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.