Prescribing drugs of dependence in general practice

Part C2 - The role of opioids in pain management


Last revised: 02 Jun 2020

Pain is a common general practice presentation and pain management is a fundamental general practitioner (GP) role. An estimated 20–40% of patient presentations involve chronic pain, which makes it the most prevalent condition managed in general practice.2,3 Almost 10% of this pain is measured at Grade IV (the highest level of severity using Von Korff’s pain scale). This level of pain is highly disabling and severely limiting.3

Bettering the Evaluation and Care of Health (BEACH) data revealed that most of the chronic pain seen in general practice is musculoskeletal (of that, 48% is osteoarthritis and 28% low back pain).3 However, one in five chronic pain presentations is neurological (of that, 20% is peripheral neuropathy).3

Opioids are important in the management of pain and are highly beneficial to some individuals. However, there are increasing community concerns regarding their use and safety. GPs need to be aware of the broad issues around opioid use in society, as well as specific problems at a patient level, and how to address these issues with evidence-based interventions.

This guide is a resource designed to assist with the appropriate and accountable prescribing of analgesic medications in the general practice context. Used in combination with Prescribing drugs of dependence in general practice, Part C1: Opioids, it is designed to discourage inappropriate use and reduce harms of opioids. It provides GPs with evidence-based guidance and practical advice regarding pain and pain management. In particular, this guide provides recommendations for GPs who are prescribing opioids for acute and chronic pain outside of active cancer treatment, palliative care, and end-of-life care.

The guide specifically relates to general practice patients (18 years and older) who have acute pain and CNCP. It covers:

  • pain – the experience, classifications and assessment
  • pain management – non-drug and drug therapies
  • the place of opioids (and other interventions) in pain management in general practice
  • the evidence-based recommendations for opioid prescribing in general practice, particularly regarding CNCP, including
    • when to initiate, continue and discontinue opioids for chronic pain
    • which opioids to select (with dosage, duration, follow-up and discontinuation)
    • how to assess risk and address harms of opioid use
  • the options for opioid tapering and withdrawal in general practice.

Implementing principles from this guide should facilitate improved patient care and reduce the risk that GPs will be involved in an adverse event associated with prescribing opioids.

This document does not examine opioid use in cancer-related pain, palliative care or end-of-life care, nor does it address use of opioids in the management of opioid dependence.

Wording of key principles and recommendations

Within the key principles and recommendations, the term ‘should’ refers to a recommended action, ‘must’ refers to an obligation, ‘must not’ to a prohibition, and ‘may’ refers to a discretionary action.

This guide is a reference for opioid prescribing and forms part of the RACGP’s series of guidance on drugs of dependence. Freely available on the RACGP website, the series includes:

  • Prescribing drugs of dependence in general practice, Part A: Clinical governance framework

This document provides general practices with a framework to ensure accountable prescribing for drugs of dependence in general practice. It provides information on national and state laws and a range of strategies (with templates) for use at the practice level.

  • Prescribing drugs of dependence in general practice, Part B: Benzodiazepines
  • Prescribing drugs of dependence in general practice, Part C1: Opioids Part C1 is a companion to Part C2. Part 

Systematic searches on PubMed and Cochrane databases were conducted to identify relevant recommendations and evidence levels to guide GP prescribing of opioids in acute pain and CNCP.

The literature search was divided into two sections. Stage I of the literature search was performed to identify guidelines, health assessments and systematic reviews in order to facilitate guidance on opioid prescribing in acute conditions and CNCP. Further literature analysis (Stage II) was performed to identify the overall management of acute conditions and CNCP. Several publications on guideline comparisons were used.

Other selected publications and references were also considered with respect to individual conditions or drugs under consideration.

To ensure consistency with other Australian guidelines, state health-based publications, Hunter Regional Health, and publications from the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists (ANZCA) were also included. External sources of recommendations include the management of pain in acute patient settings, for aged care facilities, GP after-hours services and within general practices.

The pharmacology of opioids, common concerns involving side effects and adverse reactions, and the principles of prescribing were collated from reputable national and international texts.

The RACGP has made a decision to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.6 This method specifies the systematic review of scientific evidence and offers a transparent approach to grading quality of evidence and strength of recommendations. The method grades the overall quality of each body of evidence as high, moderate, low, or very low.

High-quality publications using the GRADE approach were selected for consideration. Due to the recency and robustness of development, the Centers for Disease Control and Prevention (CDC) publication on opioids formed the basis for many of the final recommendations on the management of CNCP with opioids.

However, where supported by the evidence, Australian context-generated recommendations are asserted in these guidelines.

All conflicts of interest were managed according to RACGP policy.

The Expert Group members wish to disclose they have no financial conflicts of interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters.

Two consultation periods involved broad stakeholder (including consumer organisations) input to the guidelines. A list of all consultation bodies is found in the introductory pages.

The guideline is freely available on the RACGP website. It contains infrastructure for feedback, and a section for detailing/logging updates and corrections.

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