Opioids’ decline is good news, but we can do more

A new report shows a large drop in dispensing rates, but they are still overprescribed for chronic non-cancer pain.

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Five years ago, opioid dispensing rates in Australia were heading in the wrong direction.

The Australian Atlas of Healthcare Variation found that the national Pharmaceutical Benefits Scheme (PBS) dispensing rate of opioid medicines had increased by 5% in the four years to 2016-17. More than 15 million PBS prescriptions for opioids were dispensed that year.

The data in 2022 paints a strikingly different picture. A new time series report from the Australian Commission on Safety and Quality in Health Care (the Commission) has found that opioid medicines dispensing rates fell nationally by 18% and in all states and territories between 2016-17 and 2020-­21. There was also a 30% decrease in the overall volume of opioid medicines supplied.

The data are clear: Australian doctors are prescribing fewer and lower doses of opioids. It is good news given the documented levels of prescribing for chronic non-cancer pain where the role of opioids is limited.

The reversal is likely due to a combination of changes in clinician behaviour, consumer demand and policy and regulation. Clinicians are increasingly setting therapeutic boundaries to reduce opioid use, while consumer groups are recognising that opioids are not a simple fix and that whole-person approaches to managing chronic pain are more effective.

On the regulation side, changes to indications, pack sizes and authority requirements provide consistency and backup for clinicians. Real-time prescription monitoring in Tasmania, Victoria and the ACT has also contributed to the data, and we can expect this impact to increase with all states and territories developing or planning their own systems.

But with prescription opioids still responsible for more than 700 deaths each year, we can and should do more to reduce opioid misuse.

Opioids continue to be widely prescribed for chronic non-cancer pain, despite little evidence of benefit and significant evidence of harms.

There is clinical variation in opioid prescribing for chronic non-cancer pain across the medical profession, including hospital doctors, pain specialists and GPs, despite guidelines that recommend against the use of opioids as first-line treatment for chronic non-cancer pain.

This variation is reflected in the Commission report, which shows that while overall use of opioids is falling, geographic variation has budged little over the past five years. The number of prescriptions dispensed was around five times higher in the area with the highest rate compared to the area with the lowest rate. The report’s interactive maps, which display trends at national, state and territory, Primary Health Network and local area levels, show that opioid use is higher in regional areas and in areas with socioeconomic disadvantage.*

Although GPs are the largest group of prescribers of opioids, we need to tackle opioid use where it often starts: in hospitals.

Hospital clinicians need to address patient expectations before and during admission and most importantly at discharge – emphasising at each opportunity that opioids are an evidence-based treatment for short-term pain, but they will need to be stopped. Otherwise GPs are left having to manage patients who expect long-term access to opioids. 

These principles are central to the Commission’s new clinical care standard on the use of opioids for acute pain in acute care settings. The standard includes actions for surgical and emergency departments that are aimed at reducing inappropriate prescribing.

De-prescribing continues to be one of the most challenging issues in general practice. Balancing empathetic, compassionate connection with the patient while being clear about therapeutic boundaries can help us to meet this challenge.

For patients who are reluctant to stop opioids, we can explain that people with chronic non-cancer pain commonly feel much better once they’ve stopped using opioids. This recent Australian study can help us make the case. It found that patients with chronic non-cancer pain who stopped taking opioids had less pain than those who continued using opioids or those who halved their use.

It is important to involve patients in the decision about when and how quickly to reduce their opioid dose (but not whether the dose will reduce). Slowly reducing the dose over six months, or even one or two years, may be better for the vulnerable patient who has taken opioids for decades.

It’s also vital in complex cases to work with pain specialist colleagues to set the de-prescribing boundaries. We will achieve the best outcomes by working together.

Of course, we can’t just focus on de-prescribing – there needs to be a whole-person approach to achieving long-term pain reduction, recognising that what we think and feel and how we move and eat can change our physical state.

The Commission report is an indication that all of us across the healthcare system are nudging opioid rates in the right direction through greater alignment of practice with evidence.

What can we do in general practice?

• Do not prescribe opioids for chronic non-cancer pain
• If opioids are already prescribed, aim to de-prescribe
• Balance empathy with therapeutic boundaries – negotiate with the patient about timing and rate of reduction of opioids
• Consider a monthly step down of 10 to 25% of starting dose
• If drug dependence is an issue, consider referral to a drug and alcohol program.

What can we do in hospitals?

• Address patient expectations before and during admission and at discharge
• Develop individualised dosing based on previous 24 hours of use
• Develop a plan for short-term use and cessation, and communicate it to the patient and GP
• Implement opioid analgesic stewardship programs based on the Clinical Care Standard.

* The Commission is working with the health system, particularly PHNs, to identify and address unwarranted variation in opioid dispensing. Check out the report and interactive graphs to see rates for your local area.

Dr Damien Zilm is a GP in Meekatharra, WA. Dr Chris Hayes is a specialist pain medicine physician and director of the Hunter Integrated Pain Service at John Hunter Hospital, Newcastle. Both were members of the expert advisory group for the Australian Commission on Safety and Quality in Health Care’s time series report about the dispensing of opioid medicines 2016–17 and 2020–21.