Information for clinicians - Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard

What the standard says

The nonpharmacological and pharmacological options for managing acute pain are discussed with a patient and their carer in a way that they can understand, and that leads to a shared understanding of the decision to use an opioid analgesic or other treatment(s).

What this means for clinicians

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.

Related resources

• 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
• Pharmaceutical Society of Australia. Opioid Medicines Fact Sheet for Patients, Families and Carers

What the standard says

Analgesic prescribing for a patient with acute pain is guided by its expected severity and assessment of patient-reported pain intensity and the impact of pain on the patient’s function.

What this means for clinicians

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.2 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.27

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.

Related resources

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

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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.

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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), 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.

What the standard says

Whenever an opioid analgesic is considered for a patient with acute pain, their risk of opioid-related harm is assessed. An opioid analgesic may be prescribed when other analgesics are not clinically feasible or sufficient, and the potential benefits outweigh the potential harms.

What this means for clinicians

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.

Related resources

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

What the standard says

A patient with acute pain prescribed an opioid analgesic who is at increased risk of opioid-related harm is appropriately managed in conjunction with a locally approved pathway to mitigate the potential for harm.

What this means for clinicians

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.

Related resources

Drug and alcohol services

• Drug and Alcohol Specialist Advisory Service for New South Wales and ACT health professionals
• 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

What the standard says

If an opioid analgesic is considered appropriate for an opioid-naïve patient with acute pain, use an immediate-release formulation at the lowest appropriate dose, for a limited duration, and prescribe in line with best practice guidelines. Modified-release opioid analgesics cannot be safely or rapidly titrated and their use in acute pain should be exceptional and not routine. The patient is supported to cease any opioid analgesic use as their function and pain improve.

What this means for clinicians

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.

Related resources

• 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

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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

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Reducing guidelines

• Primary Health Tasmania. A Guide to Deprescribing Opioids

What the standard says

When an opioid analgesic is prescribed, supplied or administered for a patient with acute pain, adverse effects are monitored and managed. The patient and carer are made aware of potential adverse effects and signs of overdose, including respiratory depression.

What this means for clinicians

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.

Related resources

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.

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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
• Victorian Quality Council, Victorian Department of Human Services. Acute Pain Management Measurement Toolkit

What the standard says

When a patient with acute pain is prescribed, supplied or administered an opioid analgesic, the intended duration of therapy, and the review and referral plan are documented in the patient’s healthcare record. The cause of the pain for which the opioid analgesic is prescribed is documented, including on the inpatient prescription.

What this means for clinicians

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.

What the standard says

During hospital care, a patient prescribed an opioid analgesic for acute pain is assessed regularly to determine their response to therapy and whether an opioid analgesic is effective and appropriate for their stage of care.

What this means for clinicians

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.

What the standard says

Planning for appropriate analgesic use at the transfer of care begins when a patient is started on an opioid analgesic during their hospital visit, according to an agreed opioid analgesic weaning and cessation protocol. The number of days’ supply of an opioid analgesic on discharge is based on multiple factors, including the expected course of the patient’s condition, appropriate arrangements for follow-up and opioid analgesic use in the last 24 hours before discharge.

What this means for clinicians

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.

Related resources

Clinician resources

• SA Health. Clinical Guideline for Prescribing Opioids on Discharge
• WA Health. Recommendations for Prescribing Analgesia on Discharge Following Surgery or Acute Injury: Information for health practitioners preparing the patient for discharge
• Society of Hospital Pharmacists of Australia. Take-Home Naloxone in Australian Hospitals

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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
• Pharmaceutical Society of Australia. Opioid Medicines Fact Sheet for Patients, Families and Carers