Prescribing drugs of dependence in general practice

Part C1 - Opioids - Chapter 1

Overview of opioid use in Australia

Part C1 - Opioids
    3. Overview of opioid use in Australia
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Last revised: 10 Jan 2022

Trends in opioid use in Australia

Worldwide opioid use has increased significantly, with a doubling of opioid analgesic prescriptions recorded between 2001–03 and 2011–13.1 While Australia only has around one-third the opioid consumption of the United States (US), opioid use here is still considered high and is on par with many European countries.1

Almost three million Australians received at least one Pharmaceutical Benefit Scheme (PBS) listed opioid analgesic between April 2013 and March 2014.2 Of these three million, around 150,000 people (5%) accounted for 61% of opioid use in terms of opioid defined daily doses (DDDs) supplied.2

Australian use of opioids is also increasing at a marginal rate. The rolling annual average of DDDs/1000 population/ day supplied has increased from 15.73 to 17.06 in the 10-year PBS data collection period (Figure 1).2 Paracetamol with codeine and tramadol were the two most commonly supplied opioids for most of that period.2

Repatriation Pharmaceutical Benefits Scheme opioid utilisation in DDDs/1000 population/day

Figure 1.

Repatriation Pharmaceutical Benefits Scheme opioid utilisation in DDDs/1000 population/day
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Figure 1. Repatriation Pharmaceutical Benefits Scheme opioid utilisation in DDDs/1000 population/day

Reproduced from the Pharmaceutical Benefits Scheme Drug Utilisation Sub-committee (DUSC). Opioid analgesics: Overview. Canberra: Commonwealth of Australia, 2014. 

While overall use is only marginally increasing, there are changes in prescribing habits. The use of tramadol and morphine is decreasing, while use of fentanyl, buprenorphine, oxycodone with naloxone and hydromorphone is increasing (Figure 2).2,3 In particular, oxycodone prescribing has increased: since 2013, oxycodone has become the second most commonly used opioid.2 Numbers of oxycodone prescriptions are highest among older Australians.3

Repatriation Pharmaceutical Benefits Scheme opioid utilisation in DDDs/1000 population/day by drug

Figure 2.

Repatriation Pharmaceutical Benefits Scheme opioid utilisation in DDDs/1000 population/day by drug
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Figure 2. Repatriation Pharmaceutical Benefits Scheme opioid utilisation in DDDs/1000 population/day by drug

Reproduced from the Pharmaceutical Benefits Scheme Drug Utilisation Sub-committee (DUSC). Opioid analgesics: Overview. Canberra: Commonwealth of Australia, 2014. 

The most commonly sold opioid is over-the-counter (OTC) codeine. It is also the most accessible opioid in the community setting. Despite effectiveness and adverse event concerns, codeine is still used in quite high volumes.4 There has been a decision to up-schedule codeine to Schedule 4 (S4).5 This will come into effect in 2018.

Trends in non-medical use of opioids in Australia

The prevalence of non-medical use of pharmaceutical opioids (such as oxycodone and morphine) remains relatively low among the general Australian population.3 However, significant increases have been reported: between 2007 and 2010 the prevalence doubled from 0.2% to 0.4%.3 Refer to Problematic use of opioids.

Around half (52%) of PBS-listed opioids are used for the treatment of acutely painful conditions. The other half is almost equally divided between episodic and long-term treatment (25% and 23% respectively).6 However, it is difficult to determine what proportion of opioids is being used for acute pain, cancer pain, addiction medicine, chronic pain and selfmanagement of pain in Australia.6

Compared to people not receiving opioid analgesics, people prescribed opioids have been shown to be in poorer health with poorer functioning and higher levels of distress. It is unknown if this is due to pain-related conditions or to medication.6

Opioid prescribing appears to vary depending on patient demographics and geography.

Demographics and opioid prescribing

Patients with higher socioeconomic status indicators (eg higher education and income levels, full-time work status, private health insurance) are less likely to be on longer-term opioid analgesic treatment than older patients (Figure 3) and patients who do not speak English at home.6

Repatriation Pharmaceutical Benefits Scheme opioid utilisation in DDDs/1000 population/day by age group

Figure 3.

Repatriation Pharmaceutical Benefits Scheme opioid utilisation in DDDs/1000 population/day by age group
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Figure 3. Repatriation Pharmaceutical Benefits Scheme opioid utilisation in DDDs/1000 population/day by age group

Reproduced from the Pharmaceutical Benefits Scheme Drug Utilisation Sub-committee (DUSC). Opioid analgesics: Overview. Canberra: Commonwealth of Australia, 2014. 

Geography and opioid prescribing

Rates of opioid use are higher in areas that:4

  • are outside of major cities
  • are less populated
  • have more men and older people
  • have proportionally more low-income earning households
  • have greater proportions of people in jobs requiring physical labour.

Implications of prescribing variation

Demographic and geographic findings suggest that longer-term opioid analgesic prescribing occurs in patient groups who might be at higher risk of poor health. This is based on a wide range of health and non-health factors.6 Programs targeting inappropriate opioid prescribing and use need to focus on these groups and on areas outside of major cities.4

The RACGP is currently working with Primary Health Networks (PHNs) to address prescribing variation.

Refer to Strategies to improve appropriateness of opioid use

Prevalence of problematic use

The prevalence of non-medical use/misuse of pharmaceutical opioids (such as oxycodone and morphine) remains relatively low in Australia, despite a significant increase between 2007 and 2010 (from 0.2% to 0.4%).3

Incidence of problematic use

The incidence of problematic opioid use in primary care is hard to determine because terminology and classifications (eg ‘misuse’, ‘abuse’, ‘addiction’, ‘dependence’) are difficult to define or are very broad.7 Reported rates of problematic use range from <1% to 81%.7–9 Averaging across studies, the rate of misuse is between 21% and 29% and the rate of addiction is between 8% and 12%.7–9

Relationship between dose, duration of treatment and problematic use

Problematic use is dose dependent.9 For example, the rate of opioid dependence or abuse with low-dose chronic therapy is around 0.7%, but this increases to around 6% with high-dose chronic therapy.9 There are several factors associated with increased risk of problematic use. These include history of substance use disorder (SUD), younger age, major depression, and use of psychotropic medications.10

The mean duration between first use and problematic use of prescription opioids is 4.4 years (standard deviation 5.7 years), which presents a significant opportunity for intervention.11

Source of misused opioids

Medical practitioners are an important source of misused pharmaceuticals. However, they are not the main source of prescription opioids, with most misused opioids being obtained from dealers (via on-selling of prescribed opioids).11 Family and friends are the next most common source after dealers.11 This presents a challenge for strategies such as real-time prescription monitoring (RTPM) systems, as they will not pick up this activity.

RTPM is an important strategy in supporting safer opioid prescribing. While the RACGP strongly supports its implementation, it also recognises that this strategy is not the sole solution to curbing people misusing prescription opioids. It is therefore important for prescribers to recognise the limitations of these systems if solely relied on for the clinical assessment of drug-seeking behaviour.11 Refer to Real-time prescription monitoring.

Treatment seeking for pharmaceutical opioids increased from around 4800 to 7500 patients during the reporting period 2001/02 – 2011/12.3 As a percentage of all treatment episodes, pharmaceutical opioids represented 4% in 2001/02 and 5.1% in 2011/12.3 Morphine accounted for 25% of all treatment episodes for opioids other than heroin in 2011/12.3

Hospitalisation for pharmaceutical opioid poisoning is not common. Rates peaked in 2006/07 (83 per million persons) and have declined more recently (65 per million persons).12

Rate of opioid* hospital separations for poisoning, per million persons, 2001 to 2011

Figure 4.

Rate of opioid* hospital separations for poisoning, per million persons, 2001 to 201112
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Figure 4. Rate of opioid* hospital separations for poisoning, per million persons, 2001 to 201112

*‘Opioid’ includes morphine, oxycodone and codeine, and excludes heroin, methadone and pethidine

Reproduced from the Australian Institute of Health and Welfare. National hospital morbidity database (NHMD). Canberra: AIHW.

Overall trend in overdose and age most affected

The number of deaths due to opioid overdose in Australia is growing. Between 2004 and 2014, there was a 61% increase in deaths due to accidental overdose (from 705 deaths in 2004 to 1137 in 2014).13 Of the people who died in 2014, 78% were aged between 30 and 59 years.13

Geographical trend in overdose

The overall increase in overdose deaths is being driven by those occurring in rural and regional areas. Between 2008 and 2014, there was an 83% increase in deaths in these areas (from 3.1 deaths per 100,000 to 5.7 per 100,000).13 In the same time period in metropolitan areas the rate changed from 4.2 per 100,000 to 4.4 per 100,000.13

Overdose trend in Aboriginal and Torres Strait Islander peoples

Accidental deaths due to opioid overdose per capita for Aboriginal and Torres Strait Islander peoples has increased substantially. Between 2004 and 2014 there was an increase of 141% across the five jurisdictions with Aboriginal data; from 3.9 deaths per 100,000 in 2004 to 9.4 per 100,000 in 2014.13

Relationship between patient factors, opioid characteristics and overdose

Higher opioid dosages are associated with an increased risk of fatal overdose. There is a three-fold increase in mortality when comparing high-dose opioid (>200 mg oral morphine equivalent daily dose [OMEDD]) relative to low-dose opioids (<20 mg OMEDD); however, the differences in absolute rates are quite low.14

Refer to Metabolism and duration of activity

Additionally, the risk of fatal overdose increases with:15

  • slow-release and long-duration opioids
  • co-prescription of opioids and benzodiazepines
  • sleep-disordered breathing
  • reduced renal or hepatic function
  • older age
  • pregnancy
  • mental health disorders including SUDs.

In Victoria, 80% of all drug overdoses from 2001 to 2013 involved prescription medications, and pharmaceutical opioids contributed to half of all drug-overdose deaths during that time.3 Fatal overdosing with pharmaceutical opioids is related to dose and duration of action.3,16,17

Annual frequency of overdose deaths involving most frequent contributing individual drugs, Victoria 2009–16

Table 1.

Annual frequency of overdose deaths involving most frequent contributing individual drugs, Victoria 2009–1618
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* Pentobarbitone prescribing to humans is not permitted in Australia, and the drug could be alternatively classified as illegal † Routine post-mortem testing for pregabalin did not commence in Victoria until 2013

Reproduced from the Coroners Court of Victoria. Submission to the Inquiry into Drug Law Reform: Coronial recommendations on drug harm reduction. Melbourne: Coroners Court of Victoria, 2017.

In February 2017, the Coroners Court of Victoria in partnership with Turning Point Alcohol and Drug Centre concluded a study that examined the circumstances in which overdose deaths involving pharmaceutical drugs occur in Victoria. Regarding victims of overdose deaths:18

  • 71% had an SUD
  • 73% had a diagnosed mental illness
  • 49.6% had both a diagnosed mental illness and a documented SUD.

These patients often had a long-established clinical history of mental illness and drug dependence and had in most cases been known to the health system for extended periods of time (ie longer than 10 years).18

This conclusion underpins advice to 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.

To support quality use of opioid medication and to reduce inappropriate opioid use, the RACGP supports:

  • standardised regulatory definitions of dependency and laws regarding drugs of dependence across all state and territory jurisdictions
  • an effective, national RTPM system and surveillance program
  • up-scheduling of codeine
  • improved analysis of PBS prescriptions to detect variation in prescribing drugs of dependence
  • improved categorisation of deaths from prescription drugs by the National Coronial Information System
  • state and territory health systems that support continual and coordinated care for patients with complex and/or multiple problems (eg combined SUDs, chronic pain and mental illness) in conjunction with general practice
  • improved use and management of opioids in acute settings
  • robust handover standards between primary, secondary and tertiary care
  • a national set of clinical indicators that monitors general practice prescribing drugs of dependence
  • national support for the ‘medical home’ concept (ie a patient having one general practice and preferably one GP to provide ongoing care and accountable prescribing of drugs of dependence)
  • improved governance and monitoring of opioid prescribing at a general practice level
  • adequate resourcing of systems of care within general practice for patients with
    • chronic non-cancer pain (CNCP)
    • SUDs
  • improved collaboration with pharmacies regarding use of drugs of dependence
  • education of consumers and health professionals, and expansion of non-pharmaceutical evidence-based treatments for chronic pain as crucial elements in preventive activities.

In 2020, changes to opioid indications were made across the class to help address misuse and harms in Australia. Significantly, the use of modified-release opioids is not indicated in chronic non-cancer/malignant pain, except in exceptional circumstances. 

Additional warnings and precautions for use were also added to Product Information and Consumer Medicine Information.

PBS restrictions and authority requirements have also been updated to reflect the new indications. More detailed information on the changes is available at Section 2.2.2 Pharmaceutical Benefits Scheme requirements for opioid prescriptions and Section 3.2 Specific opioids.

Real-time prescription monitoring

The RACGP is currently working with the Australian Institute of Health and Welfare (AIHW) to improve monitoring of opioids nationally.

The RACGP strongly supports the introduction of RTPM while recognising that the current state of research19 with evidence on effectiveness in reducing inappropriate prescribing,20 abuse, and opioid-related deaths is still evolving.21,22 Consumer impact and experiences with RTPM are not always positive.23 Administrators and clinicians should be clear about the intended objectives, risks and benefits of RTPM prior to implementation.24–26 While it is not a panacea to reduction in prescription drug harm, RTPM has a key role in supporting the high-quality use of drugs of dependence.

  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  15. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. JAMA 2016;315(15):1624–45.
  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.
  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.
  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.
  21. Paulozzi LJ, Kilbourne EM, Desai HA. Prescription drug monitoring programs and death rates from drug overdose. Pain Med 2011;12(5):747–54.
  22. Li G, Brady JE, Lang BH, et al. Prescription drug monitoring and drug overdose mortality. Injury Epidemiology 2014;1(1):1–8.
  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.
  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.
  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.
  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.
  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.
  30. The Royal Australian College of General Practitioners. Standards for general practices. 4th edn. Melbourne: RACGP, 2013.
  31. Coulter A, Collins A. Making shared decision-making a reality: No decision about me, without me. London: The King’s Fund, 2011.
  32. O’Shea E. Quality in Practice Committee: Communicating risk to patients. Dublin: Irish College of General Practitioners, 2014.
  33. Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision making. JAMA 2014;312(13):1295–96.
  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.
  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.
  36. Ahmed H, Naik G, Willoughby H, Edwards AG. Communicating risk. BMJ 2012;344:e3996.
  37. Patient Safety and Quality Improvement Service. Guide to informed decision-making in healthcare. Brisbane: Queensland Health, 2012.
  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.
  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.
  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.
  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.
  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.
  43. Frei M. Opioid dependence: Management in general practice. Aust Fam Physician 2010;39(8):548–52.
  44. National Institute on Drug Abuse. Prescription drugs: Abuse and addiction. Rev edn. Bethesda, MD: NIDA, 2011.
  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.
  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].
  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.
  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.
  51. Deyo RA, Von Korff M, Duhrkoop D. Opioids for low back pain. BMJ 2015;350:g6380.
  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.
  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.
  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.
  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.
  58. Quinlan J, Carter K. Acute pain management in patients with persistent pain. Curr Opin Support Palliat Care 2012;6(2):188–93.
  59. Schug SA. Acute pain management in the opioid-tolerant patient. Pain Manag 2012;2(6):581–91.
  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.
  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.
  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.
  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.
  64. Lewis ET, Cucciare MA, Trafton JA. What do patients do with unused opioid medications? Clin J Pain 2014;30(8):654–62.
  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.
  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.
  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.
  69. Platis A, Wenzel T. Hospital oxycodone utilisation research study (HOURS). Adelaide: Pharmacy Department Royal Adelaide Hospital, 2011.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  80. Campesi I, Fois M, Franconi F. Sex and gender aspects in anesthetics and pain medication. Handb Exp Pharmacol 2012(214):265–78.
  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.
  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.
  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.
  84. Hurley RW, Adams MC. Sex, gender, and pain: An overview of a complex field. Anesth Analg 2008;107(1):309–17.
  85. Lee CW, Ho IK. Sex differences in opioid analgesia and addiction: Interactions among opioid receptors and estrogen receptors. Mol Pain 2013;9:45.
  86. Svetlik S, Hronova K, Bakhouche H, Matouskova O, Slanar O. Pharmacogenetics of chronic pain and its treatment. Mediators Inflamm 2013;2013:864319.
  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.
  88. Somogyi AA, Barratt DT, Coller JK. Pharmacogenetics of opioids. Clin Pharmacol Ther 2007;81(3):429–44.
  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.
  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.
  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.
  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.
  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.
  94. Stamer UM, Stuber F. Genetic factors in pain and its treatment. Curr Opin Anaesthesiol 2007;20(5):478–84.
  95. Vuilleumier PH, Stamer UM, Landau R. Pharmacogenomic considerations in opioid analgesia. Pharmgenomics Pers Med 2012;5:73–87.
  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.
  97. Holmquist G. Opioid metabolism and effects of cytochrome P450. Pain Med 2009;10(S1):S20–29.
  98. Smith HS. Opioid metabolism. Mayo Clin Proc 2009;84(7):613–24.
  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.
  100. Stamer UM, Stuber F. The pharmacogenetics of analgesia. Expert Opin Pharmacother 2007;8(14):2235–45.
  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.
  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.
  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.
  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.
  105. Guetti C, Angeletti C, Marinangeli F, et al. Transdermal buprenorphine for central neuropathic pain: Clinical reports. Pain Pract 2011;11(5):446–52.
  106. Wiffen PJ, Derry S, Moore RA, et al. Buprenorphine for neuropathic pain in adults. Cochrane Database Syst Rev 2015(9):CD011603.
  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.
  108. Kress HG. Clinical update on the pharmacology, efficacy and safety of transdermal buprenorphine. Eur J Pain 2009;13(3):219–30.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  119. Grape S, Schug SA, Lauer S, Schug BS. Formulations of fentanyl for the management of pain. Drugs 2010;70(1):57–72.
  120. Quigley C. Hydromorphone for acute and chronic pain. Cochrane Database Syst Rev 2002(1):CD003447.
  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.
  122. Lugo RA, Satterfield KL, Kern SE. Pharmacokinetics of methadone. J Pain Palliat Care Pharmacother 2005;19(4):13–24.
  123. Weschules DJ, Bain KT, Richeimer S. Actual and potential drug interactions associated with methadone. Pain Med 2008;9(3):315–44.
  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.
  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.
  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.
  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.
  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.
  129. Vallejo R, de Leon-Casasola O, Benyamin R. Opioid therapy and immunosuppression: A review. Am J Ther 2004;11(5):354–65.
  130. Budd K. Pain management: Is opioid immunosuppression a clinical problem? Biomed Pharmacother 2006;60(7):310–17.
  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.
  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.
  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.
  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.
  135. Kokki H, Kokki M, Sjovall S. Oxycodone for the treatment of postoperative pain. Expert Opin Pharmacother 2012;13(7):1045–58.
  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.
  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.
  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.
  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.
  140. Silverman ME, Shih RD, Allegra J. Morphine induces less nausea than meperidine when administered parenterally. J Emerg Med 2004;27(3):241–43.
  141. Latta KS, Ginsberg B, Barkin RL. Meperidine: A critical review. Am J Ther 2002;9(1):53–68.
  142. Benner KW, Durham SH. Meperidine restriction in a pediatric hospital. J Pediatr Pharmacol Ther 2011;16(3):185–90.
  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.
  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.
  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.
  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.
  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.
  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.
  149. Kemp W, Schlueter S, Smalley E. Death due to apparent intravenous injection of tapentadol. J Forensic Sci 2013;58(1):288–91.
  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.
  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.
  152. Wiffen PJ, Derry S, Naessens K, Bell RF. Oral tapentadol for cancer pain. Cochrane Database Syst Rev 2015;9:CD011460.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  160. Stamer UM, Lehnen K, Hothker F, et al. Impact of CYP2D6 genotype on postoperative tramadol analgesia. Pain 2003;105(1–2):231–38.
  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.
  162. Lim A, Schug S. Tramadol versus morphine as oral stepdown analgesia after postoperative epidural analgesia. Reg Anesth Pain Med 2001;26(2):S133.
  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.
  164. Tarkkila P, Tuominen M, Lindgren L. Comparison of respiratory effects of tramadol and oxycodone. J Clin Anesth 1997;9(7):582–85.
  165. Tarkkila P, Tuominen M, Lindgren L. Comparison of respiratory effects of tramadol and pethidine. Eur J Anaesthesiol 1998;15(1):64–8.
  166. Jick H, Derby LE, Vasilakis C, Fife D. The risk of seizures associated with tramadol. Pharmacotherapy 1998;18(3):607–11.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  178. Chang G, Chen L, Mao J. Opioid tolerance and hyperalgesia. Med Clin North Am 2007;91(2):199–211.
  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.
  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.
  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.
  183. Ahmedzai SH, Boland J. Constipation in people prescribed opioids. BMJ Clin Evid 2006;12:2407.
  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.
  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.
  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.
  187. Fanoe S, Jensen GB, Sjogren P, Korsgaard MP, Grunnet M. Oxycodone is a
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