Opioids improvement measures

Proportion of patients currently prescribed an opioid without a relevant diagnosis recorded

Definition
  • Proportion of patients* aged 18 years or more currently prescribed an opioid medicine without a relevant diagnosis recorded

Inclusion criteria

  • Patients currently prescribed: buprenorphine, codeine, fentanyl, hydromorphone, oxycodone, oxycodone + naloxone, tapentadol and tramadol

Exclusion criteria
  • Patients with a history of opioid use disorder or are using a medicine indicated for opioid use disorder or
  • Patients with a current diagnosis of cancer, or
  • Patients with a current diagnosis of acute pain, or
  • Patients receiving palliative care
  • Patients taking other opioid medicines (see full list below)

Rationale

  • A prescription for opioids should be based on a comprehensive medical assessment and a diagnosis.1 Recording diagnosis ensures all clinicians know why a patient is prescribed an opioid. It also facilitates robust handover standards between primary, secondary and tertiary care.1

Calculation instructions

  • NPS MedicineWise is working with others in the primary care data space to develop assistance in calculating this measure.
  • Data audit tools extract and analyse practice-level data. Your PHN should be your point of contact for advice and training.

*Include all patients currently prescribed an opioid whether they qualify for the RACGP definition of an active patient or not.

 

Proportion of patients currently prescribed opioids for chronic non-cancer pain for more than three months (or 7 or more prescriptions in the previous 12 months)

Definition
  • Proportion of patients* aged 18 years or more currently prescribed an opioid medicine and who have been prescribed opioids for more than three months (or 7 or more prescriptions in the previous 12 months)†

Inclusion criteria

  • Patients currently prescribed: buprenorphine, codeine, fentanyl, hydromorphone, oxycodone, oxycodone + naloxone, tapentadol and tramadol
  • Patients must have 7 or more opioid prescriptions in the last 12 months†

Exclusion criteria
  • Patients with a history of opioid use disorder or are using a medicine indicated for opioid use disorder or
  • Patients with a current diagnosis of cancer, or
  • Patients with a current diagnosis of acute pain, or
  • Patients receiving palliative care
  • Patients taking other opioid medicines (see full list below)

Rationale

  • If opioids are initiated for acute pain, clinicians must give patients clear direction about the anticipated duration of therapy. Opioids should be tapered and ceased as the acute injury heals.2
  • Three days or less of opioid therapy will often be sufficient; more than 7 days will rarely be needed for non-traumatic pain not related to major surgery.3 Even in complex postoperative cases, opioids should generally be tapered and stopped within 90 days.2
  • GPs should review the patient every 1–2 weeks to monitor progress and assess if ongoing opioid treatment is needed. At each review, the GP should assess pain, function, quality of life, cardiorespiratory status, level of sedation and other adverse effects.4
  • Dose should be titrated according to response, sedation score (an early indicator of respiratory depression) and respiratory rate. Clinicians should use small dose increments as the dose required may vary significantly between patients of similar age, irrespective of weight.

Calculation instructions

  • NPS MedicineWise is working with others in the primary care data space to develop assistance in calculating this measure.
  • Data audit tools extract and analyse practice-level data. Your PHN should be your point of contact for advice and training.

*Include all patients currently prescribed an opioid whether they qualify for the RACGP definition of an active patient or not.
† 7 or more prescriptions infer long-term opioids use (ie, 3 months or longer)

 

Proportion of patients currently prescribed ongoing opioids who do not have a current GPMP or TCA

Definition
  • Proportion of patients* aged 18 years or more currently prescribed an opioid medicine who do not have a current general practice management plan (GPMP) or team care arrangement (TCA)

Inclusion criteria

  • Patients currently prescribed: buprenorphine, codeine, fentanyl, hydromorphone, oxycodone, oxycodone + naloxone, tapentadol and tramadol
  • Patients must have 7 or more opioid prescriptions in the last 12 months

Exclusion criteria
  • Patients with a history of opioid use disorder or are using a medicine indicated for opioid use disorder or
  • Patients with a current diagnosis of cancer, or
  • Patients with a current diagnosis of acute pain, or
  • Patients receiving palliative care
  • Patients taking other opioid medicines (see full list below)

Rationale

  • Only consider prescribing an opioid after trialling non-opioid treatment options and as part of a multimodal pain management plan.5
  • Optimise non-opioid management for patients with chronic non-cancer pain before trialling an opioid.6
  • GPMPs or TCAs may help patients access non-pharmacological therapy and facilitate an organised approach to care.

Calculation instructions

  • NPS MedicineWise is working with others in the primary care data space to develop assistance in calculating this measure.
  • Data audit tools extract and analyse practice-level data. Your PHN should be your point of contact for advice and training.

*Include all patients currently prescribed an opioid whether they qualify for the RACGP definition of an active patient or not.

 

Proportion of patients currently prescribed opioids who are also co-prescribed a benzodiazepine

Definition
  • Proportion of patients* aged 18 years or more currently prescribed an opioid medicine who are also currently prescribed a benzodiazepine

Inclusion criteria

  • Patients currently prescribed: buprenorphine, codeine, fentanyl, hydromorphone, oxycodone, oxycodone + naloxone, tapentadol and tramadol

Exclusion criteria
  • Patients with a history of opioid use disorder or are using a medicine indicated for opioid use disorder or
  • Patients with a current diagnosis of cancer, or
  • Patients with a current diagnosis of acute pain, or
  • Patients receiving palliative care
  • Patients taking other opioid medicines (see full list below)

Rationale

  • Concomitant use of benzodiazepines with opioids substantially increases the risks of side effects, particularly cognitive impairment, sedation and respiratory depression.2
  • Taper benzodiazepines or refer patients before starting opioid therapy.2 Expert consensus is that an opioid and a benzodiazepine should rarely be used in combination.3

Calculation instructions

  • NPS MedicineWise is working with others in the primary care data space to develop assistance in calculating this measure.
  • Data audit tools extract and analyse practice-level data. Your PHN should be your point of contact for advice and training.

*Include all patients currently prescribed an opioid whether they qualify for the RACGP definition of an active patient or not.

 

Proportion of patients prescribed greater than or equal to 60 mg oral morphine equivalent daily dose (OMEDD)

Definition

  • All patients* aged 18 years or more currently prescribed an opioid medicine and who are using more than or equal to 60 mg OMEDD

Inclusion criteria

  • Patients currently prescribed: a) buprenorphine, codeine, fentanyl, hydromorphone, oxycodone, oxycodone + naloxone, tapentadol and tramadol; and b) strength is more than or equal to 60mg OMEDD when the standard daily dose is prescribed.α

Exclusion criteria
  • Patients with a history of opioid use disorder or are using a medicine indicated for opioid use disorder or
  • Patients with a current diagnosis of cancer, or
  • Patients with a current diagnosis of acute pain, or
  • Patients receiving palliative care
  • Patients taking other opioid medicines (see full list below)

Rationale

  • Opioid-related harms are dose dependent and risk of harms is more likely to outweigh benefits at higher doses.1,7
  • Any beneficial response to an opioid should be evident at an OMEDD of less than or equal to 60 mg.4 Consider specialist advice for patients prescribed an OMEDD greater than 60 mg.
  • Use the ANZCA Faculty of Pain Medicine opioid dose-equivalence table to calculate the OMEDD.

Calculation instructions

  • NPS MedicineWise is working with others in the primary care data space to develop assistance in calculating this measure.
  • Data audit tools extract and analyse practice-level data. Your PHN should be your point of contact for advice and training.

*Include all patients currently prescribed an opioid whether they qualify for the RACGP definition of an active patient or not.
α fentanyl ≥ 25 microgram/hr and buprenorphine ≥ 30 microgram/hr patches, morphine ≥ 30 mg, oxycodone ≥ 20 mg, hydromorphone ≥ 12 mg, tapentadol ≥ 100 mg, and tramadol ≥ 150 mg sustained/controlled release oral capsules or tablets.

 

List of excluded opioid medicines

The medicines below are not likely to be used for chronic non-cancer pain. Exclude patients taking these medicines when you generate the list of patients requiring review. This will need to be done manually at this stage.

Medicine

Excluded medicines

Rationale

Codeine

Cold and flu combinations

Indicated for cold and flu

Actacode

Indicated for dry cough

Codeine 5 mg/mL

Indicated for dry cough

Aspirin and codeine combination

Other codeine and aspirin combinations are included. Aspalgin is excluded as it has an indication specific for 'acute moderate pain, inflammation and fever'

Codeine linctus

Likely use is cough suppression

Morphine

Depodur 10 mg/mL

Indicated only for post-operative pain

Buprenorphine

Buprenorphine + naloxone

Indicated for opioid dependence

Subutex

Indicated for opioid dependence

Suboxone

Indicated for opioid dependence

Buprenorphine/naloxone 8/2 mg

Indicated for opioid dependence

Buprenorphine/suboxone 4/1 mg

Indicated for opioid dependence

Buprenorphine/suboxone 2/0.5 mg

Indicated for opioid dependence

Buprenorphine/suboxone 12/3 mg

Indicated for opioid dependence

Buprenorphine 8 mg

Indicated for opioid dependence

Buprenorphine 2 mg

Indicated for opioid dependence

Buprenorphine 400 micrograms

Indicated for opioid dependence

Buprenorphine 0.4 mg

Indicated for opioid dependence

Buprenorphine 64 mg

Indicated for opioid dependence

Buprenorphine 128 mg

Indicated for opioid dependence

Buprenorphine 96 mg

Indicated for opioid dependence

Buprenorphine 16 mg

Indicated for opioid dependence

Buprenorphine 24 mg

Indicated for opioid dependence

Buprenorphine 32 mg

Indicated for opioid dependence

Buprenorphine 8 mg

Indicated for opioid dependence

Buprenorphine 0.2 mg

Indicated for short-term use

Buprenorphine 0.3 mg/1 mL

Indicated for short-term use

Buprenorphine 200 micrograms

Indicated for short-term use

Buprenorphine 300 micrograms/1 mL

Indicated for short-term use

Fentanyl

Fentanyl injections

Short term analgesia or anaesthesia

Fentanyl nasal spray

Indicated for cancer pain

Bupivacaine hydrochloride, fentanyl citrate

Indicated for post-operative or obstetric epidural analgesia

Ropivacaine hydrochloride, fentanyl citrate

Indicated for epidural infusion for analgesia

Fentanyl sublingual tablets

Indicated for use in cancer pain

Fentanyl lozenges

Indicated for use in cancer pain

Fentanyl disintegrating tablets

Indicated for cancer pain

Fentanyl citrate

Salt for injections, tablets and lozenges

Methadone

Biodone forte

Biodone forte is indicated solely for opioid dependence

Alfentanil

All formulations

Indicated for use in specialist settings

Pethidine

All formulations

Indicated for short term analgesia and is likely to be accompanied by another opioid if used for chronic pain

Remifentanil

All formulations

Indicated for short term analgesia and anaesthesia
 

References

  1. Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice, Part C1: Opioids. East Melbourne: RACGP, 2017 (accessed 18 November 2019).
  2. Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice, Part C2: The role of opioids in pain management. East Melbourne: RACGP, 2017 (accessed 19 March 2019).
  3. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep 2016;65:1-49.
  4. NSW Therapeutic Advisory Group Inc. Preventing and managing problems with opioid prescribing for chronic non-cancer pain. Sydney: NSW TAG, 2015 (accessed 8 January 2019).
  5. Faculty of Pain Medicine. Australian and New Zealand College of Anaesthetists. Recommendations regarding the use of opioid analgesics in patients with chronic non-cancer pain. PM01 2015. Melbourne: ANZCA, 2015 (accessed 14 March 2019).
  6. Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ 2017;189:E659-E66.
  7. Juurlink DN. Rethinking "doing well" on chronic opioid therapy. CMAJ 2017;189:E1222-E3.