High-risk prescription opioid use: 10 things you need to know

Managing high-risk prescription opioid use in general practice requires commitment from prescribers and patients. At times it can be a challenge to gain traction with patients to effectively reduce opioid use. However, with clear expectations, appropriate prescribing, continuity of care, easy-to-use resources and accessible support networks, it is possible to reduce high-risk prescribing and high-risk opioid use.

Here are 10 things you need to know about managing high-risk opioid use in general practice.

Access to high-risk medicines involves prescribers, dispensers and patients. From the outset, it is important to acknowledge that management of high-risk medicines should not solely rest on the patient. Prescribers and pharmacists have an obligation to their patients to practice safe and appropriate opioid prescribing/dispensing, and to remain vigilant for signs of high-risk opioid use.

Know the risks

The likelihood of long-term prescription opioid use increases with each additional day of therapy from day 3 and rises sharply:⁴

• after 5 and 31 days of therapy
• after the second prescription or refill
• when the first prescription is for 10 days’ or 30 days’ supply.

Prescribers should exercise caution when prescribing more than 1 week’s supply of opioids or when authorising a refill or second opioid prescription because this approximately doubles the chances of opioid use 12 months later.⁴

The risk of problems associated with opioid use rises with increased opioid doses. A 2015 Australian study demonstrated that individuals prescribed opioids at higher doses (>90 mg oral morphine equivalent) were more likely to report medication tampering, non-medical opioid use and dependence than those taking lower doses.⁵

High-risk opioid use is more likely to occur when prescription opioids are used for:⁶

• patients prescribed other psychoactive medications eg, benzodiazepines, gabapentinoids, anticonvulsants or antipsychotics
• patients who have active substance use disorder (SUD), or a history of SUD
• younger people – substance use issues tend to develop before 35 years of age
• patients without a definitive pain pathology
• patients with active psychiatric/mental health problems.

It is important to remember that there is no one group or ‘type’ of person who develops high-risk prescription opioid use. At-risk groups can be found across all age, cultural and educational groups.⁷

Recognise yellow flags

The term ‘yellow flags’ is often used in chronic pain management and refers to psychosocial indicators that suggest an increased risk of progression to long-term distress and disability.

In chronic pain management, yellow flags can include:⁸

• unhelpful attitudes or beliefs about pain
• unrealistic expectations about pain management including access to opioid pain medicines
• depression, anxiety, irritability
• a passive approach to rehabilitation/activity
• unsupportive family/social networks.

Review the patient’s pain management plan

A patient-centred pain management plan should specify realistic treatment goals and a timeframe for reaching each goal. Goals should be specific and relevant to the patient. Examples of goals might include reducing the impact of pain by:⁹

• improving physical function eg, walk to the shops or the park every day
• pacing activity at home or work eg, spread cleaning chores across the week, set alarm to get up from work desk and stretch every 20–30 minutes
• increasing participation in social activities eg, grab a coffee and walk 30–60 minutes with a friend three times a week
• reducing medicines use for pain eg, stick to medicines schedule, only take medicines as directed and review with doctor as agreed
• improving mood eg, take a lunch break and walk outside every day
• improving sleep patterns eg, set alarm to start getting ready for bed, switch off TV or social media, take time to stretch and breathe deeply before going to bed.

For further information see: Prescribing wellness: comprehensive pain management outside specialist services. Australian Prescriber 2018:41;86-91.

Stay vigilant for early signs of aberrant behaviour

Aberrant behaviour is often referred to as drug-seeking behaviour – a potentially stigmatising term that is best avoided. Predictors of aberrant behaviour include a family or personal history of substance use, age between 16 and 45 years, and psychological issues. For more information refer to the Opioid Risk Assessment Tool.

A range of risk assessment tools are available, most of which can be completed easily online.

Working through assessment questions with the patient provides an opportunity to discuss the side effects and long-term harms associated with prescription opioids.

Opioid Risk Tool

The Opioid Risk Tool (ORT) is a brief, self-reported, validated screening tool used to assess the likelihood of a person developing high-risk prescription opioid use. The tool works best if used prior to prescribing opioids as it allows for discussion and stratification of the risk. The ORT and accompanying guidance are available for download from the Victorian Department of Health health.vic.gov.au.

Opioid Risk Indicator

This short self-assessment tool asks patients four questions about their opioid use over the past 3 months and is available online at healthdirect.

When a patient’s score indicates moderate risk, further checks can be made by contacting Prescription Shopping Information Service (registration required).

Pain assessment

Pain assessment tools help to identify chronic pain, physical limitations and psychosocial distress related to pain. They provide an opportunity to discuss attitudes and expectations about pain treatments, including opioids.

Pain management assessment tools include:

• PEG Pain screening tool
• Örebro Musculoskeletal Pain Questionnaire (ÖMPSQ)
• Kessler 10 (K10)
• Pain Self-Efficacy Questionnaire (PSEQ).

These tools can be downloaded while working through the Pain Management Network’s Quick steps to manage chronic pain in primary care.

A recent report³ identified low opioid literacy among people taking prescription opioids. Understanding what is meant by safe and effective use of opioids requires a clear and simple explanation about the risks for serious harm with long-term opioid use.

A one-on-one discussion with a patient might include the following:

• Asking the patient what they know about opioids including side effects and long-term harm.
• Actively confirming patient understanding of harms and then repeating back to the patient what they have said (Table 1).
• Reminding patients that opioids lose their effectiveness over time (tolerance).
• Emphasising the potential for serious harm even at low doses.

Visit conversation starters for examples on how to approach discussions about high-risk opioid use.

Table 1. Potential harms from long-term opioid treatment^2,11-15

^a Estimates based on 2015–2019 data from Penington Annual Overdose Report 2021² (2731 deaths over 5-year period).
OUD = opioid use disorder.

Table 2. Opioid withdrawal symptoms

Adapted from the Clinical Opioid Withdrawal Scale (COWS) and Subjective Opioid Withdrawal Scale (SOWS). Available from the Mental Health Commission of Western Australia.

Inherited or ‘legacy’ patients may present from other practices or prescribers requesting continuation of their long-term opioid prescription. In such cases a comprehensive clinical assessment is necessary and should include:⁶

• psychosocial assessment
• confirmation (or otherwise) of a pain diagnosis
• establishing if the continued prescription is appropriate
• using opioid risk screening tools
• considering alternatives to opioid prescribing
• reviewing the patient’s engagement with self-management strategies
• verifying any concerns about misuse or opioid dependence with previous prescriber and pharmacist – see section below on real-time prescription monitoring (RTPM).

Further information can be found in the Royal Australian College of General Practitioners (RACGP) guidelines Prescribing drugs of dependence in general practice.

Clinical governance surrounding the prescription of high-risk opioids requires GPs to act in accordance with national and state/territory regulations, and Pharmaceutical Benefits Scheme (PBS) authority requirements for prescribing opioids.⁹

Patients, prescribers and practice staff benefit from care coordination with other health professionals and practices. Establishing practice-wide policies helps to maintain cohesive management for people who are prescribed opioids.

Accountable prescribing of opioids includes:

• staying vigilant for early signs of patient dose self-escalation (eg, flagging when scripts are due) and not providing early script renewal or renewal for lost scripts
• responding to yellow flags of high-risk use
• having strategies to address risk with opioid prescriptions eg, staged supply
• making the patient aware of expected standards of behaviour including only obtaining scripts from one doctor and one pharmacy and attending scheduled appointments
• agreeing upon and documenting opioid treatment agreements with patients
• coordinating care with health professionals who are specialised in pain management and/or OUD
• thorough clinical handover and appropriate referral to specialist services when required
• regularly updating clinical skills to better understand pain and pain management strategies.

See also section 10: Incorporate RTPM into your practice.

Where there is evidence of high-risk opioid use or OUD, a prescriber’s obligations fall under state or territory legislation.

Visit the Therapeutic Goods Administration (TGA) website for information specific to your state or territory.

For patients with identified OUD, a referral may be required to a clinic where health professionals are specifically trained in this area.⁹

See section 9: Acknowledge when medication-assisted treatment of opioid disorder (MATOD) might be needed.

Practice policies

Every general practice should have a policy for prescribing high-risk medicines that supports safe, appropriate and consistent prescribing.

Practices without a policy should consider preparing one to enable a unified approach for all practice staff when managing requests for high-risk medicines.

Communication strategies and safety processes should also be in place to manage inappropriate requests for opioids by patients.¹⁶

Examples of practice policies can be found in the RACGP’s Prescribing drugs of dependence in general practice, Part A: Clinical Governance Framework (Appendix D).

Take-home naloxone

Use of take-home naloxone fits within harm-reduction strategies and patient-centred care. Naloxone is safe, effective, inexpensive and relatively easy to administer via intramuscular injection or intranasal spray.¹⁷

Offer take-home naloxone to patients at increased risk of opioid overdose and family members or carers who are likely to witness opioid overdose.

The take-home naloxone pilot in New South Wales, South Australia and Western Australia runs through to 30 June 2022.

Read the RADAR article about Naloxone nasal spray (Nyxoid) for opioid overdose.

Visit the Penington Institute COPE Program for information about overdose first aid and naloxone.

Pharmacists and other allied health professionals have a professional and legal responsibility to ensure the safe and appropriate supply of medicines or provision of clinical care to patients.

Communication between all health professionals involved in a patient’s care helps to provide safe and appropriate clinical care for the patient. Pharmacists may be able to provide valuable information, such as if a patient is accessing prescriptions from more than one practice, or where patients are accessing medications in addition to opioids that place the patient in a high-risk category (eg, obtaining benzodiazepines from one practitioner and opioids from another).

Support and coordination

Prescribers can support the role of pharmacists and other allied health professionals by:

• being available to answer enquiries from pharmacists and other allied health professionals about the management of a patient 
• coordinating medication management reviews with a local pharmacist (including Home Medicines Reviews (HMRs) if appropriate
• providing information about how to identify patients with high-risk opioid use at various points of contact eg, pharmacy dispensing, physiotherapy appointments
• working collaboratively to improve the safety of patients at high risk of harm from prescription opioids eg, developing a plan for staged supply, with the frequency of dosing instalments determined in consultation with the pharmacist and patient.

Establish clear management pathways

Where the wider healthcare team is involved, it is important to ensure that coherent management pathways are available for the team to follow. These should be backed up by process, clear written communication and regular feedback on the patient’s progress, including any challenges they may be experiencing such as aberrant behaviours.

When the harms of taking prescription opioids outweigh the perceived benefits, a comprehensive tapering plan agreed upon by patients and prescribers will be needed.

Below are steps that prescribers, patients and supporting healthcare teams can take towards achieving successful reduction of high-risk opioid use.

Explore the patient’s expectations

• Build trust through open dialogue and collaboration.
• Provide reassurance and follow guidelines for gradual tapering.

Review pain management plans

• Allow patients to set realistic and meaningful goals.
• Emphasise the importance of learning self-management strategies.
• Leverage allied health networks and coordinate management where possible.

Develop a tapering plan

• Use the NPS MedicineWise Tapering algorithm.
• Establish success criteria and monitor progress regularly.

Expect withdrawal symptoms

• Assess/manage symptoms of withdrawal (see Table 2).
• Watch for increased pain and hyperalgesia.

If in doubt, seek support

• Seek advice from drug and alcohol services, addiction specialists and mental health teams where available.
• Waiting lists for these services can be long – have strategies prepared for the interim.

Read the full article NPS MedicineWise 5 steps to tapering opioids.

Conversations about high-risk opioid use can be challenging. When handled effectively, they can create an environment where patients feel validated and more able to manage their opioid use.

Open-ended questions, like the ones listed below, create an opportunity for patients to explore the impact of their dependence on opioids and what change could look like.¹⁸

Remember that goal-setting language should reflect patient literacy levels.

• What do you know about the long-term use of opioids?
• What do you think are the upsides and downsides of continuing to take opioids?
• How do you see yourself in a few weeks’ or months’ time if you were able to reduce or stop the opioids?
• What worries you about reducing your opioid dose?
• What do you want to be able to do day-to-day that you can’t do right now?

Motivational interviewing

Motivational interviewing and other communication skills are available as part of the NPS MedicineWise Opioids – communication video series.

• Video 1: Outlines ‘motivational interviewing’, the recommended evidence-based communication approach for conversations with patients about opioid use and chronic non-cancer pain.
• Video 3: Includes a demonstration of motivational interviewing when discussing opioid tapering with a patient on long-term opioid treatment originally prescribed by a different doctor.

The Pain Management Network also features general recommendations about deprescribing opioids using a range of scenarios often encountered in general practice – from patients who are keen to stop opioids to those who are unwilling to reduce their opioid use.

MATOD may be beneficial when a patient’s high-risk opioid use develops into a chronic, debilitating disorder. It is the daily supervised dosing that sets MATOD apart from prescribing other opioid medications used in pain management.

Depending on the state or territory, further training may be required for GPs to prescribe buprenorphine or methadone as opioid substitution pharmacotherapies. Being familiar with the rationale for, and access pathways to MATOD, will help reduce barriers and stigma, and facilitate entry into this important treatment for individuals with OUD. Seek advice from your local drug and alcohol service or state/territory MATOD services.

Remember that despite best efforts to reduce opioid use with the patient and all available support networks, attempts at tapering may be unsuccessful and patients may continue to use opioids despite the risk of harm. This can be frustrating for patients and prescribers, and is a time where reassurance and support are pivotal for the patient.

RTPM is a tool designed to improve clinical decision-making and patient safety. Implementation is ongoing, and each state or territory remains responsible for the management of high-risk medicines, including which medicines are/will be monitored in that state’s RTPM program. Opioids,benzodiazepines, z-drugs and quetiapine are monitored medicines in all RTPM programs to date, with gabapentinoids also included in most RTPM programs. For information about RTPM in your state or territory see:

Australian Capital Territory

New South Wales

Northern Territory

Queensland

South Australia

Tasmania

Victoria

Western Australia

A realistic approach to managing high-risk opioid use in general practice involves committing to a consistent, patient-centred approach with clear expectations, including prescribing policies, for the wellbeing of patients, health professionals and practice staff.

Enhancing a patient’s confidence to reduce and/or cease opioid use is an important outcome of the conversation and may be achieved through a sensitive, non-judgmental and well-informed approach.

Thank you to Dr Richard O’Regan for his expert commentary. Dr O’Regan is an Addiction Medicine Specialist (FAChAM) and former Director of Clinical Services at Next Step Drug and Alcohol Services, WA. He is now an Addiction Consultant at Royal Perth Hospital.

Chronic pain resources

The Australian Prevention Partnership Centre – Chronic pain resources: a summary of online and accessible initiatives and resources.

Electronic prescriptions

Australian Digital Health Agency – What is an electronic prescription?

Electronic prescribing – Frequently asked questions (FAQs)

National Real Time Prescription Monitoring (RTPM)

Includes all state/territory contacts

https://www.health.gov.au/initiatives-and-programs/national-real-time-prescription-monitoring-rtpm

Opioids, chronic pain and the bigger picture – NPS MedicineWise program

NPS MedicineWise opioids program includes an extensive list of opioid resources, articles, research and references.

Opioid withdrawal scales (COWS and SOWS)

Clinical opioid withdrawal scale (COWS) and Subjective opioid withdrawal scale (SOWS)

• available from WA Mental Health Commission

• or download the pdf here

Prescription Shopping Program (PSP)

National prescription shopping program run by Services Australia

Take-home Naloxone

Visit Penington Institute’s COPE Program

Includes videos and patient fact sheets on overdose first aid and naloxone.

Card stacks

• Chronic pain explained
• Opioid medicines and chronic non-cancer pain
• Pain: what is going on?

Videos

• Living with pain video series – Consumers and health professionals talk about their experience with chronic non-cancer pain and opioids.
• Lowering your opioid dose: My tapering plan
• Opioids information video about opioids and chronic non-cancer pain
• Understanding pain: Brainman stops his opioid (YouTube video)

Pain networks

• Pain Australia – Includes a pain services directory and information on finding community support.

• Pain Management Network provides information for patients and families about developing knowledge and skills on how to self-manage chronic pain. Includes online information for Aboriginal and Torres Strait Islander people – Our Mob.

Medicines Line

Call 1300 MEDICINE (1300 633 424) for medicine information

Monday to Friday, 9am to 5pm AEST (excluding NSW public holidays)

www.nps.org.au/medicines-line

Reporting problems with medicines

Reporting problems with medicines or vaccines www.TGA.gov.au/reporting-problems

Report adverse events via the Adverse Medicine Events Line