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.