Ensuring safer opioid systems

Opioid analgesic stewardship is now a national medicines safety priority, targeting preventable harm across acute settings and transitions to community care.

Opioid overdose deaths in Australia increased twofold between 2002 and 2019, with the majority involving prescription opioids. Hospital-based opioid analgesic stewardship programs have since emerged in response to growing recognition that opioid-related harm more often reflects system-level failures than isolated prescribing errors.

In 2022, the Australian Commission on Safety and Quality in Health Care released the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard,¹ establishing a nationally consistent framework to support safer opioid use and minimise risks such as overdose, dependence and inappropriate long-term therapy.

The standard focuses on acute pain management, particularly in hospital emergency departments and post-operative settings where opioids are commonly initiated. It emphasises limiting opioid supply at discharge, avoiding modified-release opioids for acute pain, promoting multimodal analgesia, and ensuring patients understand how and when to taper or cease opioids.

In practice, analgesic stewardship programs prioritise high-risk moments where harm most frequently occurs, says Joyce Anthony, who leads a program at Northern Health in Melbourne. Since 2022, point prevalence surveys, targeted audits and real-time prescription monitoring (RTPM) systems at Northern Health have highlighted key points of high-risk prescribing, leading to changes ranging from prescribing templates to clinical support that have had measurable impacts.

In addition to emergency department (ED) and postoperative discharge, Anthony says risks increase during transitions from critical care to other services and from hospitals to community care, as well as during conversion from parenteral to oral opioids, opioid rotation and equianalgesic dosing, and the initiation of long-acting formulations.

Transitions into community care are critical, agrees Dr Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne.

Co-prescribing opioids with benzodiazepines or other sedatives, and concurrent alcohol use, for example, are well-established risk factors for overdose, particularly once people leave the closely monitored inpatient environment. But patients and their families often receive limited information with prescribed opioids about duration, tapering, signs of overdose and interactions with other medicines.

‘We know it has been really common in coronial data, for example, for someone to have passed during the night, but to have a family member report they’d heard the patient experience shallow breathing,’ Dr Nielsen says. In short, signs of an overdose may have been noticed, but no-one knew to call for help or to administer naloxone.

As a result, Dr Nielsen has been helping to develop successful community-facing tools that support routine outcome monitoring, patient education and naloxone awareness, which can reinforce the work being done by hospital stewards once patients return home.

AP spoke with Ms Anthony about hospital systems-level solutions, and to Dr Nielsen about a new toolkit supporting transitions to community settings.

Case 1

At Northern Health, I lead the analgesic stewardship program, optimising safe

and appropriate use of analgesia for pain management. Northern Health provides acute, sub-acute, mental health, community and home-based care across six campuses in Melbourne’s rapidly growing outer north, including among the busiest EDs in Victoria. This breadth of services requires pain management practices that are safe, consistent and adaptable – and my role includes policy reviews and quality initiatives to address system-level prescribing challenges.

The stewardship program was shaped by the Parliament of Victoria’s 2018 Inquiry into Drug Law Reform, which recommended sector-wide stewardship approaches for medicines with misuse potential. Northern Health subsequently participated in Safer Care Victoria’s Analgesic Stewardship Pilot Program (2022), supporting the development of an ongoing role focused on improving prescribing consistency, safety and transitions of care.

The program’s baseline assessments identified variation in analgesic selection, dosing and duration – particularly in surgical units. Some of our initial data also indicated that junior doctors were unfamiliar with the full range of analgesic options, dose optimisation strategies and non-opioid alternatives – sometimes leading to dose escalation or initiation of slow-release opioids before simpler measures were fully implemented.

In response, together with a multidisciplinary Analgesic Stewardship Committee, we introduced postoperative analgesic order sets within the electronic medical record. These prebuilt prescribing templates group guideline recommendations – including simple analgesia, immediate-release opioids, antiemetics and laxatives – into a single workflow, reducing reliance on manual prescribing to support safer, standardised decision making.

Targeted audits in the ED also identified slow-release opioid prescribing at discharge as a key risk point. Here, engaging with senior clinicians was key, as was optimising the ED’s electronic medical record analgesia prescribing templates, including adding restrictions on extended-release opioids without senior approval and the use of SafeScript, Victoria’s RTPM system. Practical point of care supports, such as pocket-sized lanyard cards outlining appropriate inpatient opioid doses and safety checks, were also introduced to reinforce prescribing guidance.

Embedding the Analgesic Stewardship Pharmacist within the Acute Pain Service has further strengthened oversight. Participation in ward rounds, complex pain clinics and discharge planning supports clinicians, improves communication between GPs and patients, and promotes safer transitions from hospital to community care. These clinical activities are reinforced by continued development of hospital policies, structured education programs and ongoing bedside support.

Since implementation began, there have been measurable improvements. Monitoring introduced in 2023 revealed compliance with SafeScript checking has remained above 95%. Documentation of analgesic discharge plans increased 59.2% between 2024 and 2025, and slow-release opioid prescribing at discharge reduced 86.4%. Most importantly, reported opioid-related hospital-acquired complications have remained at 0%.

Case 2

Australia continues to record one of the highest per capita rates of opioid use globally, and in practice we see firsthand how limited health literacy and fragmented clinical conversations contribute to ongoing opioid-related harm.

In community pharmacy settings, pharmacists often encounter patients prescribed opioids who have limited awareness of overdose risk or early signs of opioid-related harm. When asked, patients also consistently emphasise the value of multiple, judgement-free conversations with clinicians, while noting that communication framed solely around risk can feel discouraging or alienating.

In response to these gaps, the Commonwealth-funded Opioid Safety Toolkit² was co-designed with consumers to support patient-empowered, safer opioid use, particularly for people living with long-term chronic pain. Since its launch in 2024, the toolkit has been accessed more than 100,000 times.

The toolkit includes patient-focused risk assessment and screening instruments aimed at education, overdose prevention and harm reduction, as well as outcome monitoring, clinical guidance, conversation aids and a safety plan. All tools can be self-completed by patients digitally or in hard copy, then reviewed by a pharmacist or prescriber in a brief, structured exchange that encourages natural, judgement-free engagement. Rather than positioning safety as a warning or restriction, the toolkit reframes management as empowerment and shared decision making.

Among its resources is a 5-minute clinical screening known as the Routine Opioid Outcome Monitoring (ROOM) tool,³ which helps patients monitor six key areas: analgesia, activity, adverse effects, addiction-related behaviours, affect and alcohol-related toxicity risk. The tool’s personalised feedback highlights unmanaged pain, mood deterioration and possible dependence – flagging ineffective use and educating patients about risks.

The toolkit also allows patients to develop their own personalised Opioid Safety Plan, which can be downloaded for easy reference. These plans emphasise the importance of storing medicines safely, recognising signs of overdose risk (such as respiratory depression), and understanding why naloxone should be kept in the home and how to use it. A robust, registered, randomised controlled trial using the toolkit demonstrated significantly increased patient knowledge and naloxone requests, along with high user satisfaction.⁴

In an implementation trial, pharmacists using the tool also reported that the toolkit increased interactions related to pain management, opioid safety and constipation, often leading to follow-up conversations or referrals. It also showed increased confidence from pharmacists in identifying and responding to opioid-related issues.⁵

In 2025, the toolkit received a Victorian Premier’s Design Award and a Good Design Award Gold.⁶

Pharmacists with a few minutes are encouraged to invite patients to complete the ROOM tool and/or develop an Opioid Safety Plan via in-pharmacy QR codes, available on posters or flyers from the PSA website (https://www.psa.org.au/opioidsafety/), or downloaded hard-copy forms.

References

1. Australian Commission on Safety and Quality in Health Care. Opioid analgesic stewardship in acute pain clinical care standard. At: https://www.safetyandquality.gov.au/standards/clinical-care-standards/opioid-analgesic-stewardship-acute-pain-clinical-care-standard

2. Safer Opioid Use Australia. Safer opioid use. At: https://saferopioiduse.com.au/

3. Picco L, Middleton M, Bruno R, et al. Validity and reliability of the computer administered routine opioid outcome monitoring (ROOM) tool. Pain Med. 2020;21(12):3645–3654. doi:10.1093/pm/pnaa297

4. Nielsen S, Fox F, Lam T, et al. The opioid safety toolkit: an interactive prescription opioid safety toolkit to increase opioid safety literacy and behaviours among people prescribed opioids for pain – a randomised controlled trial. Addiction. 2026.

5. Nielsen S, Picco L, Kowalski M, et al. Routine opioid outcome monitoring in community pharmacy: outcomes from an open label single arm implementation effectiveness pilot study. Res Social Adm Pharm. 2020;16(12):1694–1701. doi:10.1016/j.sapharm.2020.02.009

6. Good Design Australia. Prescription opioid safety toolkit. At: https://good-design.org/projects/prescription-opioid-safety-toolkit/