Key principles for appropriate opioid prescribing in general practice

Part C2

Appendices

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Last revised: 02 Jun 2020

The RACGP series Prescribing drugs of dependence in general practice recognises that drugs of dependence have important therapeutic uses, but that prescription of these medicines must always be clinically appropriate and supported by national and state law.

During the development of Prescribing drugs of dependence in general practice, Part C1: Opioids, it became apparent that pain management needed its own focus. Hence, we have Part C1: Opioids and Part C2: The role of opioids in pain management. These two together provide evidence and strategies to support accountable prescribing of opioids.

Key principles

As with any treatment, prescription of opioids should be based on a comprehensive biopsychosocial-based assessment; a diagnosis; thoughtful consideration of the likely benefits and risks of any medication, as well as of non-drug alternative interventions; and a management plan derived through shared decision making (SDM) and continual clinical monitoring.
General practitioners (GPs) should be aware of the common concerns associated with opioids, such as potential dependence, withdrawal, problematic drug use (including diversion and misuse) and known harmful effects, including falls, potential cognitive effects and motor vehicle accidents. These risks should be discussed with patients.
Opioid treatment seeks to maximise outcomes for 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 timeframe.
Avoid prescribing opioids to patients with comorbid alcohol or substance use disorders or polydrug use. GPs should consider seeking specialist opinion in the management of these patients. Patients who use two or more psychoactive drugs in combination (particularly benzodiazepines and opioids) and those with a history of substance misuse may be more vulnerable to major harms.
Opioids are generally regarded by clinical practice guidelines as a short-term therapeutic option. Long-term use should be uncommon, made with caution and based on consideration of the likely risks and benefits of opioids.
If alternatives to opioid treatment fail, have limited benefit or are inappropriate, supervised opioid treatment may remain an acceptable long-term therapeutic option.
Long-term opioid prescriptions should be at the lowest effective dose, and regular attempts at reduction should be scheduled. Continued professional monitoring of health outcomes is required.
Opioids should be prescribed from one practice and preferably one GP and dispensed from one pharmacy.
GPs may wish to use the diagnosis of substance use disorder (SUD) rather than dependence, addiction or abuse; this is based on the sedative, hypnotic or anxiolytic use disorder criteria in the Diagnostic and statistical manual of mental disorders (5th edition) (DSM-5). This is a more neutral term that may reduce stigmatisation of patients with problematic use of opioids, benzodiazepines and other drugs or alcohol.
GPs should have communication strategies and safety processes in place to manage inappropriate requests for opioids by patients.
All patients, including those who use opioids and other drugs or alcohol problematically, have the right to best practice care that is respectful and promotes their dignity, privacy and safety.

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