Update July 2022
This article mentions the Take Home Naloxone (THN) Program. From 1 July 2022 a national rollout of this program will begin in selected states, with the remaining states and territories to have available participation from 1 November. Naloxone will remain available through the PBS to provide access for those who do not participate in the program. Learn more through the Australian Government Take Home Naloxone Program page.
High-risk prescription opioid use is a recognised problem in primary care and is not only due to patients becoming tolerant, dependent, or aberrant in their use of opioids. Prescribers, dispensers and patients all have a responsibility to maintain safe and appropriate use of prescribed opioids.
Here, we talk about recognising and managing high-risk opioid use in primary care.
Fast facts about opioid use in Australia
- In 2019, over 8% of Australians aged 14 years and older reported having used prescription opioids for non-medical purposes.1
- Between 2015 and 2019, there were 2731 unintentional deaths due to prescription opioids in Australia (increased from 1140 in 2005–2009).2
- Among people who used prescription opioids for non-medical purposes, one-third (31%) said they could not reduce their use even though they wanted to.1
- A recent report identified that 18% of people taking prescription opioids did not recognise the term ‘opioids’.3
- Less than half (43%) were able to correctly identify all their current opioid medicines as being opioids.
- Around one-third (32%) incorrectly believed that opioid dependence was only a risk for certain people.
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.
1. Recognise signs of high-risk opioid use
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.
"It is useful to remember that all chronic pain commences as acute pain, and all long-term opioid prescribing begins as short-term prescribing.
"When we refer to ‘yellow flags’ in the context of opioid medicines, they are indicators of high-risk use. Yellow flags include self-escalation of opioid dose, single script loss, requesting specific brands of opioids, early re-presentation for script renewal, history of alcohol or other substance overuse or dependence, and becoming hostile or aggressive if requests for opioids are not met.
"Red flags include obtaining medicines from multiple GPs, repeated non-sanctioned dose increases, repeated script loss or early script renewal request, injecting substances, refusing physical examination or urine drug screen (UDS), UDS positive for illicit drugs, script forgery, presenting intoxicated or in acute withdrawal."
Dr Richard O’Regan, addiction medicine consultant
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:
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.
Signs of aberrant behaviour include but are not limited to:10
- using more opioids than have been prescribed
- unauthorised dose escalation
- requesting early repeats or new prescriptions
- reporting lost or stolen prescriptions
- forging or selling prescriptions
- requesting opioids from other prescribers, including hospital emergency doctors
- admitting to seeking euphoria or anxiety relief from opioids.
2. Consider use of opioid risk and pain assessment tools
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).
"Patients whose score indicates high risk should have their ongoing management discussed with an addiction medicine or pain specialist."
Dr Richard O’Regan, addiction medicine consultant
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.
3. Discuss side effects and long-term harms
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 treatment2,11-15
Tolerance, physical dependence and withdrawal
Respiratory system effects and sleep apnoea
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
Observable clinical features
Patient-reported features (in addition to observable features)
Clinical opioid withdrawal scale (COWS)
Subjective opioid withdrawal scale (SOWS)
Adapted from the Clinical Opioid Withdrawal Scale (COWS) and Subjective Opioid Withdrawal Scale (SOWS). Available from the Mental Health Commission of Western Australia.
4. Work with inherited patients
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.
5. Understand your prescribing obligations
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.
"Documenting opioid treatment agreements (and providing a copy to the patient) can help establish boundaries regarding required behaviours and other conditions for continued opioid prescribing. Formal agreements also signal the seriousness with which opioids are prescribed and monitored.
"If aberrant behaviour and/or overuse is occurring, prescribers can restrict access by increasing the frequency of medicine collection (ie, to weekly, twice weekly, or daily pickup). While unpopular with patients, staged dispensing (also known as staged supply) may help to address when patients are struggling with self-control, and will reduce the impact from medicine loss, theft or bartering for other drugs.
"Consider use of urine drug screening to monitor for illicit drug use, which may adversely impact on patient safety and wellbeing. If illicit drug use is detected, liaise with an addiction medicine specialist."
Dr Richard O’Regan, addiction medicine consultant
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.
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).
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.
6. Involve pharmacists and other allied health professionals
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.
7. Work with patients to reduce opioids
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.
8. Build on communication skills
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 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.
"Establish clear boundaries for opioid prescribing. You could consider using a written treatment agreement signed with the patient. Also consider routine urine drug screening for patients on opioids to monitor for illicit drug use, which may adversely impact on patient safety and wellbeing. Where routine systems are established, there is less room for patients to refuse.
"It pays to practice how to respond to difficult conversations – remaining polite, respectful, and assertive in your responses."
Dr Richard O’Regan, addiction medicine consultant
9. Acknowledge when MATOD is needed
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.
10. Incorporate RTPM into your practice
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:
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.
Glossary of terms related to high-risk medicine (opioid) use12,16,19-21
High-risk (opioid) use
Non-medical use of opioids
A physical condition resulting from repeated use of a drug or medicine whereby cessation or reduction in drug intake results in a characteristic syndrome of symptoms and signs.
a The term ‘misuse’ is preferred over the term ‘abuse’ which can be considered stigmatising.
b Opioid use disorder (OUD), also called opioid dependence, is the preferred term over ‘opioid addiction’.
c Diagnostic Statistical Manual of Mental Disorder (5th Edition) DSM-5 criteria for diagnosing SUD (including OUD) involve; impaired control; social impairment; risky use; tolerance; withdrawal. For full details refer to RACGP guidelines Prescribing drugs of dependence in general practice
OUD = opioid use disorder; SUD = substance use disorder.
Resources for health professionals
Chronic pain resources
The Australian Prevention Partnership Centre – Chronic pain resources: a summary of online and accessible initiatives and resources.
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
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
Prescription Shopping Program (PSP)
National prescription shopping program run by Services Australia
Visit Penington Institute’s COPE Program
Includes videos and patient fact sheets on overdose first aid and naloxone.
Resources for patients
- 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 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.
Call 1300 MEDICINE (1300 633 424) for medicine information
Monday to Friday, 9am to 5pm AEST (excluding NSW public holidays)
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
- Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2019. Canberra: AIHW, 2020 (accessed 1 August 2021).
- Penington Institute. Australia's Annual Overdose Report 2021. Melbourne: Penington Institute, 2021 (accessed 20 September 2021).
- ORIMA Research. Australian Government Department of Health and Therapeutic Goods Administration: A report on communications developmental research relating to opioid regulatory reforms, 30 July 2020 (accessed 11 November 2021).
- Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use – United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:265-9.
- Campbell G, Nielsen S, Larance B, et al. Pharmaceutical opioid use and dependence among people living with chronic pain: Associations observed within the Pain and Opioids in Treatment (POINT) Cohort. Pain Med 2015;16:1745-58.
- 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 20 July 2021).
- Royal Australian College of General Practitioners. Drugs of dependence: Responding to requests. Melbourne: RACGP, 2020 (accessed 21 July 2021).
- Agency for Clinical Innovation – Pain Management Network. Yellow Flags – Psychological indicators. St Leonards: NSW Agency for Clinical Innovation, 2021 (accessed 11 November 2021).
- Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice, Part C1: Opioids. East Melbourne: RACGP, 2017 (accessed 11 November 2021).
- Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med 2005;6:432-42.
- Juurlink DN. Rethinking "doing well" on chronic opioid therapy. CMAJ 2017;189:E1222-E3.
- Royal Australian College of General Practitioners (RACGP). Standards for general practices. 5th edition. East Melbourne: RACGP, 2017 (accessed 7 July 2021).
- Baldini A, Von Korff M, Lin EH. A review of potential adverse effects of long-term opioid therapy: A practitioner's guide. Prim Care Companion CNS Disord 2012;14.
- Mazereeuw G, Sullivan MD, Juurlink DN. Depression in chronic pain: might opioids be responsible? Pain 2018;159:2142-5.
- Murphy L, Chang F, Dattani S, et al. A pharmacist framework for implementation of the Canadian Guideline for Opioids for Chronic Non-Cancer Pain. Can Pharm J (Ott) 2019;152:35-44.
- Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice, Part A: Clinical governance framework. East Melbourne: RACGP, 2015 (accessed 11 November 2021).
- Australian Medicines Handbook. Naloxone. Adelaide: AMH Pty Ltd, 2019 (accessed 19 September 2021).
- Crawley A, Murphy L, Regier L, et al. Tapering opioids using motivational interviewing. Can Fam Physician 2018;64:584-7.
- Pain and Analgesia Expert Group. Opioids in pain management: opioid-related harms. West Melbourne: Therapeutic Guidelines Ltd, 2020 (accessed 11 November 2021).
- NSW Ministry of Health. NSW Clinical Guidelines: Treatment of opioid dependence – 2018 North Sydney: NSW Ministry of Health, 2018 (accessed 11 November 2021).
- American Psychiatric Association. Opioid use disorder. Washington DC: American Psychiatric Association, 2019 (accessed 25 August 2019).