Prescribing drugs of dependence in general practice

Part C1 - Opioids - Chapter 2

Clinical governance

Part C1 - Opioids
    4. Clinical governance
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Last revised: 10 Jan 2022

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
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Pharmaceutical Benefits Scheme requirements for opioid prescriptions

On 1 June 2020, the PBS listings for opioid medications were amended. These changes were recommended by the Pharmaceutical Benefits Advisory Committee (PBAC) in response to the suite of regulatory reforms implemented by the Therapeutic Goods Administration (TGA) to reduce the harms caused by prescription opioid medications. Amendments to the opioid PBS listings included reducing pack sizes for use in acute pain, changes to the indications and changes to the authority process that doctors must follow to prescribe opioids subsidised through the PBS.

Further, opioids on the PBS were broadly categorised into first- and second-line treatments for acute severe pain and for chronic, severe pain:

  • Opioids for short-term use in the first-line setting (codeine tablets; codeine + paracetamol tablets; tramadol capsules, injections and oral drops; s) are now restricted benefits for the treatment of patients with severe, postoperative or cancer-related pain where non-opioid analgesics are contraindicated, not tolerated or have not provided adequate pain relief. Reduced pack sizes are also available for these products and are intended for use when other medications are not enough to manage pain, but ongoing pain management is unlikely to be required beyond 2–3 days.
  • Opioids for short-term use in the second-line setting (hydromorphone tablets, injections and oral solutions; and morphine tablets, oral solutions and injections) are now restricted benefits for the treatment of patients with severe or cancer-related pain, those in preoperative care or as an adjunct to general anaesthesia where non-opioid analgesics and first-line opioid analgesics are contraindicated, not tolerated or have not provided adequate pain relief. Reduced pack sizes are also available for these products and are intended for use when other medications are not enough to manage pain, but ongoing pain management is unlikely to be required beyond 2–3 days.
  • Opioids for long-term use in the first-line setting (buprenorphine transdermal patches; morphine capsules, tablets and granules; oxycodone tablets; oxycodone + naloxone tablets; tapentadol tablets; and tramadol tablets) are now authority-required (STREAMLINED) benefits for the treatment of patients with chronic, severe pain requiring daily, continuous, long-term therapy where non-opioid or other opioid analgesics are contraindicated, not tolerated or have not provided adequate pain relief.
  • Opioids for long-term use in the second-line setting (hydromorphone tablets, methadone tablets and injection, fentanyl transdermal patches) are now authority-required (STREAMLINED) benefits for the treatment of non-opioid-naïve patients with chronic, severe pain requiring daily, continuous, long-term therapy where non-opioid and other opioid analgesics are contraindicated, not tolerated or have not provided adequate pain relief.

The eligibility requirements for supplying increased quantities and/or repeats were also amended by the PBAC. Under the terms of the PBS listings for opioids most patients whose opioid treatment has exceeded 12 months duration will require a second medical practitioner to review their condition and confirm the patient’s ongoing need for pain management with opioids. These secondary reviews may be conducted by phone or telehealth consultation. It is not mandatory to consult a pain specialist as part of the secondary review requirement as any doctor registered in Australia may conduct this review. 

It is important to note palliative care nurse practitioners can perform the secondary review for palliative care patients. This is a requirement for palliative patients who have been receiving or are expected to receive treatment with opioids for more than 12 months, unless their clinical condition is such that a secondary review is not possible.

Restricted benefits

Restricted benefits listed on the PBS may only be prescribed under the circumstances listed in the restriction. No authority approval is required before prescribing listed quantities of these medicines.

Authority-required (STREAMLINED) benefits

Authority-required (STREAMLINED) benefits are prescribed only for specific conditions and do not need prior approval from Services Australia or the Department of Veterans' Affairs. Instead, the process is streamlined by providing a four-digit streamlined authority code. The streamlined authority code is located on the relevant PBS listing on the PBS website.

Authorities for increased quantities and/or repeats

Prescribers may request real-time authority approval through the Online PBS Authorities (OPA) system for quantities and/or repeats that provide up to three months’ treatment. This removes the need for prescribers to call or submit a written application to Services Australia.

Alternatively, prescribers can request up to one month’s treatment via telephone and up to three months’ treatment in writing (via mail or Health Professional Online Services [HPOS] form upload). Telephone authority requests seeking treatment beyond one-month requests will not be approved.

To assist in streamlining this process, it is important for prescribers to familiarise themselves with the relevant PBS restriction.

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
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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
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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
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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
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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

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