Clinical guidelines, such as the National Prescribing Service’s Opioids – a planned approach to prescribing opioids for persistent non-cancer pain, recommend a cautious approach for the management of patients with chronic pain. Prescribers are encouraged to implement strategies to optimise the benefits of opioids while minimising risks of harm. Strategies include careful patient selection, clear communication about the goals of opioid therapy, thorough instructions about proper use and following up on adherence.
Observing possible aberrant drug-related behaviours
If you are considering treatment with an opioid, your patient assessment should include whether aberrant drug-related behaviours are present (see Table 1).
Table 1: Aberrant drug-related behaviours
More predictive behaviours
Less obvious behaviours
Selling prescription drugs
Stealing or borrowing drugs from others
Injecting oral formulations
Obtaining prescription drugs from nonmedical sources
Concurrent abuse of alcohol or illicit drugs
Multiple nonsanctioned dose escalations
Multiple claims that previously written prescriptions have been lost or misplaced
Repeatedly seeking prescriptions from other sources
Deterioration in interpersonal relationships, including with family or work colleagues
Repeated resistance to change in therapy despite evidence of adverse drug effects
Abrupt requests for increased dose or quantity of drug
Drug hoarding during periods of reduced symptoms
Requesting specific drugs
Openly acquiring similar drugs from other medical sources
Unsanctioned dose escalation on one or two occasions
Unapproved use of the drug to treat other symptoms
Reporting psychic effects not intended by the clinician
The opioid risk tool
The opioid risk tool is a common screening tool used to predict which individuals may develop aberrant drug-related behaviours when they are prescribed opioids for chronic pain. It is a short questionnaire that assesses the risk factors most predictive of development of a substance abuse disorder. These risk factors include personal or family history of alcohol or other drug abuse, and other mental illnesses. (Smoking may also be a predictor of more frequent use of opioids, although this risk factor is not included in the opioid risk tool.)
The opioid risk tool should be used to screen all patients for whom treatment with an opioid is being considered. For patients whose score indicates a high risk, prescribers should consider seeking advice from a pain medicine or addiction medicine specialist before beginning treatment with an opioid.
Prescribers should contact Medicare Australia’s Prescription Shopping Information Service to check whether patients whose score indicates a moderate or high risk have been identified to have received medicines in excess of medical need.
Prescribers may also contact the department for a history of permits issued, or notifications of drug dependency or other aberrant drug-related behaviours received in relation to patients they intend to treat.
Opioids for migraine treatment – use with extreme caution
Opioids should be used with extreme caution in the treatment of headache because of the risk of dependency and other adverse effects, such as medication overuse headache and hyperalgesia (1).
The Therapeutic guidelines state that opioid analgesics should be used with great reluctance in the treatment of migraine, and only after all other measures have failed (2).
If opioids are required repeatedly for treatment of migraine, management should, where possible, be in hospital in consultation with a psychiatrist or physician experienced in pain management (2).
Regular preventive treatment with a non-opioid medication is recommended for patients experiencing more than two or three acute attacks of migraine per month (3).
1 Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists. Acute pain management: scientific evidence, 3rd edition (2010).
2 Therapeutic guidelines: neurology (2011). Acute migraine attack.
3 Therapeutic guidelines: neurology (2011). Prophylaxis of migraine attacks.
Faculty of Pain Medicine: Australian and New Zealand College of Anaesthetists
The faculty’s publication Acute pain management: scientific evidence provides a review of the best available evidence for acute pain management with current clinical and expert practice. Guidelines for the treatment of acute migraine are in Section 9.6.5, ‘Acute headache’ (p. 260).
The faculty advises the following:
- Opioids are of limited benefit in migraine.
- Pethidine, in particular, is not recommended for the treatment of migraine, because of lack of evidence of efficacy and the risk of developing dependency.
- Although opioids are commonly used for the emergency treatment of headache, they cannot be recommended for use on a regular basis because of the risk of dependency and other opioid-related adverse effects.
- The Australian Association of Neurologists recommended that opioids should not be used for migraine unless the patient is unresponsive to all other measures, or where the use of ergot agents and triptans is contraindicated.
The department has sought advice from the faculty with regard to long-term continuous opioid prescribing to treat migraine. The faculty has advised the department that it is unaware of any rationale or evidence supporting continuous opioid prescription.
National Prescribing Service
The National Prescribing Service (NPS) website contains the latest evidence-based information and resources for health professionals and consumers. In the section titled ‘Medicines to avoid in migraine attacks’, the NPS advises the following:
- Morphine and related opioid pain relievers, such as pethidine, codeine, oxycodone and buprenorphine, should rarely, if ever, be used in the treatment of migraine, and even then only under specialist supervision. They can aggravate nausea and vomiting, and are potentially addictive.
- Many pharmacy-only pain relievers contain paracetamol, aspirin or ibuprofen, in combination with low doses of codeine. These medicines are frequently promoted for the relief of strong pain, but there is no evidence that they are any more effective for migraine than simple pain relievers. The addition of codeine only increases the risk of side effects and medication overuse headache.
Management of migraine in Australian general practice
A study by Associate Professor Richard Stark, a neurologist, reviewed acute and prophylactic medicine treatments prescribed by general practitioners for patients with migraine. The study revealed that prophylactic medication appeared to be underused, especially in patients with frequent migraine, and that inappropriate use of acute medications for prophylactic treatment was significant.
Coroners Court finding
In February 2014, the Coroner delivered a finding into the death of a man who died from oxycodone toxicity.
During the investigation, the Coroner found that the deceased had injected crushed oxycodone tablets, which had been prescribed by his medical practitioner for migraine pain.
The full finding and the department’s response to the recommendations can be found on the Coroners Court website (case number 408809).
Opioid prescribing – further information
Clinical advice for health professionals
The NPS fact sheet NPS News 69 (2010): Opioids – a planned approach to prescribing opioids for persistent non-cancer pain provides information on evidence-based treatment strategies for chronic noncancer pain.
To obtain clinical advice from addiction medicine consultants, health professionals may phone the Drug and Alcohol Clinical Advisory Service (DACAS).
Counselling and advice for patients
For 24-hour confidential drug and alcohol counselling and treatment information, patients, families and health professionals may phone DirectLine.