Prescribing drugs of dependence in general practice

Part C1 - Opioids - Chapter 2

Clinical governance

Last revised: 03 Mar 2020

Patient perspectives

Patients have the right to best practice care that is respectful and promotes their dignity, privacy and safety.

Those who misuse medication and/or illicit drugs have the same entitlement as other patients to respectful care. Treatment should aim to optimise outcomes across a range of areas including health, problematic drug and alcohol use, social functioning and crime.

Good pain management or opioid replacement therapy (ORT) can have significant benefits. For many people, effective therapy can transform quality of life: it can allow people to function and participate in their families, communities and workplaces. Some patients have experienced clinical improvement from opioid therapy, but have also experienced stigma and/or difficulties in accessing long-term care.27 Patients report being continually judged or shamed by the media, society and the medical profession. Care should be undertaken not to stigmatise patients with these complex conditions.

This means balancing patient-centred care, evidence-based practice, legislative requirements and partnerships with other healthcare providers to patients across the spectrum. Further considerations when balancing patient care and legal requirements include such things as drivers licence requirements and potential risks to others  (eg children and others in the patient’s care).

Maintaining a patient focus ensures that care is provided in partnership with patients and their families and carers, respecting their diverse needs, preferences and choices, and in coordination with other organisations whose services impact on patient wellbeing.28 Integrating the patient perspective has the potential to increase the patient’s satisfaction with the consultation, as well as result in better decisions and in improved management of the illness and health outcomes.29

The healthcare provider may be faced with misaligned expectations of opioid therapy, especially where patients are either reluctant to consider therapeutic alternatives to opioids or to participate in a time-limited therapeutic trial of the opioid. Clinical discipline is required as there can sometimes be elements of manipulation behind patient requests for opioids. Patient-centred care does not mean professional boundaries can be crossed, laws ignored or therapy continued if it is considered detrimental to the patient’s health.

Setting patient behaviour standards for patients on opioid therapy

When prescribing drugs of dependence or when changing a prescription (to manage risk), prescribers have a responsibility to make patients aware of expected standards of behaviour. This process is best undertaken in an empathetic, non-judgemental manner, where there is a good therapeutic alliance with the patient. Having practice policies will help this process.

Patient behaviour standards may include:

  • only obtaining scripts from one doctor and one pharmacy
  • receiving a staged supply through the pharmacy
  • a supervised dose taken by the patient at the pharmacy
  • attending appointments regularly
  • engaging with other supports
  • engaging with psychological supports
  • agreement when a therapeutic trial of treatment will cease
  • the consequences of inappropriate patient behaviour (eg formal review, possible referral or cessation of clinical relationship).

Any coercion or threat (physical or verbal) in order to manipulate the doctor to prescribe is an immediate red flag and a breach of the therapeutic alliance. A GP has the right to discontinue the care if a patient has crossed boundaries and behaved in a violent or threatening manner.30

The therapeutic relationship may be ended by the GP during a consultation or by letter or telephone.30 Safety determines which method is used. Practices should consider having a process that staff can follow if the patient makes any further contact.30

Shared decision making around opioid therapy

Shared decision making (SDM) is vital to patient-centred care. For patients to be an active partner in their care, they need to be well informed.

SDM is the process of bringing evidence into the consultation and incorporating it into a discussion about the patient’s values, expectations and preferences: it is the integration of communication and evidence skills.31–33

Very few clinical situations surrounding opioid therapy involve consideration of just one option, and no treatments are 100% effective or 100% safe. When considering pain management options, often the evidence does not strongly support a single clinically superior option.31,32,34 Hence, pain management typically involves a preferencesensitive decision that is likely to be strongly influenced by patients’ beliefs and values.34–36

Information provided should allow realistic expectations about the likely or potential outcomes of the treatment. SDM has been shown to build trust, prevent harm and reduce surprise and distress if complications or adverse events occur.37–41

As most patients overestimate the benefits of medical interventions and underestimate the risks, it is important to know what expectations patients have, help correct any misperceptions and be honest about uncertainty (to do with their pain condition and with treatments).42

A caveat

While most patient involvement with opioids is clinically driven, there can also be elements of manipulation (and rarely, criminal intent) behind patient requests for opioids. The important caveat when prescribing opioids relates to healthcare benefits. Some patients with CNCP or drug dependence may request higher opioid doses on the basis that they have a ‘right’ to analgesic drugs for pain and are making a choice as an informed patient.

Patients do have a right to receive good healthcare, but not a right to access drugs of dependence. Patients need to be informed of this at the beginning of any trial using drugs of dependence. If the clinician feels that further therapy is detrimental to a patient’s health, then clinical withdrawal of medication should begin.

Doctors typically have a strong desire to alleviate patient distress and suffering. There are GPs who find it difficult to set boundaries for patients and are at risk of being pressured to prescribe inappropriately. The psychological phenomenon of ‘transference’ in addiction, pain and mental illness can result in doctors having difficulty in these clinical areas. Others have difficulties in saying ‘no’ or hold the belief that they are ‘helping’ or using a harm minimisation approach by giving patients who are seeking drugs what they ask for.

All practitioners express difficulty responding to manipulative behaviours or techniques posed by some patients seeking opioids inappropriately. GPs should educate themselves about appropriate responses to common manipulative techniques and behaviours posed by some patients to access opioids. To aid GP negotiation skills, scripted replies have been developed to help with appropriate responses in difficult situations.

Box 1. Helping patients make informed decisions

The RACGP’s gplearning platform has developed an online activity to help GPs communicate information about risk and benefits to patients. The activity provides a framework for assisting patients to share decisions about their treatment.

Legislative requirements for opioid prescribing in general practice

State and territory law

There are strict legal requirements around the prescription of drugs of addiction or controlled drugs, known as Schedule 8 (S8) medicines, which include opioid medications. Doctors must abide by the laws and regulations that govern prescribing. Those who disregard their responsibility risk civil, disciplinary or coronial proceedings.

Before prescribing an opioid, GPs must take all reasonable steps to ensure a therapeutic need exists. Once a therapeutic need is established, GPs are required to comply with state-specific or territory-specific health legislation and, in some cases, obtain a permit from the relevant health authority.

The legislative requirements vary across Australia. There are inconsistencies across states and territories regarding the definition of ‘drug dependency’, the authority required for prescribing, and the rules of interstate prescribing. It is the prescriber’s responsibility to ensure that prescriptions comply with all aspects of their state or territory legislation.

Consistently, the state or territory legislative requirements for prescribing S8 drugs depend on the person’s drug dependency status and the duration of opioid prescribing. That is:

  • For people who are known or suspected to be drug dependent, S8 medications (and in some states and territories, certain S4 benzodiazepines) cannot be prescribed without a permit or an appropriate approval from the relevant state or territory health department’s pharmaceutical services unit (PSU). A prescriber must understand the legislative definition of ‘drug dependence’ in their state or territory and use their clinical judgement to determine whether the patient is drug dependent in accordance with that definition. Patients currently or previously on opioid treatment programs need special consideration as some states consider these patients to be drug dependent.
  • For people who are not drug dependent, S8 medications cannot be prescribed for a period greater than two months without an appropriate approval under current state and territory legislation. The New South Wales, Tasmanian and Northern Territory governments have subtle variations to this law and prescribers are referred to relevant legislation.

These approvals are distinct from, and in addition to, any authority under the PBS for scripts.

Box 2. Information needed for an S8 prescription to comply with state and territory standards

  • The prescriber’s full name, address and prescriber number
  • Date the prescription was written
  • The patient’s full name, address and date of birth
  • Description and quantity of the medicine of addiction to be dispensed
  • Precise directions for use
  • Number of repeats (if any) and intervals at which they may be dispensed
  • Signature of the prescriber

For computer-generated S8 prescriptions, the information highlighted in italics (above) must be written in the doctor’s own handwriting.

Adapted from the Government of Western Australia Department of Health. WA Regulatory requirements for prescribing Schedule 8 medicines (S8s). Perth: WA Drug and Alcohol Office, 2009. 


It is important that prescribers are aware of and comply with the legislative restrictions that apply in the state where the prescription is dispensed. This is a particular issue for GPs working close to state or territory borders. To avoid potential issues, GPs should advise patients that prescriptions should be dispensed in the state or territory where the prescription is written.

GPs need to be aware of their obligations regarding the impact of medication on the patient’s ability to safely perform usual activities such as driving (eg Jet’s Law in Queensland)

Opioid prescribing in Australia: Definitions of drug dependence, state and territory authority requirements* and prescription rules

Table 2

Opioid prescribing in Australia: Definitions of drug dependence, state and territory authority requirements* and prescription rules

Pharmaceutical Benefits Scheme requirements for opioid prescriptions

Under PBS categorisation, most S8 opioids are ‘Restricted benefits’ items and some are ‘Authority required benefits’ items. Before initial prescribing and before requesting repeats or increased maximum quantities, prescribers need to check the status of each item.

The following descriptions are taken from Western Australia and Queensland health department regulatory requirements for S8 medications.

Restricted benefits

Authorities for increased maximum quantities and/or repeats for restricted benefit items will be granted only for:

  • chronic severe disabling pain associated with proven malignant neoplasia
  • chronic severe disabling pain not responding to non-opioid analgesics where the total duration of narcotic analgesic treatment is less than 12 months
  • first application for treatment beyond 12 months of chronic severe disabling pain not responding to non-narcotic analgesics where the patient’s pain management has been reviewed through consultation by the patient with another medical practitioner, and the clinical need for continuing narcotic analgesic treatment has been confirmed. The date of the consultation must be no more than three months prior to the application for a PBS authority. The full name of the medical practitioner consulted and the date of consultation are to be provided at the time of application
  • subsequent application for treatment of chronic severe disabling pain not responding to non-narcotic analgesics where a PBS authority prescription for treatment beyond 12 months has previously been issued for this patient.

Authority required benefits

Authority required benefits are restricted benefits that require prior approval from Medicare Australia or the Department of Veterans’ Affairs (DVA).

When a PBS or Repatriation Pharmaceutical Benefits Scheme (RPBS) authority application is for an S8 opioid, the following guidelines apply:

  • The supply quantity is generally for 14–28 tablets.
  • Where supply for a longer period is warranted
    • telephone approvals are limited to one month’s supply by calling the PBS Authority approvals enquiry line  (1800 888 333)
    • quantities are usually for up to three months’ therapy with written application posting an Authority prescription form to Medicare Australia. After approval, Medicare Australia will forward both copies of the prescription to the patient or the prescriber (if it is to be sent direct to the patient, the prescriber should mark the box next to the patient’s details).

The quality and safety of patient care is no longer confined to the individual practitioner. General practices have responsibilities to work collaboratively with practitioners to address the safety and quality of health services provided in their facilities.

A simple checklist has been included (Appendix B4) to inform practice owners of their position regarding drugs of dependence. It is not a standard or practice requirement; rather, it is designed to enable general practices to evaluate their status in managing drugs of dependence for their respective populations. As each general practice is different, findings should be interpreted individually.

Refer to Appendix B4: Simple checklist for a general practice to review its quality management of drugs of dependence.

Practice systems of care around opioids can be put in place to maximise health outcomes and social functioning for patients while minimising drug and alcohol misuse, abuse, diversion and crime. Systems of care also provide the necessary infrastructure and support for GPs to perform their jobs efficiently and effectively.

Staff education and competency

Practices should ensure they have the level of knowledge among team members and practice capacity to address the issues associated with opioid prescribing (eg identification of patients with more complex needs and those at higher risk). Prescriber education is particularly important.

GPs who are regularly involved in managing patients with problematic use of opioids or other drugs and alcohol should consider further training and developing good working relationships with addiction specialists.

Practices should promote the development of competency in prescribing opioids. Where potentially inappropriate and suboptimal prescribing is identified, practices and GPs have an opportunity to engage in education and support to improve patient outcomes.

Opioid dependence programs within the general practice

Access to relevant programs is limited in some areas of Australia. Opioid substitution therapy (ie using methadone and buprenorphine) is effective for the management of opioid dependence and is within the scope of most Australian GPs.43 The training and regulatory requirements for prescribing opioids for substitution therapy varies between jurisdictions.

Opioid replacement and detoxification typically requires significant and frequent communication with patients, more regular visits with the GP and other clinical staff, on-call mechanisms, and management of patients who are often highly anxious.44 Suitably qualified staff, organised support and ongoing quality assurance arrangements may be required. GPs involved in this type of program should feel comfortable prescribing adjunct medications.45

Balancing patients’ needs with practice capacity  (risk stratification)

Patients should be appropriately evaluated to determine the complexity of services required. A goal of the initial patient assessment is to make a reasonable determination of clinical complexity and risk in the context of concurrent SUD or psychopathology. From this, patients can be placed into one of three basic risk groups: patients who may be safely managed in the primary care setting, patients who should be co-managed with specialist support, and patients who should be referred on for management in a specialist setting (Table 3).

GPs with advanced training in addiction medicine and/or mental health management are suited to taking on higher responsibilities under this model.

Table 3.

Table 3.

Patient risk groups46

Key prescribing principles

As with any treatment, prescription of opioids should be based on:

  • a comprehensive medical assessment
  • a diagnosis
  • thoughtful consideration of the likely risks and benefits of any medication, as well as alternative nonpharmacological treatments and interventions. GPs should be aware of
    • the characteristics of each opioid, its accepted indications for use, and its general and specific risks
    • patient groups or contexts which require additional caution or exclusion (eg pregnancy and lactation, workers’ compensation injuries, patients who drive, patients with sleep apnoea or disordered breathing, patients over 65 years of age, patients with renal or hepatic disease, Aboriginal and Torres Strait Islander patients or culturally diverse populations, and patients with comorbid mental health disorders)
  • a management plan derived through SDM and continual clinical monitoring.

Accountable prescribing also involves provision of adequate therapeutic monitoring, dose limitations and compliance with national and state law.

In acute pain, opioids should only be prescribed at the lowest effective doses and in amounts no more than the number of doses needed (and should not be pro re nata [PRN]). This should be based on the expected duration of pain that is severe enough to justify prescribing opioids for that condition.47 Less than three days of opioid therapy will usually be sufficient for non-traumatic pain not related to major surgery, and continuing requirements for opioid therapy after this time should prompt review.48

Recognising patients at risk with opioid prescribing

Opioids are often useful analgesics, but care needs to be taken when prescribing these drugs in order to limit the risks including inappropriate use and diversion. Clinically, problematic opioid usage is more likely when prescribed to:

  • younger patients – substance use issues generally commence before 35 years of age
  • patients without a definite diagnosis or pathology
  • patients with active substance use problems or in contact with patients with such problems
  • patients with active psychiatric problems
  • patients who use benzodiazepines – concomitant use of opioids substantially increases the risks of side effects, particularly cognitive impairment, sedation and respiratory depression10
  • patients with socioenvironmental problems.

Refer to Patient selection/exclusion process for opioid therapy.

Strategies to address risk with opioid prescriptions

The risk of opioid misuse is addressed by comprehensive assessment.49,50 Although screening for opioid risk has been recommended, there is little current evidence that it is effective. Treatment agreements and urine testing have also been recommended, however do not appear to reduce overall rates of opioid prescribing, misuse or overdose.51,52

As patients with a history of SUD are at higher risk of harms, checking state-based prescription monitoring systems is advocated. Those patients with a history of SUD should probably not be offered opioids in a general practice setting but, rather, if pain control cannot be gained by other means, should be offered referral to specialist services.

A routine urine drug screen may reveal evidence of substances of which the practitioner is not aware. Not all substances are routinely tested for (eg oxycodone, methadone and fentanyl testing may need to be specifically requested). If such drugs are found, whether illicit or legal, the patient should be referred for specialist assessment and management. Alternatively, negative results on urine testing for specified prescribed medications may raise the possibility of diversion.

Patient selection/exclusion process for opioid therapy

Opioid medications should only be used for the treatment of acute pain when non-opioid pain medications and therapies have failed, are likely to fail to provide adequate pain relief, or are contraindicated.

 Patient groups that require caution when considering opioid therapy

Table 4.

Patient groups that require caution when considering opioid therapy53

Adapted from the Australian and New Zealand College of Anaesthetists. Guidelines on acute pain management. Melbourne: ANZCA, 2013.


Evaluate the risk factors for opioid-related harms in individual patients. This may include a review of the patient’s history of controlled substance prescriptions using the Prescription Shopping Programme (PSP) or state prescription drug monitoring program (PDMP) data to check if the patient is receiving other opioids or medications (especially benzodiazepines54) that increase risk of overdose.

Avoid prescribing opioids to patients with polydrug use or comorbid alcohol or substance use disorders. GPs should consider tapering benzodiazepines and seeking specialist opinion or a specialised pain management facility in the management of these patients.55

Prescribing practices to minimise risks in opioid therapy

Opioid treatment seeks to maximise outcomes for the health and social functioning of the patient while minimising risks. To minimise risks, opioids should be prescribed at the lowest effective dose for the shortest clinical time frame, but also by dispensing patients a manageable ‘pill load’ (ie dispense only the amount of opioid medication needed for a defined interval).

Prescribers can also decrease the risk of misuse by reducing access and temptation to overuse medication through much more frequent dispensing of smaller quantities of medications. This can range from weekly, twice weekly to daily (supervised) dispensing.

Prescriptions can also have ‘Do not fill until [insert date]’ instructions. This can reduce the number of tablets a patient is given at a time without requiring unnecessary visits for repeat prescriptions. This is aided by a onepractice and, preferably, one-GP approach, and the dispensing of medication through one pharmacy. Refer to Appendix B7: Risk assessment for patients with ongoing needs for drugs of dependence

Getting urgent advice and support for patients on opioid therapy

All state and territory health authorities have 24-hour telephone access to assist drug and alcohol queries.

Table 5.

Table 5.

State and territory legislative frameworks and clinical advisory services

Clinical coordination needs to occur whenever care is to be delivered by different providers. Poor transfer of care risks patient safety and is a common cause of serious adverse outcomes. Inadequate handover can also lead to medication errors, wasted resources and unnecessary repetition of tests, delayed treatment or follow-up of significant test results, and increased risk of medico-legal action. Within general practices there should be an effective handover system that ensures safe and continuing healthcare delivery for patients in the event of staff absences.

GPs also work with a range of care facilities and other professionals who prescribe drugs of dependence, and may work as part of a wider organisation or in a multidisciplinary team. It is important to be aware of accepted bestpractice protocols used in each setting and work in accordance with these.

It is usually good practice to ensure that clinical practices are standardised through local area policies and protocols.

Managing patients prescribed opioid therapy who see multiple providers

Occasionally, some complex patients are managed by several practitioners working in collaboration. It is important to determine and agree on a primary medication provider to avoid medication adverse events.

The doctor writing the prescription ultimately assumes responsibility for the prescription and its compliance with legislation. This is irrespective of whether another doctor at the practice primarily prescribes or a specialist has recommended the treatment.

When a GP does not feel happy to provide a prescription, they should not feel pressured to do so. The ideal situation is to have an independent drug and alcohol specialist review the case. Alternatively, referral back to the original provider for scripts may be warranted.

Referral of patients prescribed long-term opioid therapy

Inter-practice referral of patients prescribed long-term opioid therapy

Patients will travel within Australia and appropriate handover of care to another practice or practitioner is often necessary. For patients who are prescribed opioid therapy this can be complicated. Referral of patients should be both written to Australian Commission for Safety and Quality in Health Care (ACSQHC) handover standards, and assisted by GP-to-GP communication or practice-to-practice communication prior to the arrival of the patient at the new destination.

GPs at the new practice have an obligation to reassess the clinical context and prescribing appropriateness Prescribing drugs of dependence in general practice, Part C2: The role of opioids in general practice – Section 1.5.5 The inherited patient – Continuation of long-term opioid management plans initiated by other healthcare providers). All referrals should contain relevant information pertaining to short-term and long-term pain management including:

  • a summary of biopsychosocial assessment and pain history
  • a pain diagnosis, and the rationale and plan for pain management
  • a medical summary including medications and known adverse reactions
  • relevant specialists involved in care
  • a copy of relevant state permits.

Deciding when to seek advice or consider referral to a specialist

Patients who are at higher risk for dependence or have more complex issues need to be jointly managed between primary care and specialised drug and alcohol addiction services. They also may also require the input of mental health and/or pain specialists.

The ongoing treatment of pain, addiction and mental illness comorbidities is a complex undertaking. Initial referral may be needed to obtain a comprehensive evaluation or to clarify the optimal therapeutic strategies.

Referral is typically considered for patients who are at higher risk, who have more complex needs or for patients at risk of adverse events. This includes patients who:56

  • are relatively young (<35 years)
  • have a comorbid psychiatric or psychological disorder
  • have previous or current opioid (or other) SUDs
  • have indeterminate pathology.

Once an optimal regimen and monitoring approach has been implemented, referral may be warranted in the case of:56

  • unexpected drug dose escalation
  • ceiling drug dosages reached
  • suspected abuse or misuse
  • risk category change
  • high levels of patient distress
  • unusual opioid requirements or suspicions of drug diversion
  • poorly controlled comorbid psychiatric or psychological disorder.

Deciding when to refer a patient for hospital admission (through emergency departments)

Patients may need referral to hospital if they are at risk to themselves, pose risks to others or are at risk of harm by others. Typically, these situations are sensitive, and contact with state or territory helplines and accident and emergency staff may be appropriate.

Identifying patient risk

Table 6.

Identifying patient risk

Hospital staff often find it difficult to manage referred patients with chronic pain on long-term treatment even when admission is not related to opioid use. Without the relevant information and a clear understanding of the patient’s pain management, the patient’s treatment may be stopped or altered, which may affect other treatment and outcomes and impact on morbidity, mortality, length of stay and discharge.

All referrals, whether for pain, trauma, injury or other reasons, should contain the relevant information pertaining to short-term and long-term pain management, including:

  • medications and known adverse reactions
  • diagnosis including reason for requiring inpatient pain management
  • relevant specialists involved in care
  • duration of treatment
  • a summary of biopsychosocial assessment and forensic history.

Providing this information assists hospital teams to seek appropriate consults relevant to the patient’s care and optimises outcomes and discharge. Patients with chronic pain may benefit from a chronic pain service consult while in hospital, and linking in with the service if required. The chronic pain service may request follow-up by a community-based chronic pain service on discharge.

Clinical handover of patients using opioid therapy to general practice

Overview

Clinical handover needs to occur whenever care is to be delivered by different providers.

Inadequate transfer of care is a major risk to patient safety and may result in delays in treatment or follow-up, medication errors and unnecessary repetition of tests. It also increases the risk of medico-legal action.

Patients on opioid therapy – handover from hospital clinics to general practice

An effective and efficient health system relies on high standards of care, particularly where handover of care from hospital to community is involved. General practices and GPs should insist on high standards for referral letters for clinical handover or shared-care arrangements from secondary care before accepting the ongoing care of a patient. This facilitates the continuity of care and transfer back to higher levels of care if the need arises.

A practice or GP may not accept the ongoing management of a high-risk patient referred from a public sector facility, unless there is:

  • a medical summary
  • a clear management plan, particularly with ongoing drugs of dependence including opioids
  • patient-specific instructions, including specific clinical issues that would prompt referral back to secondary care
  • contact details of a case manager and a clinically responsible person
  • documentation that details mechanisms for rapid transfer back to specialty care if deterioration occurs.

These requirements should be supported by practice policies and communicated to referral agencies if information does not meet required standards. It might also be useful to document non-attendance by patients.

Refer to Appendix C: Preliminary RACGP position statements regarding health services integration.

ACSQHC handover standards are available for reading.

Patients on opioid therapy – handover from emergency departments to general practice

An effective and efficient health system relies on high standards of care, particularly where handover of care from hospital to community is involved. It is vital that hospitals make clear plans for analgesia reduction after discharge and have reliable systems for communication with usual treating practitioners.57–59

Problematic opioid use often has its origins in the acute pain setting.15,60,61 Therefore, before prescribing opioids at discharge, possible adverse effects of opioids should be considered. These include potential risks of longterm opioid use, injury, drug diversion, misuse, abuse, and death from accidental overdose.62 Three days or less of opioid therapy will often be sufficient for acute analgesia; more than seven days will rarely be needed.15 The number of doses dispensed should be no more than the number needed. This prescription should be based on the expected duration of pain that is severe enough to justify prescribing opioids for that condition.47

Additionally, patients discharged from emergency departments (EDs) with opioids may not safely store and dispose of their medications.63 One study found that after receiving opioid prescriptions for an acute episode, 64% of patients kept unused opioids and 34% shared them with others.64 Patients should be advised of the risks associated with these behaviours and what they should do with unused opioids (ie return them to a pharmacy).62

When patients present for acute exacerbation of chronic pain, it is important to identify the source of the pain rather than just treating for acute pain, since treatment for the chronic pain patient can be significantly different. Clinicians should:

  • consult the patient’s pain care plan prior to prescribing any medications
  • confer with the clinician managing the patient’s chronic pain, their interdisciplinary team or available resources to provide appropriate chronic pain management
  • avoid prescribing increased dosage or additional opioids
  • manage exacerbations of pain with non-opioid therapy65
  • check state-based prescription monitoring services for history of opioid prescriptions
  • assess the patient’s mental health status and social situation to determine if additional resources may be appropriate.

Patients on opioid therapy – handover from hospital surgical and rehabilitation units

An effective and efficient health system relies on high standards of care, particularly where handover of care from hospital to community is involved. Over-prescription of opioids has been noted for surgical discharges.66–68 For example, 19% of postoperative patients were prescribed oxycodone upon discharge from a large Australian teaching hospital even though they had not needed any opioid treatment in the 24 hours prior to discharge.69

In part due to the increase in the number of patients and procedures considered suitable for short stay or early discharge, the number of patients discharged from hospital or rehabilitation units with opioid medication is rising.62 There is an association between long-term use of analgesics and early discharge after day-stay surgery with a prescription of opioids, with up to 8% of patients continuing to use opioid medication for months or even years after surgery.70–72

In a population of almost 400,000 opioid-naïve patients over 65 years of age who underwent short-stay surgery, the patients who received an opioid prescription within seven days after surgery were more likely to become long-term opioid users within one year, in comparison to those without a prescription.70 In another study of 39,000 opioid-naïve patients having major elective surgery, 3.1% showed prolonged opioid use after discharge.72

In the majority of cases, opioid therapy can be stopped within one week of surgery or injury.73 With more complex cases, opioids should be weaned and ceased within three months at the most.73

A clear plan for analgesia reduction after discharge and good communication with usual treating practitioners will assist in avoiding long-term treatment and unintended dose escalation.57–59

Patients on opioid therapy – handover after admission with intentional nonfatal overdose of opioids

Patients who have had a presentation or admission for opioid overdose are at significant risk for another overdose and further harms.74

At two years, the cumulative incidence of repeated overdose was:74

  • 17% (95% confidence interval [CI]: 14%, 20%) for patients receiving high dosages of opioids after the index overdose
  • 15% (CI: 10%, 21%) for those receiving moderate dosages
  • 9% (CI: 6%, 14%) for those receiving low dosages
  • 8% (CI: 6%, 11%) for those receiving no opioids.

Opioid discontinuation after overdose is associated with lower risk for repeated overdose.74 Non-fatal opioid overdose is an opportunity to identify and treat SUDs, as patients often have both pain and substance abuse issues.

Alternatively, naloxone distribution programs are firmly rooted in the principles of harm reduction. Naloxone is safe, effective, inexpensive, and relatively easy to administer via intramuscular (IM) injection.75 Please refer to ‘Naloxone therapy’ in Part C2: The role of opioids in pain management for further information.

All patients presenting to hospital EDs with non-fatal opioid overdose should undergo a full pain and psychiatric evaluation, including consideration of opioid cessation or naloxone therapy. A clear plan for opioid safety after discharge and communication with the patient’s usual treating GP in the community is essential.

Box 3. Summary of requirements for effective handover from hospital to general practice

  • Hospitals should develop robust communication systems for transfer of care to usual treating practitioners in the community consistent with ACSQHC standards for handover
  • Patients discharged from hospitals (including EDs, rehabilitation units and day care facilities) on opioids should be educated regarding the safe and optimal use of the pain medications that have been prescribed
  • Patients discharged from hospitals (including EDs, rehabilitation units and day care facilities) on opioids should have a clear plan of pain management to facilitate handover of care:
    • A post-surgery discharge letter must accurately reflect information on opioid dose frequency and suggested duration of treatment, including plan for dose reduction
    • Patients commenced on long-term opioids in hospital for chronic (cancer or non-cancer) pain should contain detailed documentary support justifying continued opioid use
    • Psychiatric patients, or patients who were admitted with opioid overdose, should have clear justifications for opioid use and clear plans for future monitoring
  • Prescriptions of opioids on discharge should, in most cases, not exceed seven days’ supply (or until earliest office opening and follow-up from the patient’s usual GP)
  • If a patient with a history of chronic pain is admitted to a hospital for non-fatal overdose:
  • the patient should have a full pain and psychiatric evaluation, and consideration of opioid cessation or provision of naloxone therapy for peer or family administration in situations of overdose – the patient’s usual GP or care team should be notified.

Managing opioid discontinuation

Where there is evidence of substance use disorder

The legislative requirements vary in each state and territory. Importantly, the legislative requirements for prescribing S8 drugs vary depending on the person’s dependence, but all are consistent for patients with respect to SUD: S8 medications (most opioids, alprazolam and flunitrazepam) cannot be prescribed without a permit or an appropriate approval from the relevant state or territory health department’s pharmaceutical services unit.

In some cases, it may become apparent during weaning that the primary problem is opioid dependency rather than pain.76 For patients with opioid use disorder, GPs should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine-naloxone or methadone in combination with behavioural therapies).15

Where there are complex patient comorbidities

Referral to an addiction or pain specialist is advised.15,52

Where there is no evidence of substance use disorder

A commonly used approach is decreasing the original dose by 10% every five to seven days until 30% of the original dose is reached.77 Then, decreasing the remaining dose by 10% each week.77 This approach rarely precipitates withdrawal symptoms and facilitates adherence.77

If discontinuation is required after a shorter period of opioid therapy then a faster rate of weaning is generally appropriate.52 One option is reducing the daily opioid dose each week by 10–25% of the starting dose.52

  1. Berterame S, Erthal J, Thomas J, et al. Use of and barriers to access to opioid analgesics: A worldwide, regional, and national study. Lancet 2016;387(10028):1644–56.
  2. The Pharmaceutical Benefits Scheme (PBS) Drug Utilisation Sub-committee (DUSC). Opioid analgesics: Overview. Canberra: Department of Health, 2014. Available at www. [Accessed 11 July 2017].
  3. Roxburgh A, Ritter A, Slade T, Burns L. Trends in drug use and related harms in Australia, 2001 to 2013. Sydney: National Drug and Alcohol Research Centre, University of New South Wales, 2013. [Accessed 11 July 2017].
  4. Degenhardt L, Gisev N, Cama E, et al. The extent and correlates of community-based pharmaceutical opioid utilisation in Australia. Pharmacoepidemiol Drug Saf 2016;25(5):521–38. [Accessed 11 July 2017].
  5. Therapeutic Goods Administration. Update on the proposal for the rescheduling of codeine products: Codeine containing medicines to move to prescription only. Canberra: TGA, 2016 [Accessed 20 December 2016].
  6. Rogers KD, Kemp A, McLachlan AJ, Blyth F. Adverse selection? A multi-dimensional profile of people dispensed opioid analgesics for persistent non-cancer pain. PLoS One 2013;8(12):e80095. [Accessed 20 December 2016].
  7. Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain 2015;156(4):569–76. [Accessed 20 December 2016].
  8. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain 2007;8(7):573–82. [Accessed 20 December 2016].
  9. Chou R, Deyo R, Devine E, et al. The effectiveness and risks of long-term opioid treatment of chronic pain. Rockville, MD: Agency for Healthcare Research and Quality, 2014 ehc/products/557/1971/chronic-pain-opioid-treatmentreport-141007.pdf [Accessed 11 July 2017].
  10. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015;162(4):276–86. [Accessed 11 July 2017].
  11. Nielsen S, Bruno R, Degenhardt L, et al. The sources of pharmaceuticals for problematic users of benzodiazepines and prescription opioids. Med J Aust 2013;199(10):696–69. [Accessed 11 July 2017].
  12. Australian Institute of Health and Welfare. National hospital morbidity database (NHMD). Canberra: AIHW, 2017 [Accessed 4 September 2017].
  13. Pennington Institute. Australia’s annual overdose report. Melbourne: Pennington Institute, 2016. Available at www. [Accessed 11 July 2017].
  14. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med 2011;171(7):686–91. [Accessed 11 July 2017].
  15. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. JAMA 2016;315(15):1624–45. [Accessed 11 July 2017].
  16. Paulozzi L, Mack K, Jone C. Vital signs: Risk for overdose from methadone used for pain relief — United States, 1999–2010. Atlanta, GA: Centers for Disease Control and Prevention, 2012 mmwrhtml/mm6126a5.htm [Accessed 11 July 2017].
  17. Paulozzi LJ, Xi Y. Recent changes in drug poisoning mortality in the United States by urban–rural status and by drug type. Pharmacoepidemiol Drug Saf 2008;17(10):997–1005. [Accessed 11 July 2017].
  18. Coroners Court of Victoria. Submission to the Inquiry into Drug Law Reform: Coronial recommendations on drug harm reduction. Melbourne: Coroners Court of Victoria, 2017. [Accessed 11 July 2017].
  19. Sproule B. Prescription monitoring programs in Canada: Best practice and program review. Ottawa, ON: Canadian Centre on Substance Abuse, 2015 Resource Library/CCSA-Prescription-Monitoring-Programs-inCanada-Report-2015-en.pdf [Accessed 29 September 2016].
  20. Brady JE, Wunsch H, DiMaggio C, et al. Prescription drug monitoring and dispensing of prescription opioids. Public Health Rep 2014;129(2):139–47. [Accessed 29 September 2016].
  21. Paulozzi LJ, Kilbourne EM, Desai HA. Prescription drug monitoring programs and death rates from drug overdose. Pain Med 2011;12(5):747–54. [Accessed 29 September 2016].
  22. Li G, Brady JE, Lang BH, et al. Prescription drug monitoring and drug overdose mortality. Injury Epidemiology 2014;1(1):1–8. [Accessed 29 September 2016].
  23. Goodin A, Blumenschein K, Freeman PR, Talbert J. Consumer/patient encounters with prescription drug monitoring programs: Evidence from a Medicaid population. Pain Physician 2012;15(3 Suppl):ES169–75. [Accessed 29 September 2016].
  24. Islam MM, McRae IS. An inevitable wave of prescription drug monitoring programs in the context of prescription opioids: Pros, cons and tensions. BMC Pharmacol Toxicol 2014;15:46. [Accessed 29 September 2016].
  25. Clark T, Eadie J, Knue P, Kreiner P, Strickler G. Prescription drug monitoring programs: An assessment of the evidence for best practices: The Prescription Drug Monitoring Program Center of Excellence, 2012. [Accessed 29 September 2016].
  26. Ogeil RP, Heilbronn C, Lloyd B, Lubman DI. Prescription drug monitoring in Australia: Capacity and coverage issues. Med J Aust 2016;204(4):148. [Accessed 29 September 2016].
  27. Sabanovic H, Harris B, Clavisi O, Bywaters L. Attitudes towards opioids among patients prescribed medication in Victoria. Melbourne: Move Muscle, Bone & Joint Health, 2016 MOVE-Opioid-study.aspx [Accessed 19 February 2017].
  28. Harris S, Taylor S, National Treatment Agency. Clinical governance in drug treatment: A good practice guide for providers and commissioners. London: NHS National Treatment Agency for Substance Misuse, 2009 [Accessed 11 July 2017].
  29. Chewning B, Bylund CL, Shah B, et al. Patient preferences for shared decisions: A systematic review. Patient Educ Couns 2012;86(1):9–18. [Accessed 11 July 2017].
  30. The Royal Australian College of General Practitioners. Standards for general practices. 4th edn. Melbourne: RACGP, 2013. [Accessed 11 July 2017].
  31. Coulter A, Collins A. Making shared decision-making a reality: No decision about me, without me. London: The King’s Fund, 2011. [Accessed 11 July 2017].
  32. O’Shea E. Quality in Practice Committee: Communicating risk to patients. Dublin: Irish College of General Practitioners, 2014. [Accessed 11 July 2017].
  33. Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision making. JAMA 2014;312(13):1295–96. [Accessed 11 July 2017].
  34. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2011(10):CD001431. [Accessed 11 July 2017].
  35. Hoffmann TC, Legare F, Simmons MB, et al. Shared decision making: What do clinicians need to know and why should they bother? Med J Aust 2014;201(1):35–39. [Accessed 11 July 2017].
  36. Ahmed H, Naik G, Willoughby H, Edwards AG. Communicating risk. BMJ 2012;344:e3996. [Accessed 11 July 2017].
  37. Patient Safety and Quality Improvement Service. Guide to informed decision-making in healthcare. Brisbane: Queensland Health, 2012. [Accessed 11 July 2017].
  38. Clayman ML, Bylund CL, Chewning B, Makoul G. The impact of patient participation in health decisions within medical encounters: A systematic review. Med Decis Making 2016;36(4):427–52. [Accessed 11 July 2017].
  39. Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Making 2015;35(1):114–31. [Accessed 11 July 2017].
  40. Thompson-Leduc P, Clayman ML, Turcotte S, Legare F. Shared decision-making behaviours in health professionals: A systematic review of studies based on the Theory of Planned Behaviour. Health Expect 2015;18(5):754-74. [Accessed 11 July 2017].
  41. Legare F, Stacey D, Turcotte S, et al. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev 2014;9:Cd006732. [Accessed 11 July 2017].
  42. Hoffmann TC, Del Mar C. Patients’ expectations of the benefits and harms of treatments, screening, and tests: A systematic review. JAMA Intern Med 2015;175(2):274–86. [Accessed 11 July 2017].
  43. Frei M. Opioid dependence: Management in general practice. Aust Fam Physician 2010;39(8):548–52. [Accessed 11 July 2017].
  44. National Institute on Drug Abuse. Prescription drugs: Abuse and addiction. Rev edn. Bethesda, MD: NIDA, 2011. [Accessed 11 July 2017].
  45. Gowing L, Ali R, Dunlop A, Farrell M, Lintzeris N. National guidelines for medication-assisted treatment of opioid dependence. Canberra: Commonwealth of Australia, 2014 CA257CD1001E0E5D/$File/National_Guidelines_2014.pdf [Accessed 11 July 2017].
  46. Heit H, Lipman A. Pain: Substance abuse issue in the treatment of pain. In: Moore R, editor. Biobehavioral approaches to pain. New York: Springer Science+Business Media, LLC, 2009. [Accessed 11 July 2017].
  47. Arizona Department of Health Services. Arizona opioid prescribing guidelines: A voluntary, consensus set of guidelines that promotes best practices for prescribing opioids for acute and chronic pain. Phoenix, AZ: Arizona Department of Health, 2014. Available at http://azdhs. gov/documents/audiences/clinicians/clinical-guidelinesrecommendations/prescribing-guidelines/az-opiodprescribing-guidelines.pdf [Accessed 11 July 2017]. [Accessed 11 July 2017].
  48. Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J, editors. Acute pain management: Scientific evidence. 4th edn. Melbourne: Australia and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2015 [Accessed 11 July 2017].
  49. Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: A review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician 2012;15(3 Suppl):ES67–92. [Accessed 11 July 2017].
  50. Gordon A, Cone EJ, DePriest AZ, Axford-Gatley RA, Passik SD. Prescribing opioids for chronic noncancer pain in primary care: Risk assessment. Postgrad Med 2014;126(5):159–66. [Accessed 11 July 2017].
  51. Deyo RA, Von Korff M, Duhrkoop D. Opioids for low back pain. BMJ 2015;350:g6380. [Accessed 11 July 2017].
  52. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Recommendations regarding the use of opioid analgesics in patients with chronic noncancer pain. Melbourne: ANZCA and FPM, 2015 [Accessed 11 July 2017].
  53. Australian and New Zealand College of Anaesthetists. Guidelines on acute pain management. Melbourne: ANZCA, 2013 Documents/ps41-2013-guidelines-on-acute-painmanagement [Accessed 11 July 2017].
  54. Hughes MA, Biggs JJ, Theise MS, et al. Recommended opioid prescribing practices for use in chronic non-malignant pain: A systematic review of treatment guidelines. J Manag Care Med 2011;14(3):52. [Accessed 11 July 2017].
  55. Kahan M, Mailis-Gagnon A, Wilson L, Srivastava A, National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic noncancer pain: Clinical summary for family physicians. Part 1: general population. Can Fam Physician 2011;57(11):1257-66, e407–18. [Accessed 11 July 2017].
  56. Drug and Alcohol Services South Australia. Opioid prescription in chronic pain conditions. Adelaide: DAAS SA, Flinders Medical Centre Pain Management Unit, Royal Adelaide Hospital Pain Management Unit, 2008. [Accessed 11 July 2017].
  57. Huxtable CA, Roberts LJ, Somogyi AA, MacIntyre PE. Acute pain management in opioid-tolerant patients: A growing challenge. Anaesth Intensive Care 2011;39(5):804–23. [Accessed 11 July 2017].
  58. Quinlan J, Carter K. Acute pain management in patients with persistent pain. Curr Opin Support Palliat Care 2012;6(2):188–93. [Accessed 11 July 2017].
  59. Schug SA. Acute pain management in the opioid-tolerant patient. Pain Manag 2012;2(6):581–91. [Accessed 11 July 2017].
  60. Lyapustina T, Castillo R, Omaki E, et al. The contribution of the emergency department to opioid pain reliever misuse and diversion: A critical review. Pain Pract 2017. doi: 10.1111/ papr.12568. [Accessed 11 July 2017].
  61. Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med 2017;376(7):663–73. [Accessed 11 July 2017].
  62. Macintyre PE, Huxtable CA, Flint SL, Dobbin MD. Costs and consequences: A review of discharge opioid prescribing for ongoing management of acute pain. Anaesth Intensive Care 2014;42(5):558–74. [Accessed 11 July 2017].
  63. Tanabe P, Paice JA, Stancati J, Fleming M. How do emergency department patients store and dispose of opioids after discharge? A pilot study. J Emerg Nurs 2012;38(3):273–79. [Accessed 11 July 2017].
  64. Lewis ET, Cucciare MA, Trafton JA. What do patients do with unused opioid medications? Clin J Pain 2014;30(8):654–62. [Accessed 11 July 2017].
  65. Thorson D, Biewen P, Bonte B, et al. Acute pain assessment and opioid prescribing protocol. Bloomington, MN: Institute for Clinical Systems Improvement, 2014 [Accessed 11 July 2017].
  66. Harris K, Curtis J, Larsen B, et al. Opioid pain medication use after dermatologic surgery: A prospective observational study of 212 dermatologic surgery patients. JAMA Dermatol 2013;149(3):317–21. [Accessed 11 July 2017].
  67. Bates C, Laciak R, Southwick A, Bishoff J. Overprescription of postoperative narcotics: A look at postoperative pain medication delivery, consumption and disposal in urological practice. J Urol 2011;185(2):551–55. [Accessed 11 July 2017].
  68. Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am 2012;37(4):645–50. [Accessed 11 July 2017].
  69. Platis A, Wenzel T. Hospital oxycodone utilisation research study (HOURS). Adelaide: Pharmacy Department Royal Adelaide Hospital, 2011. [Accessed 11 July 2017].
  70. Alam A, Gomes T, Zheng H, et al. Long-term analgesic use after low-risk surgery: A retrospective cohort study. Arch Intern Med 2012;172(5):425–30. [Accessed 11 July 2017].
  71. Carroll I, Barelka P, Wang CK, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg 2012;115(3):694–702. [Accessed 11 July 2017].
  72. Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ 2014;348:g1251. [Accessed 11 July 2017].
  73. Hunter New England Local Health District. Reconsidering opioid therapy: NSW Government, 2014 opioid_therapy_May 2014.pdf [Accessed 12 July 2017].
  74. Larochelle MR, Liebschutz JM, Zhang F, Ross-Degnan D, Wharam JF. Opioid prescribing after nonfatal overdose and association with repeated overdose: A cohort study. Ann Intern Med 2016;164(1):1–9. [Accessed 12 July 2017].
  75. Bazazi AR, Zaller ND, Fu JJ, Rich JD. Preventing opiate overdose deaths: Examining objections to takehome naloxone. J Health Care Poor Underserved 2010;21(4):1108–13. [Accessed 12 July 2017].
  76. MacIntyre PE, Scott DA, Scott SA, Visser EJ, Walker SM, editors. Acute pain management: Scientific evidence. 3rd edn. Melbourne: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2010. [Accessed 12 July 2017].
  77. Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: Evidence and recommendations for everyday practice. Mayo Clin Proc 2015;90(6):828–42. [Accessed 12 July 2017].
  78. Corbett AD, Henderson G, McKnight AT, Paterson SJ. 75 years of opioid research: The exciting but vain quest for the Holy Grail. Br J Pharmacol 2006;147 Suppl 1:S153–62. [Accessed 12 July 2017].
  79. Dahan A, Kest B, Waxman AR, Sarton E. Sex-specific responses to opiates: Animal and human studies. Anesth Analg 2008;107(1):83–95. [Accessed 12 July 2017].
  80. Campesi I, Fois M, Franconi F. Sex and gender aspects in anesthetics and pain medication. Handb Exp Pharmacol 2012(214):265–78. [Accessed 12 July 2017].
  81. Scott JC, Stanski DR. Decreased fentanyl and alfentanil dose requirements with age. A simultaneous pharmacokinetic and pharmacodynamic evaluation. J Pharmacol Exp Ther 1987;240(1):159–66. [Accessed 12 July 2017].
  82. Minto CF, Schnider TW, Egan TD, et al. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil. I. Model development. Anesthesiology 1997;86(1):10–23. [Accessed 12 July 2017].
  83. Macintyre P, Upton R. Acute pain management in the elderly patient. In: Macintyre P, Walker S, Rowbotham D, editors. Clinical pain management: Acute pain. 2nd edn. London: Hodder Arnold, 2008. [Accessed 12 July 2017].
  84. Hurley RW, Adams MC. Sex, gender, and pain: An overview of a complex field. Anesth Analg 2008;107(1):309–17. [Accessed 12 July 2017].
  85. Lee CW, Ho IK. Sex differences in opioid analgesia and addiction: Interactions among opioid receptors and estrogen receptors. Mol Pain 2013;9:45. [Accessed 12 July 2017].
  86. Svetlik S, Hronova K, Bakhouche H, Matouskova O, Slanar O. Pharmacogenetics of chronic pain and its treatment. Mediators Inflamm 2013;2013:864319. [Accessed 12 July 2017].
  87. Xu Y, Johnson A. Opioid therapy pharmacogenomics for noncancer pain: Efficacy, adverse events, and costs. Pain Res Treat 2013;2013. doi:10.1155/2103/864319. [Accessed 12 July 2017].
  88. Somogyi AA, Barratt DT, Coller JK. Pharmacogenetics of opioids. Clin Pharmacol Ther 2007;81(3):429–44. [Accessed 12 July 2017].
  89. Yang Z, Yang Z, Arheart KL, et al. CYP2D6 poor metabolizer genotype and smoking predict severe postoperative pain in female patients on arrival to the recovery room. Pain Med 2012;13(4):604–09. [Accessed 12 July 2017].
  90. Kelly LE, Rieder M, van den Anker J, et al. More codeine fatalities after tonsillectomy in North American children. Pediatrics 2012;129(5):e1343–47. [Accessed 12 July 2017].
  91. Kirchheiner J, Schmidt H, Tzvetkov M, et al. Pharmacokinetics of codeine and its metabolite morphine in ultra-rapid metabolizers due to CYP2D6 duplication. Pharmacogenomics J 2007;7(4):257–65. [Accessed 12 July 2017].
  92. Friedrichsdorf SJ, Nugent AP, Strobl AQ. Codeineassociated pediatric deaths despite using recommended dosing guidelines: Three case reports. J Opioid Manag 2013;9(2):151–55. [Accessed 12 July 2017].
  93. Stamer UM, Stuber F, Muders T, Musshoff F. Respiratory depression with tramadol in a patient with renal impairment and CYP2D6 gene duplication. Anesth Analg 2008;107(3):926–69. [Accessed 12 July 2017].
  94. Stamer UM, Stuber F. Genetic factors in pain and its treatment. Curr Opin Anaesthesiol 2007;20(5):478–84. [Accessed 12 July 2017].
  95. Vuilleumier PH, Stamer UM, Landau R. Pharmacogenomic considerations in opioid analgesia. Pharmgenomics Pers Med 2012;5:73–87. [Accessed 12 July 2017].
  96. Crews KR, Gaedigk A, Dunnenberger HM, et al. Clinical pharmacogenetics implementation consortium guidelines for cytochrome P450 2D6 genotype and codeine therapy: 2014 update. Clin Pharmacol Ther 2014;95(4):376–82. [Accessed 12 July 2017].
  97. Holmquist G. Opioid metabolism and effects of cytochrome P450. Pain Med 2009;10(S1):S20–29. [Accessed 12 July 2017].
  98. Smith HS. Opioid metabolism. Mayo Clin Proc 2009;84(7):613–24. [Accessed 12 July 2017].
  99. Zhou SF, Liu JP, Chowbay B. Polymorphism of human cytochrome P450 enzymes and its clinical impact. Drug Metab Rev 2009;41(2):89–295. [Accessed 12 July 2017].
  100. Stamer UM, Stuber F. The pharmacogenetics of analgesia. Expert Opin Pharmacother 2007;8(14):2235–45. [Accessed 12 July 2017].
  101. Manchikanti L, Ailinani H, Koyyalagunta D, et al. A systematic review of randomized trials of long-term opioid management for chronic non-cancer pain. Pain Physician 2011;14(2):91–121. [Accessed 12 July 2017].
  102. Karlsson M, Berggren AC. Efficacy and safety of low-dose transdermal buprenorphine patches (5, 10, and 20 microg/h) versus prolonged-release tramadol tablets (75, 100, 150, and 200 mg) in patients with chronic osteoarthritis pain: A 12-week, randomized, open-label, controlled, parallel-group noninferiority study. Clin Ther 2009;31(3):503–13. [Accessed 12 July 2017].
  103. Licina L, Hamsher C, Lautenschager K, et al. Buprenorphine/naloxone therapy for opioid refractory neuropathic pain following traumatic amputation: A case series. Mil Med 2013;178(7):e858–61. [Accessed 12 July 2017].
  104. Simpson RW, Wlodarczyk JH. Transdermal buprenorphine relieves neuropathic pain: A randomized, double-blind, parallel-group, placebo-controlled trial in diabetic peripheral neuropathic pain. Diabetes Care 2016;39(9):1493–500. [Accessed 12 July 2017].
  105. Guetti C, Angeletti C, Marinangeli F, et al. Transdermal buprenorphine for central neuropathic pain: Clinical reports. Pain Pract 2011;11(5):446–52. [Accessed 12 July 2017].
  106. Wiffen PJ, Derry S, Moore RA, et al. Buprenorphine for neuropathic pain in adults. Cochrane Database Syst Rev 2015(9):CD011603. [Accessed 12 July 2017].
  107. Pergolizzi J, Aloisi AM, Dahan A, et al. Current knowledge of buprenorphine and its unique pharmacological profile. Pain Pract 2010;10(5):428–50. [Accessed 12 July 2017].
  108. Kress HG. Clinical update on the pharmacology, efficacy and safety of transdermal buprenorphine. Eur J Pain 2009;13(3):219–30. [Accessed 12 July 2017].
  109. Dahan A, Yassen A, Romberg R, et al. Buprenorphine induces ceiling in respiratory depression but not in analgesia. Br J Anaesth 2006;96(5):627–32. [Accessed 12 July 2017].
  110. Boom M, Niesters M, Sarton E, et al. Non-analgesic effects of opioids: Opioid-induced respiratory depression. Curr Pharm Des 2012;18(37):5994–6004. [Accessed 12 July 2017].
  111. Hunter Integrated Pain Service. Health professional resources: Opioid selection. Newcastle, NSW: Hunter New England Health, 2013 au/__data/assets/pdf_file/0003/212961/Opioid_Selection. pdf [Accessed 12 July 2017].
  112. Lotsch J. Opioid metabolites. J Pain Symptom Manage 2005;29(5 Suppl):S10–24. [Accessed 12 July 2017].
  113. Shaheed CA, Maher CG, McLachlan AJ. Investigating the efficacy and safety of over-the-counter codeine containing combination analgesics for pain and codeine based antitussives. Canberra: Therapeutic Goods Association, 2016 [Accessed 12 July 2017].
  114. Derry S, Moore RA, McQuay HJ. Single dose oral codeine, as a single agent, for acute postoperative pain in adults. Cochrane Database Syst Rev 2010(4):CD008099. [Accessed 12 July 2017].
  115. Derry S, Karlin SM, Moore RA. Single dose oral ibuprofen plus codeine for acute postoperative pain in adults. Cochrane Database Syst Rev 2015;2:CD010107. [Accessed 12 July 2017].
  116. Buckley NA, Faunce TA. Trials and tribulations in the removal of dextropropoxyphene from the Australian Register of Therapeutic Goods. Med J Aust 2013;199(4):257–60. [Accessed 12 July 2017].
  117. Collins SL, Edwards JE, Moore RA, McQuay HJ. Single dose dextropropoxyphene, alone and with paracetamol (acetaminophen), for postoperative pain. Cochrane Database Syst Rev 2000(2):CD001440. [Accessed 12 July 2017].
  118. Li Wan Po A, Zhang WY. Systematic overview of co-proxamol to assess analgesic effects of addition of dextropropoxyphene to paracetamol. BMJ 1997;315(7122):1565–71. [Accessed 12 July 2017].
  119. Grape S, Schug SA, Lauer S, Schug BS. Formulations of fentanyl for the management of pain. Drugs 2010;70(1):57–72. [Accessed 12 July 2017].
  120. Quigley C. Hydromorphone for acute and chronic pain. Cochrane Database Syst Rev 2002(1):CD003447. [Accessed 12 July 2017].
  121. Felden L, Walter C, Harder S, et al. Comparative clinical effects of hydromorphone and morphine: A meta-analysis. Br J Anaesth 2011;107(3):319–28. [Accessed 12 July 2017].
  122. Lugo RA, Satterfield KL, Kern SE. Pharmacokinetics of methadone. J Pain Palliat Care Pharmacother 2005;19(4):13–24. [Accessed 12 July 2017].
  123. Weschules DJ, Bain KT, Richeimer S. Actual and potential drug interactions associated with methadone. Pain Med 2008;9(3):315–44. [Accessed 12 July 2017].
  124. Fredheim OM, Moksnes K, Borchgrevink PC, Kaasa S, Dale O. Clinical pharmacology of methadone for pain. Acta Anaesthesiol Scand 2008;52(7):879–89. [Accessed 12 July 2017].
  125. Weschules DJ, Bain KT. A systematic review of opioid conversion ratios used with methadone for the treatment of pain. Pain Med 2008;9(5):595–612. [Accessed 12 July 2017].
  126. Klimas R, Mikus G. Morphine-6-glucuronide is responsible for the analgesic effect after morphine administration: A quantitative review of morphine, morphine-6-glucuronide, and morphine-3-glucuronide. Br J Anaesth 2014;113(6):935–44. [Accessed 12 July 2017].
  127. Faura CC, Collins SL, Moore RA, McQuay HJ. Systematic review of factors affecting the ratios of morphine and its major metabolites. Pain 1998;74(1):43–53. [Accessed 12 July 2017].
  128. Klepstad P, Dale O, Kaasa S, et al. Influences on serum concentrations of morphine, M6G and M3G during routine clinical drug monitoring: A prospective survey in 300 adult cancer patients. Acta Anaesthesiol Scand 2003;47(6):725–31. [Accessed 12 July 2017].
  129. Vallejo R, de Leon-Casasola O, Benyamin R. Opioid therapy and immunosuppression: A review. Am J Ther 2004;11(5):354–65. [Accessed 12 July 2017].
  130. Budd K. Pain management: Is opioid immunosuppression a clinical problem? Biomed Pharmacother 2006;60(7):310–17. [Accessed 12 July 2017].
  131. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: A systematic review and metaanalysis. Lancet Neurol 2015;14(2):162–73. [Accessed 12 July 2017].
  132. Lalovic B, Kharasch E, Hoffer C, et al. Pharmacokinetics and pharmacodynamics of oral oxycodone in healthy human subjects: Role of circulating active metabolites. Clin Pharmacol Ther 2006;79(5):461–79. [Accessed 12 July 2017].
  133. Samer CF, Daali Y, Wagner M, et al. Genetic polymorphisms and drug interactions modulating CYP2D6 and CYP3A activities have a major effect on oxycodone analgesic efficacy and safety. Br J Pharmacol 2010;160(4):919–30. [Accessed 12 July 2017].
  134. Zwisler ST, Enggaard TP, Mikkelsen S, Brosen K, Sindrup SH. Impact of the CYP2D6 genotype on post-operative intravenous oxycodone analgesia. Acta Anaesthesiol Scand 2010;54(2):232–40. [Accessed 12 July 2017].
  135. Kokki H, Kokki M, Sjovall S. Oxycodone for the treatment of postoperative pain. Expert Opin Pharmacother 2012;13(7):1045–58. [Accessed 12 July 2017].
  136. Olkkola KT, Kontinen VK, Saari TI, Kalso EA. Does the pharmacology of oxycodone justify its increasing use as an analgesic? Trends Pharmacol Sci 2013;34(4):206–14. [Accessed 12 July 2017].
  137. DePriest AZ, Miller K. Oxycodone/naloxone: Role in chronic pain management, opioid-induced constipation, and abuse deterrence. Pain Ther 2014;3(1):1–15. [Accessed 12 July 2017].
  138. Nieminen TH, Hagelberg NM, Saari TI, et al. St John’s wort greatly reduces the concentrations of oral oxycodone. Eur J Pain 2010;14(8):854–59. [Accessed 12 July 2017].
  139. Simopoulos TT, Smith HS, Peeters-Asdourian C, Stevens DS. Use of meperidine in patient-controlled analgesia and the development of a normeperidine toxic reaction. Arch Surg 2002;137(1):84–88. [Accessed 12 July 2017].
  140. Silverman ME, Shih RD, Allegra J. Morphine induces less nausea than meperidine when administered parenterally. J Emerg Med 2004;27(3):241–43. [Accessed 12 July 2017].
  141. Latta KS, Ginsberg B, Barkin RL. Meperidine: A critical review. Am J Ther 2002;9(1):53–68. [Accessed 12 July 2017].
  142. Benner KW, Durham SH. Meperidine restriction in a pediatric hospital. J Pediatr Pharmacol Ther 2011;16(3):185–90. [Accessed 12 July 2017].
  143. Tzschentke TM, Christoph T, Kogel BY. The mu opioid receptor agonist/noradrenaline reuptake inhibition (MORNRI) concept in analgesia: The case of tapentadol. CNS Drugs 2014;28(4):319–29. [Accessed 12 July 2017].
  144. Vinik AI, Shapiro DY, Rauschkolb C, et al. A randomized withdrawal, placebo-controlled study evaluating the efficacy and tolerability of tapentadol extended release in patients with chronic painful diabetic peripheral neuropathy. Diabetes Care 2014;37(8):2302–09. [Accessed 12 July 2017].
  145. Raffa RB, Buschmann H, Christoph T, et al. Mechanistic and functional differentiation of tapentadol and tramadol. Expert Opin Pharmacother 2012;13(10):1437–49. [Accessed 12 July 2017].
  146. Riemsma R, Forbes C, Harker J, et al. Systematic review of tapentadol in chronic severe pain. Curr Med Res Opin 2011;27(10):1907–30. [Accessed 12 July 2017].
  147. Biondi DM, Xiang J, Etropolski M, Moskovitz B. Evaluation of blood pressure and heart rate in patients with hypertension who received tapentadol extended release for chronic pain: A post hoc, pooled data analysis. Clin Drug Investig 2014;34(8):565–76. [Accessed 12 July 2017].
  148. Xu XS, Smit JW, Lin R, et al. Population pharmacokinetics of tapentadol immediate release (IR) in healthy subjects and patients with moderate or severe pain. Clin Pharmacokinet 2010;49(10):671–82. [Accessed 12 July 2017].
  149. Kemp W, Schlueter S, Smalley E. Death due to apparent intravenous injection of tapentadol. J Forensic Sci 2013;58(1):288–91. [Accessed 12 July 2017].
  150. Dart RC, Cicero TJ, Surratt HL, et al. Assessment of the abuse of tapentadol immediate release: The first 24 months. J Opioid Manag 2012;8(6):395–402. [Accessed 12 July 2017].
  151. Cepeda MS, Fife D, Ma Q, Ryan PB. Comparison of the risks of opioid abuse or dependence between tapentadol and oxycodone: Results from a cohort study. J Pain 2013;14(10):1227–41. [Accessed 12 July 2017].
  152. Wiffen PJ, Derry S, Naessens K, Bell RF. Oral tapentadol for cancer pain. Cochrane Database Syst Rev 2015;9:CD011460. [Accessed 12 July 2017].
  153. Afilalo M, Etropolski MS, Kuperwasser B, et al. Efficacy and safety of tapentadol extended release compared with oxycodone controlled release for the management of moderate to severe chronic pain related to osteoarthritis of the knee: A randomized, double-blind, placebo- and active-controlled phase III study. Clin Drug Investig 2010;30(8):489–505. [Accessed 12 July 2017].
  154. Buynak R, Shapiro DY, Okamoto A, et al. Efficacy and safety of tapentadol extended release for the management of chronic low back pain: Results of a prospective, randomized, double-blind, placebo- and active-controlled Phase III study. Expert Opin Pharmacother 2010;11(11):1787–804. [Accessed 12 July 2017].
  155. Lee YK, Ko JS, Rhim HY, et al. Acute postoperative pain relief with immediate-release tapentadol: Randomized, double-blind, placebo-controlled study conducted in South Korea. Curr Med Res Opin 2014;30(12):2561–70. [Accessed 12 July 2017].
  156. Lange B, Kuperwasser B, Okamoto A, et al. Efficacy and safety of tapentadol prolonged release for chronic osteoarthritis pain and low back pain. Adv Ther 2010;27(6):381–99. [Accessed 12 July 2017].
  157. Niesters M, Proto PL, Aarts L, et al. Tapentadol potentiates descending pain inhibition in chronic pain patients with diabetic polyneuropathy. Br J Anaesth 2014;113(1):148–56. [Accessed 12 July 2017].
  158. Raffa RB, Friderichs E, Reimann W, et al. Opioid and nonopioid components independently contribute to the mechanism of action of tramadol, an ‘atypical’ opioid analgesic. J Pharmacol Exp Ther 1992;260(1):275–85. [Accessed 12 July 2017].
  159. Lee CR, McTavish D, Sorkin EM. Tramadol. A preliminary review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in acute and chronic pain states. Drugs 1993;46(2):313–40. [Accessed 12 July 2017].
  160. Stamer UM, Lehnen K, Hothker F, et al. Impact of CYP2D6 genotype on postoperative tramadol analgesia. Pain 2003;105(1–2):231–38. [Accessed 12 July 2017].
  161. Radbruch L, Grond S, Lehmann KA. A risk–benefit assessment of tramadol in the management of pain. Drug Saf 1996;15(1):8–29. [Accessed 12 July 2017].
  162. Lim A, Schug S. Tramadol versus morphine as oral stepdown analgesia after postoperative epidural analgesia. Reg Anesth Pain Med 2001;26(2):S133. [Accessed 12 July 2017].
  163. Wilder-Smith CH, Hill L, Wilkins J, Denny L. Effects of morphine and tramadol on somatic and visceral sensory function and gastrointestinal motility after abdominal surgery. Anesthesiology 1999;91(3):639–47. [Accessed 12 July 2017].
  164. Tarkkila P, Tuominen M, Lindgren L. Comparison of respiratory effects of tramadol and oxycodone. J Clin Anesth 1997;9(7):582–85. [Accessed 12 July 2017].
  165. Tarkkila P, Tuominen M, Lindgren L. Comparison of respiratory effects of tramadol and pethidine. Eur J Anaesthesiol 1998;15(1):64–8. [Accessed 12 July 2017].
  166. Jick H, Derby LE, Vasilakis C, Fife D. The risk of seizures associated with tramadol. Pharmacotherapy 1998;18(3):607–11. [Accessed 12 July 2017].
  167. Gasse C, Derby L, Vasilakis-Scaramozza C, Jick H. Incidence of first-time idiopathic seizures in users of tramadol. Pharmacotherapy 2000;20(6):629–34. [Accessed 12 July 2017].
  168. Nelson EM, Philbrick AM. Avoiding serotonin syndrome: The nature of the interaction between tramadol and selective serotonin reuptake inhibitors. Ann Pharmacother 2012;46(12):1712–16. [Accessed 12 July 2017].
  169. Radbruch L, Glaeske G, Grond S, et al. Topical review on the abuse and misuse potential of tramadol and tilidine in Germany. Subst Abus 2013;34(3):313–20. [Accessed 12 July 2017].
  170. Norrbrink C, Lundeberg T. Tramadol in neuropathic pain after spinal cord injury: A randomized, double-blind, placebocontrolled trial. Clin J Pain 2009;25(3):177–84. [Accessed 12 July 2017].
  171. Australian medicines handbook 2015. Adelaide: Australian Medicines Handbook Pty Ltd, 2015. Available at http:// [Accessed 12 July 2017].
  172. McQuay HJ. Opioid clinical pharmacology and routes of administration. Br Med Bull 1991;47(3):703–17. [Accessed 12 July 2017].
  173. Gammaitoni AR, Fine P, Alvarez N, McPherson ML, Bergmark S. Clinical application of opioid equianalgesic data. Clin J Pain 2003;19(5):286–97. [Accessed 12 July 2017].
  174. Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2 – Guidance. Pain Physician 2012;15(3 Suppl):S67–116. [Accessed 12 July 2017].
  175. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Public policy statement on the rights and responsibilities of health care professionals in the use of opioids for the treatment of pain: A consensus document from the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine. Pain Med 2004;5(3):301–02. [Accessed 12 July 2017].
  176. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician 2011;14(2):145–61. [Accessed 12 July 2017].
  177. Low Y, Clarke CF, Huh BK. Opioid-induced hyperalgesia: A review of epidemiology, mechanisms and management. Singapore Med J 2012;53(5):357–60. [Accessed 12 July 2017].
  178. Chang G, Chen L, Mao J. Opioid tolerance and hyperalgesia. Med Clin North Am 2007;91(2):199–211. [Accessed 12 July 2017].
  179. Mao J. Opioid-induced hyperalgesia. Washington, DC: International Association for the Study of Pain, 2008 [Accessed 12 July 2017].
  180. Joo DT. Mechanisms of opioid tolerance: Merging evidence and therapeutic implications. Can J Anaesth 2007;54(12):969–76. [Accessed 12 July 2017].
  181. Chu LF, Angst MS, Clark D. Opioid-induced hyperalgesia in humans: Molecular mechanisms and clinical considerations. Clin J Pain 2008;24(6):479–96. [Accessed 12 July 2017].
  182. Reznikov I, Pud D, Eisenberg E. Oral opioid administration and hyperalgesia in patients with cancer or chronic nonmalignant pain. Br J Clin Pharmacol 2005;60(3):311–18. [Accessed 12 July 2017].
  183. Ahmedzai SH, Boland J. Constipation in people prescribed opioids. BMJ Clin Evid 2006;12:2407. [Accessed 12 July 2017].
  184. Rosow CE, Gomery P, Chen TY, et al. Reversal of opioidinduced bladder dysfunction by intravenous naloxone and methylnaltrexone. Clin Pharmacol Ther 2007;82(1):48–53. [Accessed 12 July 2017].
  185. Kjellberg F, Tramer MR. Pharmacological control of opioidinduced pruritus: A quantitative systematic review of randomized trials. Eur J Anaesthesiol 2001;18(6):346–57. [Accessed 12 July 2017].
  186. Mujtaba S, Romero J, Taub CC. Methadone, QTc prolongation and torsades de pointes: Current concepts, management and a hidden twist in the tale? J Cardiovasc Dis Res 2013;4(4):229–35. [Accessed 12 July 2017].
  187. Fanoe S, Jensen GB, Sjogren P, Korsgaard MP, Grunnet M. Oxycodone is associated with dose-dependent QTc prolongation in patients and low-affinity inhibiting of hERG activity in vitro. Br J Clin Pharmacol 2009;67(2):172–79. [Accessed 12 July 2017].
  188. Lowenstein O, Leyendecker P, Lux EA, et al. Efficacy and safety of combined prolonged-release oxycodone and naloxone in the management of moderate/severe chronic non-malignant pain: Results of a prospectively designed pooled analysis of two randomised, double-blind clinical trials. BMC Clin Pharmacol 2010;10:12. [Accessed 12 July 2017].
  189. Soderberg KC, Laflamme L, Moller J. Newly initiated opioid treatment and the risk of fall-related injuries. A nationwide, register-based, case-crossover study in Sweden. CNS Drugs 2013;27(2):155–61. [Accessed 12 July 2017].
  190. Rolita L, Spegman A, Tang X, Cronstein BN. Greater number of narcotic analgesic prescriptions for osteoarthritis is associated with falls and fractures in elderly adults. J Am Geriatr Soc 2013;61(3):335–40. [Accessed 12 July 2017].
  191. Takkouche B, Montes-Martinez A, Gill SS, Etminan M. Psychotropic medications and the risk of fracture: A metaanalysis. Drug Saf 2007;30(2):171–84. [Accessed 12 July 2017].
  192. Teng Z, Zhu Y, Wu F, et al. Opioids contribute to fracture risk: A meta-analysis of 8 cohort studies. PLoS One 2015;10(6):e0128232. [Accessed 12 July 2017].
  193. Li L, Setoguchi S, Cabral H, Jick S. Opioid use for noncancer pain and risk of fracture in adults: A nested case-control study using the general practice research database. Am J Epidemiol 2013;178(4):559–69. [Accessed 12 July 2017].
  194. National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic non-cancer pain. Part B: Recommendations for practice. Ontario: NOUGG, 2010. [Accessed 12 July 2017].
  195. Kraut A, Shafer LA, Raymond CB. Proportion of opioid use due to compensated workers’ compensation claims in Manitoba, Canada. Am J Ind Med 2015;58(1):33–39. [Accessed 12 July 2017].
  196. Australasian Faculty of Occupational Medicine, Royal Australasian College of Physicians. Compensable injuries and health outcomes. Sydney: RACP, 2001. Available at www. [Accessed 12 July 2017].
  197. Royal Australasian College of Physicians, Australasian Faculty of Occupational and Evironmental Medicine. Helping people return to work: Using evidence for better outcomes – A position statement. Sydney: RACP, 2010. Available at www. Helping_people_return_to_work.pdf [Accessed 10 June 2016].
  198. Australasian Faculty of Occupational and Environmental Medicine, Royal Australasian College of Physicians. Australian consensus statement on the health benefits of work. Sydney: AFOEM, RACP, 2015 [Accessed 10 June 2016].
  199. Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med 2001;16(2):120–31. [Accessed 10 June 2016].
  200. Hayden JA, Cartwright JL, Riley RD, Vantulder MW, Chronic Low Back Pain IPDM-AG. Exercise therapy for chronic low back pain: Protocol for an individual participant data meta-analysis. Syst Rev 2012;1:64. [Accessed 10 June 2016].
  201. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev 2010(6):CD007612. [Accessed 10 June 2016].
  202. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev 2005(3):CD000335. [Accessed 10 June 2016].
  203. Drummer O. The role of drugs in road safety. Australian Prescriber 2008;31:33–35. [Accessed 10 June 2016].
  204. Wilhelmi BG, Cohen SP. A framework for ‘driving under the influence of drugs’ policy for the opioid using driver. Pain Physician 2012;15(3 Suppl):ES215–30. [Accessed 10 June 2016].
  205. Austroads. Assessing fitness to drive for commercial and private vehicle drivers. Sydney: Austroads, 2016 [Accessed 12 July 2017].
  206. Strand MC, Fjeld B, Arnestad M, Morland J. Can patients receiving opioid maintenance therapy safely drive? A systematic review of epidemiological and experimental studies on driving ability with a focus on concomitant methadone or buprenorphine administration. Traffic Inj Prev 2013;14(1):26–38. [Accessed 12 July 2017].
  207. Dassanayake T, Michie P, Carter G, Jones A. Effects of benzodiazepines, antidepressants and opioids on driving: A systematic review and meta-analysis of epidemiological and experimental evidence. Drug Saf 2011;34(2):125–56. [Accessed 12 July 2017].
  208. Sabatowski R, Mordenti G, Miceli L. Opioids and driving ability: Current data do not support one opioid being more favorable than another. Pain Pract 2014;14(2):196–97. [Accessed 12 July 2017].
  209. Kaye AM, Kaye AD, Lofton EC. Basic concepts in opioid prescribing and current concepts of opioid-mediated effects on driving. Ochsner J 2013;13(4):525–32. [Accessed 12 July 2017].
  210. Currow DC, Phillips J, Clark K. Using opioids in general practice for chronic non-cancer pain: An overview of current evidence. Med J Aust 2016;204(8):305–09. [Accessed 12 July 2017].
  211. Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Are opioiddependent/tolerant patients impaired in driving-related skills? A structured evidence-based review. J Pain Symptom Manage 2003;25(6):559–77. [Accessed 12 July 2017].
  212. Austroads. Assessing fitness to drive for commercial and private vehicle drivers. Sydney: Austroads, 2013. [Accessed 12 July 2017].
  213. Mailis-Gagnon A, Lakha SF, Furlan A, et al. Systematic review of the quality and generalizability of studies on the effects of opioids on driving and cognitive/psychomotor performance. Clin J Pain 2012;28(6):542–55. [Accessed 12 July 2017].
  214. Drug and Alcohol Services South Australia. Prescription drugs and driving: Information for the prescriber. Adelaide: SA Health, 2014 fe565c00452aa91abac9fa005ba75f87/Prescription+Drugs+D AJPERES&CACHEID=fe565c00452aa91abac9fa005ba75f87 [Accessed 12 July 2017].
  215. Tan K-H. Opioids and driving – A review. Australasian Anaesthesia 2007. [Accessed 12 July 2017].
  216. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA 2004;291(16):2013–16. [Accessed 12 July 2017].
  217. Doufas AG, Tian L, Padrez KA, et al. Experimental pain and opioid analgesia in volunteers at high risk for obstructive sleep apnea. PLoS One 2013;8(1):e54807. [Accessed 12 July 2017].
  218. Mulier JP. Perioperative opioids aggravate obstructive breathing in sleep apnea syndrome: Mechanisms and alternative anesthesia strategies. Curr Opin Anaesthesiol 2016;29(1):129–33. [Accessed 12 July 2017].
  219. Lam KK, Kunder S, Wong J, Doufas AG, Chung F. Obstructive sleep apnea, pain, and opioids: Is the riddle solved? Curr Opin Anaesthesiol 2016;29(1):134–40. [Accessed 12 July 2017].
  220. Guilleminault C, Cao M, Yue HJ, Chawla P. Obstructive sleep apnea and chronic opioid use. Lung 2010;188(6):459–68. [Accessed 12 July 2017].
  221. Teichtahl H, Wang D. Sleep-disordered breathing with chronic opioid use. Expert Opin Drug Saf 2007;6(6):641–49. [Accessed 12 July 2017].
  222. Webster LR, Choi Y, Desai H, Webster L, Grant BJ. Sleepdisordered breathing and chronic opioid therapy. Pain Med 2008;9(4):425–32. [Accessed 12 July 2017].
  223. Ward CW. Safe use of opioids in individuals with obstructive sleep apnea. Pain Manag Nurs 2015;16(3):411–17. [Accessed 12 July 2017].
  224. Krebs EE, Paudel M, Taylor BC, et al. Association of opioids with falls, fractures, and physical performance among older men with persistent musculoskeletal pain. J Gen Intern Med 2016;31(5):463–69. [Accessed 12 July 2017].
  225. Milos V, Bondesson A, Magnusson M, et al. Fall riskincreasing drugs and falls: A cross-sectional study among elderly patients in primary care. BMC Geriatr 2014;14:40. [Accessed 12 July 2017].
  226. Abdulla A, Adams N, Bone M, et al. Guidance on the management of pain in older people. Age and Ageing 2013;42:i1–i57. [Accessed 12 July 2017].
  227. National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic noncancer pain. Ontario: NOUGG, 2010. Available at http:// [Accessed 8 April 2016].
  228. Chau DL, Walker V, Pai L, Cho LM. Opiates and elderly: Use and side effects. Clin Interv Aging 2008;3(2):273–78. [Accessed 8 April 2016].
  229. McLachlan AJ, Bath S, Naganathan V, et al. Clinical pharmacology of analgesic medicines in older people: Impact of frailty and cognitive impairment. Br J Clin Pharmacol 2011;71(3):351–64. [Accessed 8 April 2016].
  230. Villesen HH, Banning AM, Petersen RH, et al. Pharmacokinetics of morphine and oxycodone following intravenous administration in elderly patients. Ther Clin Risk Manag 2007;3(5):961–67. [Accessed 8 April 2016].
  231. Macintyre PE, Jarvis DA. Age is the best predictor of postoperative morphine requirements. Pain 1996;64(2):357– 64. [Accessed 8 April 2016].
  232. Woodhouse A, Mather LE. The influence of age upon opioid analgesic use in the patient-controlled analgesia (PCA) environment. Anaesthesia 1997;52(10):949–55. [Accessed 8 April 2016].
  233. Scott LJ, Perry CM. Tramadol: A review of its use in perioperative pain. Drugs 2000;60(1):139–76. [Accessed 8 April 2016].
  234. Barkin RL, Barkin SJ, Barkin DS. Perception, assessment, treatment, and management of pain in the elderly. Clin Geriatr Med 2005;21(3):465–90. [Accessed 8 April 2016].
  235. Upton RN, Semple TJ, Macintyre PE, Foster DJR. Population pharmacokinetic modelling of subcutaneous morphine in the elderly. Acute Pain 2006;8(3):109–16. [Accessed 8 April 2016].
  236. Conway BR, Fogarty DG, Nelson WE, Doherty CC. Opiate toxicity in patients with renal failure. BMJ 2006;332(7537):345–46. [Accessed 8 April 2016].
  237. Nayak-Rao S. Achieving effective pain relief in patients with chronic kidney disease: A review of analgesics in renal failure. J Nephrol 2011;24(1):35–40. [Accessed 8 April 2016].
  238. Mercadante S, Arcuri E. Opioids and renal function. J Pain 2004;5(1):2–19. [Accessed 8 April 2016].
  239. Imani F, Motavaf M, Safari S, Alavian SM. The therapeutic use of analgesics in patients with liver cirrhosis: A literature review and evidence-based recommendations. Hepat Mon 2014;14(10):e23539. [Accessed 8 April 2016].
  240. Dwyer JP, Jayasekera C, Nicoll A. Analgesia for the cirrhotic patient: A literature review and recommendations. J Gastroenterol Hepatol 2014;29(7):1356–60. [Accessed 8 April 2016].
  241. Staton LJ, Panda M, Chen I, et al. When race matters: Disagreement in pain perception between patients and their physicians in primary care. J Natl Med Assoc 2007;99(5):532–38. [Accessed 8 April 2016].
  242. Merry B, Campbell CM, Buenaver LF, et al. Ethnic group differences in the outcomes of multidisciplinary pain treatment. J Musculoskelet Pain 2011;19(1):24–30. [Accessed 8 April 2016].
  243. Narayan MC. Culture’s effects on pain assessment and management. Am J Nurs 2010;110(4):38-47; quiz 8–9. [Accessed 8 April 2016].
  244. Shavers VL, Bakos A, Sheppard VB. Race, ethnicity, and pain among the U.S. adult population. J Health Care Poor Underserved 2010;21(1):177–220. [Accessed 8 April 2016].
  245. McGrath P. ‘The biggest worry…’: Research findings on pain management for Aboriginal peoples in Northern Territory, Australia. Rural Remote Health 2006;6(3):549. [Accessed 8 April 2016].
  246. Fenwick C. Pain management strategies for health professionals caring for central Australian Aboriginal people. Canberra: Department of Health and Aged Care, 2001. [Accessed 8 April 2016].
  247. Fenwick C, Stevens J. Post operative pain experiences of central Australian Aboriginal women. What do we understand? Aust J Rural Health 2004;12(1):22–27. [Accessed 8 April 2016].
  248. Fenwick C. Assessing pain across the cultural gap: Central Australian Indigenous peoples’ pain assessment. Contemp Nurse 2006;22(2):218–27. [Accessed 8 April 2016].
  249. Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander people: An overview 2011. Cat. no. IHW 42. Canberra: AIHW, 2011. [Accessed 8 April 2016].
  250. Howe PW, Condon JR, Goodchild CS. Anaesthesia for Aboriginal Australians. Anaesth Intensive Care 1998;26(1):86–91. [Accessed 8 April 2016].
  251. Taylor K, Guerin P. Health care and Indigenous Australians: Cultural safety in practice. Melbourne: Palgrave Macmillan, 2014. [Accessed 8 April 2016].
  252. Australian Institute of Health and Welfare. Back problems, associated comorbidities and risk factors. Canberra: AIHW, 2016 associated-comorbidities-and-risk-factors [Accessed 12 July 2017].
  253. Arnow BA, Hunkeler EM, Blasey CM, et al. Comorbid depression, chronic pain, and disability in primary care. Psychosom Med 2006;68(2):262–68. [Accessed 12 July 2017].
  254. Knaster P, Estlander AM, Karlsson H, Kaprio J, Kalso E. Diagnosing depression in chronic pain patients: DSM-IV major depressive disorder vs. Beck depression inventory (BDI). PLoS One 2016;11(3):e0151982. [Accessed 12 July 2017].
  255. Burke AL, Mathias JL, Denson LA. Psychological functioning of people living with chronic pain: A meta-analytic review. Br J Clin Psychol 2015;54(3):345–60. [Accessed 12 July 2017].
  256. Primary Health Care Advisory Group final report. Better outcomes for people with chronic and complex health conditions. Canberra: Department of Health, 2016 nsf/Content/76B2BDC12AE54540CA257F72001102B9/$ File/Primary-Health-Care-Advisory-Group_Final-Report.pdf [Accessed 12 July 2017].
  257. Manchikanti L, Kaye AM, Knezevic NN, et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician 2017;20(2S):S3–S92. [Accessed 12 July 2017].
  258. Robinson G. Prescription drug misuse: How to identify and manage drug seekers. BPJ 2008(16):18–23. [Accessed 12 July 2017].
  259. Friese G, Wojciehoski R, Friese A. Drug seekers: Do you recognize the signs? Emerg Med Serv 2005;34(10):64–7, 88–89. [Accessed 12 July 2017].
  260. Moeller KE, Lee KC, Kissack JC. Urine drug screening:Practical guide for clinicians. Mayo Clin Proc 2008;83(1):66–76. [Accessed 12 July 2017].
  261. NSW Therapeutic Advisory Group Inc. Preventing and managing problems with opioid prescribing for chronic non-cancer pain. Sydney: NSW TAG, 2015 publications/guidelines/pain-guidance-july-2015.pdf [Accessed 12 July 2017].
  262. Krebs EE, Lorenz KA, Bair MJ, et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. J Gen Intern Med 2009;24(6):733–38. [Accessed 12 July 2017].
  263. Smith HS, Peppin JF. Toward a systematic approach to opioid rotation. J Pain Res 2014;7:589–608. [Accessed 12 July 2017].
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