First Do No Harm: a guide to choosing wisely in general practice

GP Resources

Opioids to treat chronic non-cancer pain (CNCP)

For GPs

The use of opioids for chronic non-cancer pain.

RACGP position

  •  Although opioid analgesics have historically been commonly used in chronic non-cancer pain (CNCP), they can cause significant patient harms.
  • There is limited evidence to support opioids as a treatment for CNCP and there is no evidence to suggest long-term benefits for treating patients with opioids.1
  • The RACGP advises that long-term opioid use in CNCP should not be common, must be undertaken with caution and must be based on consideration of the likely risks and benefits.1

 Traffic lights


Do not take this action

  • Do not initiate or escalate opioid treatment in patients with CNCP unless you have:
    • completed a comprehensive biopsychosocial assessment
    • completed a thorough diagnosis
    • given careful consideration of the likely benefits and risks
    • developed a management plan as a result of shared decision making
    • developed a plan for ongoing regular clinical monitoring.1
  • Do not initiate or escalate opioid treatment in patients with CNCP who also have comorbid alcohol or substance use disorder or polydrug use.1
  • Do not abruptly cease opioids in patients already prescribed opioids for CNCP.2


Under specified circumstances,
take this action

  • If treating a patient using prescribed opioids for CNCP, prescribe the lowest effective dose, guided by regular assessment of pain and function.1,2
  • If treating a patient using prescribed opioids for CNCP, unless the patient is using opioids for dyspnoea or pain at the end of life, initiate a deprescribing plan, based on shared decision making.2



Take this action

  • Use non-drug interventions and consider non-opioid analgesia for patients with CNCP.1,3
  • Consider referring patients with CNCP to a multidisciplinary chronic pain service if the pain continues to cause loss of function or reduced quality of life.4


Given the lack of evidence that long-term opioids commonly reduce pain or improve the patient’s functioning or quality of life, the harms will often outweigh the benefits.

Common side effects of opioids include nausea, constipation, pruritus, sedation, dental caries, sexual dysfunction and low mood.5

Less common but serious side effects include falls, impaired ability to drive, overdose, respiratory depression, cardiac arrhythmias, exacerbation of sleep apnoea and death.5

Opioid use may also lead to dependence, withdrawal effects, opioid-induced hyperalgesia, tolerance and a range of personal and societal harms resulting from diversion of opioids.5

The balance of benefits and harms may change if the patient becomes more frail, the dose of opioids is increased, or if the patient takes sedative medication or consumes alcohol.

About CNCP

  • CNCP is a collection of clinical conditions that involve one or multiple pathophysiological mechanisms leading to persistent pain. It is also an individual, multifactorial experience influenced by culture, previous pain events, beliefs, expectations, mood and resilience.1

Managing CNCP

  • CNCP is rarely improved by opioids.
  • There is no evidence to suggest long-term opioid use is effective in reducing chronic low back pain,
  • osteoarthritis or fibromyalgia.4,6–8
  • There is evidence to suggest that patients who have weaned from high-dose and chronic low-dose opioids had sustained long-term improvements in pain, mood and function.9
  • The basis for effective pain management is a strong, continuous therapeutic relationship between the doctor and patient,1 elements of which include:
    • best practice care that is respectful and promotes the patient’s dignity, privacy and safety, even if their use of opioids, alcohol or other drugs is problematic1
    • providing information and reassurance to enable collaboration, shared decision making and the setting of treatment goals and outcomes that are clear, realistic and agreed upon
    • open discussions about the more difficult aspects of pain management, such as the prescription monitoring service, responsible prescribing, opioid contracts, tapering doses, transitioning to opioid replacement programs and the use of a chronic pain team or tertiary referral.1

Minimising harm in patients using opioids for CNCP

  • When patients are already using prescribed opioids, minimise the risk of harms by conducting close clinical monitoring, using real-time prescription monitoring programs, reviewing co-prescriptions of other sedating medications and initiating staged deprescribing with consent.
  • If a patient is at risk of overdose, facilitate access to naloxone.

The following list contains examples of complex situations where a pain specialist or multidisciplinary review should be considered.

  • A patient taking two or more psychoactive medications (eg antipsychotics or antiepileptics and opioids)
  • A patient taking opioids and benzodiazepines in combination
  • A patient with complex mental health comorbidities or living with enduring mental health symptoms
  • A patient with a history of, or living with, substance abuse problems
  • A new patient requesting opioid medications where there is no established therapeutic relationship or where a therapeutic relationship is not possible
  • A patient recently discharged from a correctional facility or with a significant forensic history
  • A patient displaying signs of potential high-risk behaviour
  • A patient with a history of suicidality or drug overdose
  • Unexpected dose escalation
  • High levels of patient distress

Appropriate multidisciplinary reviews may include community pharmacists, drug and alcohol services and mental health or psychiatry professionals.4

Consider non-pharmacological therapies

Extensive evidence suggests there are some benefits of and less harm from using non-pharmacological and non-opioid pharmacological therapy.6 Non-pharmacological therapy may include:10,11

  • psychological interventions such as cognitive behavioural therapy, behavioural therapy and acceptance and commitment therapy
  • physical therapies that aim to improve goals of function, despite baseline persisting pain, such as general strengthening, yoga, hydrotherapy and Tai Chi
  • involvement of a multidisciplinary team (eg occupational therapist, physiotherapist and/or psychologist).

Educate the patient about pain and pain management

There is evidence to suggest that a program that educates patients about the nature of pain, its effects and how it is perceived by the brain can help manage expectations and promote self-management to achieve short-term reductions in pain and disability and decrease catastrophising (see Resources and information for patients).1,12 Typically, this would include dedicated consultations over an extended time, rather than, for example, just giving the patient an information sheet.

Encourage regular activities

  • Encourage your patient to return to normal activities because there is strong evidence that patients with CNCP who are physically active experience a reduction in pain levels and an improvement in function and wellbeing.
  • Encourage your patient to return to work (where appropriate) because this may reduce morbidity and improve wellbeing.1
  1. The Royal Australian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice, Part C2: The role of opioids in pain management. RACGP, 2017 [Accessed 2 February 2024].
  2. Langford AV, Schneider CR, Lin CWC, et al. Evidence-based clinical practice guideline for deprescribing opioid analgesics. The University of Sydney, 2022 [Accessed 2 February 2024].
  3. The Royal Australian College of General Practitioners (RACGP). Handbook of non-drug interventions. RACGP, 2023 [Accessed 2 February 2024].
  4. Dowell D, Haegerich T, Chou R. CDC guideline for prescribing opioids for chronic pain – United States 2016. JAMA 2016;315(15):1624–45. doi: 10.1001/jama.2016.1464.
  5. SA Health. Adverse effects due to long term opioids [Accessed 2 February 2024].
  6. The Australian and New Zealand College of Anaesthetists (ANZCA). Statement regarding the use of opioid analgesics in patients with chronic non-cancer pain. ANZCA, 2021 [Accessed 15 April 2023].
  7. Welsch P, Petzke F, Klose P, et al. Opioids for chronic osteoarthritis pain: An updated systematic review and meta‐analysis of efficacy, tolerability and safety in randomized placebo‐controlled studies of at least 4 weeks double‐blind duration. Eur J Pain 2020; 24: 685–703. doi: 10.1002/ejp.1522.
  8. NPS MedicineWise. If not opioids, then what? NPS MedicineWise, 2019 [Accessed 15 April 2023].
  9. Huffman K, Rush T, Fan Y, et al. Sustained improvements in pain, mood, function and opioid use post interdisciplinary pain rehabilitation in patients weaned from high and low dose chronic opioid therapy. Pain 2017;158(7):1380–94. doi: 10.1097/j.pain.0000000000000907.
  10. The Royal Australian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice, Part C1: Opioids. RACGP, 2017 [Accessed 2 February 2024].
  11. Williams ACC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2020;8(8):CD007407. doi: 10.1002/14651858.cd007407.pub4.
  12. Garland E, Brintz C, Hanley A, et al. Mind–body therapies for opioid-treated pain: A systematic review and meta-analysis. JAMA Intern Med 2020;180(1):91–105. doi: 10.1001/jamainternmed.2019.4917.
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