australia continue to be longer than the recommended maximum wait of six months and are longest for services offering multidisciplinary care.¹³

COVID-19 and elective surgery

A decrease in elective surgery due to COVID-19 restrictions may have reduced the dispensing of opioids at hospital discharge.²⁵

Prescriber monitoring

In 2018, the Australian Government Chief Medical Officer sent letters to more than 4,500 GPs who were in the top 20% of prescribers of opioids. The ‘nudge’ letters highlighted the GPs’ high prescribing in comparison to their peers and prompted them to change their prescribing when it was safe and appropriate. An evaluation found that metropolitan GPs who were sent the letter reduced their opioids prescribing by 6% compared to a group of high prescribers who did not receive the letter.²⁶

Stewardship and improvement programs

Opioid stewardship programs, which include coordinated interventions to improve, monitor and evaluate the use of opioids,²⁵ may help to reduce inappropriate prescribing. These programs include structured approaches to governance and accountability, policy, education, monitoring and improvement activities.²⁷

Examples of stewardship programs include:

• an opioid-focused practice improvement program was piloted in two Emergency Departments in 2018 as part of the Queensland Stewardship Program. It resulted in a 21% relative reduction in total oxycodone prescriptions and improved clinical handover communication at discharge.²⁸
• a quality improvement program at St Vincent’s Hospital Sydney, which included prescriber audit and feedback, achieved a rapid 40% reduction in the number of oxycodone tablets prescribed at discharge.²⁹
• an Analgesic Stewardship Pilot Program supported best practice in acute pain management in up to 10 Victorian health services in 2021 and 2022.³⁰

Real time prescription monitoring

Real time prescription monitoring (RTPM) is the use of digital health systems to provide information to doctors and pharmacists about a patient’s use of controlled medicines.³¹

Tasmania was the first state to implement RTPM with a program called DORA (Drugs and Poisons Information System Online Remote Access). The program, established in 2009, has contributed to a reduction in opioid-related harms in the state, including a reduction in opioid-related deaths.³²

The Australian Government has funded each state and territory to build its own RTPM database to interact with the National Data Exchange, which it established in 2018.³¹

Victoria established its SafeScript program in 2020,³³ which may have contributed to the state recording the biggest reduction in opioid medicine dispensing rates of all states and territories. Other states and territories have started or are planning their own RTPM programs.

Pain management educational programs

The Veterans' Medicines Advice and Therapeutics Education Services project (Veterans' MATES) aims to improve the use of medicines and health services in the veteran community. It uses administrative claims data to identify Department of Veterans’ Affairs (DVA) clients who are at risk of medicine-related problems. It provides feedback to treating doctors and health services about the treatment they provide to DVA clients. The program has provided consumer resources on topics including chronic pain and recovering from pain.¹⁷

NPS MedicineWise implemented national programs in 2015 and 2019 to improve the quality use of opioids and reduce associated harms for people with chronic non-cancer pain who are managed in primary care. The programs involved general practice education visits, clinical audit tools, PBS/MBS feedback reports, and a range of resources for health professionals and consumers. In 2021, NPS MedicineWise started work on the quality use of medicines in acute pain.

The Tasmania Health Service has implemented educational programs to improve the prescribing of opioid medicines, including a campaign to encourage clinicians to consider dispensing smaller quantities of opioids at discharge, and online education for all staff involved in the management of opioid medicines.

National strategies

The Australian Government’s first National Strategic Action Plan for Pain Management sets out priority actions to improve access to, and knowledge of, best practice pain management.¹⁷ The actions are based around the themes of coordination and leadership; care; implementation; research; prevention and support.

Obesity is often associated with chronic pain.¹⁷The National Strategic Action Plan for Pain Management includes options for preventing chronic pain, including strategies such as reducing the prevalence of obesity through increased physical activity and recognising the role of nutrition.¹⁷

The National Preventive Health Strategy 2021–2030 also sets out actions to reduce the risks of poor health and disease, including reducing harms related to alcohol and other drugs.¹⁸Although these findings are encouraging, a continued focus on reducing the inappropriate prescribing of opioid medicines is warranted because of the harms of opioid medicines and continued variation in dispensing. Options for further action are discussed below.

Shared care between health professionals and pain services

Multidisciplinary pain services are well positioned to support and offer advice to GPs and other health professionals, such as pharmacists, on the evidence-based care of patients with chronic non-cancer pain.  

Shared decision-making

Shared decision-making is central to the appropriate use of opioid medicines. Options for managing pain should be discussed with a patient and their carer in a way that that leads to a shared understanding of the decision to use an opioid analgesic or other treatment.³⁴ Patients, and their family or carer, should be informed about the potential benefits and harms of acute pain treatment options so that they can participate in decision-making about their treatment with their clinician.

Regional focus

An increased focus on initiatives in regional areas may help to improve the appropriate use of opioid medicines. Initiatives could include improving access to specialist pain management services.

Prescriber and consumer education

Increased prescriber and consumer awareness of the regulatory changes around opioid medicines may decrease inappropriate use. The TGA found that only 40% of prescribers³⁵ and 20% of consumers were aware of the reforms in 2021.³⁶The report also found that only 52% of consumers who were taking opioid medicines knew they were taking an opioid medicine, while 59% reported that they were using opioids safely and 76% believed their opioid medicine was effective.³⁶

Continued efforts to educate prescribers of opioid medicines about appropriate use should include GPs as well as hospital doctors, who should consider weaning and cessation plans at the time of initial prescribing of opioid medicines for acute pain in hospitals.

Education in safe de-prescribing is important. The Royal Australasian College of Physicians recommends that clinicians should weigh up the potential consequences of de-prescribing for each patient.³⁷ Abrupt de-prescribing or rapid tapering can lead to physical and psychological harms, including untreated pain. The College recommended that prescribers must consider each patient’s unique circumstances and work compassionately with them to minimise opioid-related harms.³⁷

GPs should be supported to develop an appropriate de-prescribing schedule for each patient. This support could include pain services providing a GP advisory service and education about de-prescribing opioids safely.

New approaches to managing pain

Recent evidence supports the use of brain retraining tools, such as cognitive behavioural therapy, mindfulness, and graded exposure or imagery, to manage persistent pain.³⁸

The results of two small randomised controlled trials in 2021 suggest brain retraining techniques are most effective when used in combination. The trials tested strategies comprising at least four techniques for brain retraining: pain neuroscience education; graded exposure or imagery; cognitive therapy and emotional regulation; and stress reduction therapy. More than 50% of participants were pain free or near pain free at six months.^39,40

Opioid Analgesic Clinical Care Standard

The Commission, in conjunction with the TGA, launched the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard³⁴ in April 2022. The standard provides guidance to ensure the appropriate use and review of opioid analgesics for the management of acute pain.

As well as the actions above, members of the expert advisory group for this report have proposed a variety of options to support the appropriate use of opioid medicines:

Pain services

• Increase investment in pain services and allied health services, especially in under-served rural and regional areas
• Expand transitional care services to bridge the gaps in care between GPs and acute care settings.

Prescriber education and support

• Improve support for GPs through better communication of analgesic plans from hospitals
• Develop capacity for an ‘advice step’ before GPs refer a patient to a specialist pain service. This would be similar to the UK NHS’s ‘advice and guidance’ program, which allows GPs to seek advice from another clinician before or instead of referral⁴²
• Further encourage virtual health services for pain management.

Prescribing clarification

• The TGA, in collaboration with professional groups, should define the ‘exceptional’ circumstances in which opioid medicines can be used for chronic non-cancer pain.

Medication monitoring

• Encourage the use of My Health Record and medical software such as Best Practice to monitor opioid medicines use.

• Opioids medicines dispensing, all ages, 2016-17 to 2020-21

• Number of opioid medicines dispensed, all ages from 2016-17 to 2020-21
• Number of opioid medicines dispensed, all ages from 2013-14 to 2016-17

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