Opioids in Chronic Noncancer Pain

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

📋

Opioids provide little or no long-term benefit for most chronic noncancer pain (CNCP) and are associated with dose-dependent harms including respiratory depression, dependence, tolerance, opioid-induced hyperalgesia, falls, cognitive impairment, and death.
Before initiating opioids for CNCP, clinicians must conduct a structured risk assessment using validated tools (e.g., Opioid Risk Tool, SOAPP-R) and screen for substance use disorders, mental health comorbidities, and red-flag pathology requiring specialist referral.
A time-limited therapeutic trial (typically 4–12 weeks) with predefined functional and pain-outcome goals should be agreed before prescribing; if goals are not met, a structured taper and cessation plan must be enacted.
A written opioid treatment agreement (shared-care agreement) should be signed by patient and prescriber, outlining goals, risks, monitoring expectations, random urine drug screening, single-prescriber/single-pharmacy arrangements, and circumstances for dose reduction or discontinuation.
Australian and international guidelines recommend a morphine equivalent daily dose (MEDD) ceiling of ≤ 50 mg/day for CNCP; doses ≥ 50 mg/day double the risk of opioid-related overdose compared with ≤ 20 mg/day, and doses ≥ 100 mg/day should be avoided or require specialist co-management.
Codeine is no longer recommended as first-line for chronic pain; it is available only by prescription in Australia (since 2018) and has unpredictable metabolism via CYP2D6.
Regular structured reviews at 4-weekly intervals during the trial phase, then at least every 3 months once stable, must document pain intensity (NRS/VAS), functional status, adverse effects, aberrant behaviours, and ongoing need for opioids.
Naloxone (take-home) should be co-prescribed to patients on MEDD ≥ 50 mg/day, those on concurrent benzodiazepines, or those with a history of substance use disorder; available as intranasal Nyxoid® on PBS Authority Required.
Non-pharmacological therapies (graded exercise, cognitive-behavioural therapy, physiotherapy, mindfulness-based stress reduction) and non-opioid pharmacotherapy (NSAIDs, SNRIs, gabapentinoids, TCAs) should be trialled first-line per the RACGP and ANZCA Faculty of Pain Medicine guidance.
Aboriginal and Torres Strait Islander communities face higher chronic pain prevalence, barriers to accessing multidisciplinary pain services, and greater risk of opioid-related harm; culturally safe, community-led models and Close-the-Gap PBS co-payment arrangements must be considered.
Clinicians must be aware of state and territory regulatory requirements for Schedule 8 prescribing, including real-time prescription monitoring programs (e.g., SafeScript VIC, SafeScript NSW, QScript QLD, ScriptCheckWA, NT RAPID, ACT DPS, TAS DORA, SA EPMS) and mandatory notification obligations.

Introduction & Australian Epidemiology

Chronic noncancer pain (CNCP) — defined as pain persisting beyond three months or beyond expected tissue-healing time — affects an estimated 1.6 million Australians (approximately 6.9% of the adult population) according to the Australian Institute of Health and Welfare (AIHW, 2020). Low back pain, osteoarthritis, neuropathic pain, fibromyalgia, and chronic widespread pain syndromes are the most common presentations in primary care.

Despite their established role in acute pain and cancer pain, opioids have limited evidence for sustained benefit in CNCP. Systematic reviews (Busse et al., 2018; Krebs et al., 2018) demonstrate small, clinically insignificant improvements in pain and function at 12 months, accompanied by significant increases in nausea, constipation, dizziness, falls, opioid use disorder, and overdose death. The 2020 Lancet Global Burden of Disease study identified opioid use as a leading cause of drug-related morbidity in high-income countries including Australia.

🚨

Australian opioid-related harm: Between 2001 and 2021, opioid-induced deaths in Australia more than doubled, reaching approximately 1,200 per year (Penington Institute, 2022). Pharmaceutical opioids (oxycodone, tramadol, codeine) are implicated in more deaths than heroin. The rate of opioid-related hospitalisations is approximately 150 per 100,000 population, with the highest rates in the 45–64 age group.

The Royal Australian College of General Practitioners (RACGP), the Australian and New Zealand College of Anaesthetists (ANZCA) Faculty of Pain Medicine, NPS MedicineWise, and the Therapeutic Goods Administration (TGA) all recommend a cautious, evidence-based approach to opioid prescribing for CNCP. Key principles include: (1) exhaustive non-opioid and non-pharmacological measures first, (2) structured risk assessment before initiation, (3) time-limited trials with predefined goals, (4) regular review with clear stop criteria, and (5) multimodal, patient-centred care plans.

This guideline covers the Australian context for opioid prescribing in CNCP, encompassing risk assessment, treatment agreements, dose limits, and structured review processes. It does not cover acute pain, cancer pain, palliative care, or medication-assisted treatment for opioid dependence (which is addressed elsewhere).

Risk Assessment

A comprehensive risk assessment is mandatory before initiating any opioid for CNCP. This assessment identifies patients at higher risk of misuse, aberrant behaviours, overdose, and poor outcomes, and guides the decision to prescribe — or not prescribe — opioids.

Components of Risk Assessment

Domain	Assessment	Tools / Approach
Personal history of substance use	Alcohol, cannabis, benzodiazepines, opioids, methamphetamine, illicit drugs	AUDIT-C, DAST-10, clinical history, pathology
Family history	First-degree relative with substance use disorder	Detailed family history
Mental health comorbidity	Depression, anxiety, PTSD, personality disorders, sleep disorders	PHQ-9, GAD-7, K10, clinical interview
Age	Patients < 30 or > 65 years at higher risk (misuse / falls respectively)	Demographic assessment
Red-flag pathology	Night pain, progressive neurological signs, unexplained weight loss, cauda equina features, malignancy	Clinical examination, imaging, urgent referral
Concurrent sedating medications	Benzodiazepines, gabapentinoids, sedating antihistamines, muscle relaxants	Medication reconciliation, real-time monitoring checks
Renal and hepatic function	Impaired clearance increases overdose and toxicity risk	eGFR, LFTs, hepatitis serology

Validated Risk Stratification Tools

Tool	Purpose	Score Interpretation
Opioid Risk Tool (ORT)	Predicts risk of aberrant opioid-related behaviours (0–26)	0–3: Low risk; 4–7: Moderate risk; ≥ 8: High risk
SOAPP-R (Screener and Opioid Assessment for Patients with Pain — Revised)	24-item self-report screening for risk of opioid misuse	≥ 18: Elevated risk (sensitivity 81%, specificity 68%)
DIRE (Diagnosis, Intractability, Risk, Efficacy)	Clinician-rated tool assessing suitability for long-term opioid therapy	≤ 13: Poor candidate; ≥ 14: Appropriate candidate
COMM (Current Opioid Misuse Measure)	17-item patient self-report monitor for current misuse among existing opioid patients	≥ 9: Concern for current misuse

⚠️

No single tool is sufficient. Validated instruments must be combined with clinical judgement, collateral information, real-time prescription monitoring data, and longitudinal assessment. Risk is dynamic — it must be reassessed at every review.

Risk Stratification and Prescribing Approach

Low Risk

ORT 0–3, no SUD history

May be suitable for a cautious short-term trial with GP-led monitoring. Standard treatment agreement. Review at 4 weeks. MEDD target ≤ 20 mg/day.

Setting: Primary care (GP)

Moderate Risk

ORT 4–7, resolved SUD, significant mental health comorbidity

Requires enhanced monitoring, stricter agreement terms, urine drug screening, 2-weekly reviews during trial, and early pain-management specialist or addiction medicine input. MEDD target ≤ 30 mg/day.

Setting: Shared care — GP + pain specialist / drug health

High Risk

ORT ≥ 8, active SUD, concurrent benzodiazepine use

Opioids generally contraindicated for CNCP. If considered at all, must be under specialist-led multidisciplinary care with addiction medicine co-prescriber, frequent UDS, naloxone co-prescription, and structured contingency management.

Setting: Specialist pain service / multidisciplinary pain clinic

Investigations Prior to Opioid Initiation

Essential Urine Drug Screen (UDS) Baseline immunoassay panel including opioids, benzodiazepines, amphetamines, cannabis, cocaine. Detects non-prescribed substances and absence of prescribed medications. MBS item 71139 (urine drug screening panel).

Essential Serum creatinine / eGFR Renal impairment alters opioid clearance. MBS item 66503 / 66512.

Essential Liver function tests (LFTs) Hepatic impairment affects metabolism of codeine, tramadol, oxycodone, methadone. MBS item 66515.

Available Hepatitis B and C serology If history of injecting drug use or high-risk behaviours. MBS items 69327, 69330.

Available Pharmacogenomic testing (CYP2D6) Consider for codeine or tramadol — identifies ultra-rapid or poor metabolisers. Not routinely PBS-funded; available through private pathology. MBS item 73301.

Available FBC, CRP / ESR Screen for inflammatory or red-flag aetiology. MBS item 65070 / 65090.

Opioid Treatment Agreements

A written opioid treatment agreement (also termed a shared-care agreement or treatment contract) is a cornerstone of safe prescribing for CNCP in Australian practice. It establishes mutual expectations, documents informed consent regarding risks and benefits, and provides a framework for monitoring and decision-making. The ANZCA Faculty of Pain Medicine and the RACGP both recommend agreements for all patients commenced on opioids for CNCP.

Essential Components of an Opioid Agreement

Treatment Goals

Specific, measurable, achievable, relevant, time-bound (SMART) goals for pain reduction and functional improvement — e.g., return to part-time work, walk 30 minutes daily, reduce NRS pain score by ≥ 30%, improved sleep quality.

Risks Acknowledged

Documented discussion of: addiction risk, respiratory depression, constipation, nausea, sedation, falls, cognitive effects, hormonal effects (hypogonadism), opioid-induced hyperalgesia, tolerance, dependence, and withdrawal.

Single Prescriber & Single Pharmacy

Patient agrees to obtain opioid prescriptions from one nominated prescriber and dispense from one nominated pharmacy. Any deviation is grounds for reassessment of the treatment plan.

Urine Drug Screening

Patient consents to random and scheduled urine drug screens to detect non-prescribed substances and confirm adherence. Frequency: baseline, then per risk stratification (low risk — annually; moderate — 3-monthly; high — monthly or more).

No Dose Escalation Without Approval

Patient agrees not to request dose increases outside scheduled review appointments and not to seek opioids from other sources (including emergency departments for the same complaint).

Safe Storage & Disposal

Opioids stored securely away from children and others in the household. Unused medications returned to community pharmacy for destruction under the RUM (Return Unwanted Medicines) programme.

Driving & Occupational Safety

Patient informed of impairment risk and legal obligations. In most Australian states, driving with detectable opioids (even if prescribed) may be an offence unless the patient is not impaired — state-specific legislation applies.

Trial Period & Exit Strategy

Clear trial duration (typically 4–12 weeks). Defined criteria for continuation (≥ 30% pain reduction AND functional improvement) vs. dose reduction and cessation (failure to meet goals, intolerable adverse effects, aberrant behaviour).

Naloxone Co-Prescription

For patients at elevated overdose risk (MEDD ≥ 50 mg, concurrent benzodiazepines, SUD history), the agreement documents co-prescription of intranasal naloxone (Nyxoid® 1.8 mg/0.1 mL) and training of the patient and a nominated support person in its use.

Signatures & Review Date

Signed by patient, prescriber, and ideally a witness. Next review date documented. A copy provided to the patient and filed in the medical record.

ℹ️

The agreement is a clinical communication tool, not a punitive contract. Language should be empathetic and collaborative. Breach of agreement terms should trigger a structured clinical review, not abrupt termination of care. Abandoning a patient on opioids is both unethical and dangerous.

Dose Limits

Dose-dependent harms are among the strongest evidence findings in the opioid–CNCP literature. The relationship between morphine equivalent daily dose (MEDD) and overdose death, emergency department presentations, and opioid use disorder is log-linear and exponential above 50 mg MEDD. Australian and international guidelines converge on the following dose thresholds:

Low Risk

MEDD ≤ 20 mg/day

Lowest overdose risk category. Represents the target dose range for CNCP trials. Even at this dose, harms (constipation, nausea) are common and long-term efficacy remains unproven.

Setting: Primary care with standard monitoring

Moderate Risk

MEDD 21–50 mg/day

Overdose risk approximately 2× that of ≤ 20 mg/day. Requires documented clinical justification, enhanced monitoring, specialist co-management discussion, and mandatory naloxone co-prescription consideration.

Setting: Shared care GP + pain specialist

High Risk

MEDD ≥ 50 mg/day (esp. ≥ 100 mg/day)

Overdose risk 2–6× higher than low-dose. Doses ≥ 100 mg/day should be actively avoided for CNCP. If a patient arrives on high doses, initiate a structured taper toward ≤ 50 mg/day. Specialist pain medicine and/or addiction medicine oversight required.

Setting: Specialist-led multidisciplinary pain clinic

Common Opioid MEDD Conversion Table (Australian Context)

Opioid	Oral Dose Equivalent to 30 mg Oral Morphine	PBS Status (CNCP)
Morphine (oral)	30 mg	Restricted Benefit
Oxycodone (oral)	20 mg (= MEDD factor × 1.5)	Restricted Benefit
Tapentadol (oral)	150 mg (= MEDD factor × 0.2–0.4)	Authority Required
Tramadol (oral)	150 mg (= MEDD factor × 0.1–0.2)	✔ PBS General Benefit
Codeine (oral)	200 mg (= MEDD factor × 0.15)	✔ PBS General Benefit
Buprenorphine (transdermal)	~20 µg/hr patch ≈ MEDD ~36 mg	Restricted Benefit
Methadone (oral)	Variable — non-linear conversion; specialist initiation only	Authority Required

🚨

Concomitant benzodiazepines + opioids: The combination increases overdose death risk by up to 10× compared with opioid monotherapy. Avoid concurrent prescribing wherever possible. If benzodiazepine dependence is established, prioritise dose reduction or supervised cessation before or concurrently with opioid initiation.

State and Territory Real-Time Prescription Monitoring (RTPM)

All Australian jurisdictions now operate or are implementing real-time prescription monitoring for Schedule 8 and certain Schedule 4 medicines. Clinicians must check RTPM before initiating and at each opioid prescription:

Jurisdiction	System Name	Status
Victoria	SafeScript	Mandatory (active since April 2020)
New South Wales	SafeScript NSW	Active (2023)
Queensland	QScript	Active (2022)
Western Australia	ScriptCheckWA	Active (2023)
South Australia	EPMS	Active (2024)
Tasmania	DORA	Active (2013, expanded)
ACT	DPS	Active (2023)
Northern Territory	RAPID	Active (2024)

Review After Trial

A structured review after the initial opioid trial period is essential and must be documented. The purpose of the review is to determine whether the predefined treatment goals have been met and whether continuation is justified — or whether the patient requires dose reduction, opioid cessation, and/or transition to alternative management strategies.

Trial Phase Structure

Week 0

Baseline assessment: Document NRS/VAS pain score, functional measures (Oswestry Disability Index, Patient-Specific Functional Scale), psychological screening (PHQ-9, GAD-7), baseline UDS, signed treatment agreement, RTPM check, naloxone discussion.

Week 1–2

Early safety review: Telephone or in-person assessment for adverse effects (nausea, constipation, sedation, respiratory concerns), adherence, dose adequacy, and tolerance. Adjust dose if needed (upward titration permitted during trial). Confirm bowel management plan in place.

Week 4

First formal review: Repeat NRS/VAS, functional assessment, adverse-effect screen. Compare against baseline goals. If no meaningful improvement (≥ 30% pain reduction AND functional gain), consider dose optimisation or early transition to tapering plan. Repeat RTPM check.

Week 8–12

Trial endpoint review: Definitive decision point. If goals met → continue with 3-monthly reviews. If goals not met → initiate structured taper at a rate of ≤ 10% of the current dose per week (or per 2 weeks if on long-term therapy). Document rationale for continuation or cessation in the medical record.

Month 3 onwards (ongoing)

Maintenance reviews: At least every 3 months for patients continuing opioids. Repeat UDS per risk tier, RTPM check at each prescription, re-evaluate functional goals, assess for dose creep, tolerance, opioid-induced hyperalgesia, hormonal effects, and bone health. Annual comprehensive review including referral considerations.

Criteria for Continuation vs. Cessation

✅ Continue Opioids When:

≥ 30% reduction in pain intensity (NRS/VAS)
Meaningful functional improvement documented
No or manageable adverse effects
No aberrant behaviours or UDS concerns
Agreement terms adhered to
MEDD within acceptable range (≤ 50 mg/day preferred)
Ongoing engagement with non-pharmacological strategies

❌ Discontinue / Taper When:

< 30% pain reduction and no functional improvement at 12 weeks
Intolerable adverse effects (sedation, constipation, cognitive impairment)
Evidence of dose escalation without clinical rationale
Positive UDS for non-prescribed substances
Aberrant behaviours (lost scripts, early refills, doctor shopping)
Signs of opioid-induced hyperalgesia
Development of opioid use disorder
New contraindication (e.g., pregnancy, severe hepatic impairment)

Structured Tapering Protocol

When the decision is made to reduce or cease opioids, a gradual, patient-centred taper is essential. Abrupt cessation risks severe withdrawal, patient distress, and dangerous illicit opioid substitution.

💊

Tapering Principles

RACGP / ANZCA Faculty of Pain Medicine guidance

Rate Reduce by ≤ 10% of the current dose every 1–4 weeks. Faster tapers acceptable for short-term use (< 1 month). Slower tapers (over months to years) for long-term high-dose patients.

Schedule Stabilise at each new dose for 1–4 weeks before further reduction. Hold the taper if withdrawal symptoms, intolerable pain, or significant psychological distress occur.

Support Regular GP follow-up during taper (minimum 2-weekly). Concurrent non-pharmacological therapy. Psychological support (psychologist, counsellor). Consider referral to drug and alcohol services if opioid use disorder develops during taper.

Monitor Withdrawal symptoms (COWS score for assessment), pain scores, mood (PHQ-9), sleep quality, functional status, suicidal ideation.

PBS status ✔ N/A — tapering is a clinical process

⚠️

Never abruptly cease opioids in a patient established on long-term therapy. Sudden withdrawal is medically dangerous (seizures with tramadol, severe withdrawal with all opioids), psychologically harmful, and associated with increased risk of illicit opioid use and overdose. If a prescriber-patient relationship must end, ensure a minimum 3-month supply of tapering prescriptions and documented transfer of care to another provider.

Monitoring

Ongoing monitoring is a non-negotiable component of opioid prescribing for CNCP. It serves to detect adverse effects, confirm adherence, identify aberrant behaviours, ensure functional goals are being met, and provide an evidence base for continuation decisions.

Monitoring Framework

Parameter	Frequency	Method
Pain intensity	Every review (4-weekly during trial; 3-monthly when stable)	Numeric Rating Scale (NRS 0–10) or Visual Analogue Scale (VAS)
Functional status	Every review	Patient-Specific Functional Scale, Oswestry Disability Index, PHQ-9 (activities of daily living domain)
Adverse effects	Every review	Structured enquiry: constipation (Bristol Stool Scale), nausea, sedation (Epworth Sleepiness Scale), falls, cognitive effects, sexual dysfunction
Urine drug screen	Per risk tier (see agreements section)	Point-of-care immunoassay ± confirmatory LC-MS/MS (MBS item 71139)
Real-time prescription monitoring	Every opioid prescription	State/territory RTPM system (SafeScript, QScript, etc.)
Morphine equivalent daily dose (MEDD)	Every prescription	Calculated using published equianalgesic tables; documented in medical record
Mental health screening	At least 6-monthly	PHQ-9, GAD-7, K10; screen for suicidal ideation
Endocrine assessment	Annually (if on opioids > 6 months)	Testosterone (males), oestradiol/LH/FSH (females with amenorrhoea), prolactin if symptomatic
Bone density	Consider DEXA if long-term opioid use + risk factors	MBS item 12312 (bone densitometry)
Naloxone availability	Confirm at each review for high-risk patients	Check expiry, confirm patient and support person trained

Medications for Opioid Side-Effect Management

💊

Macrogol (Polyethylene glycol 3350)

Movicol® · Opioid-induced constipation prophylaxis

Adult dose 1–3 sachets daily (each sachet = 13.125 g), adjusted to stool consistency

Paediatric dose ≥ 2 years: ½–1 sachet daily

Renal adjustment Caution if eGFR < 30 (electrolyte absorption); monitor potassium

PBS status ✔ PBS General Benefit

💊

Naloxegol

Moventig® · Peripherally-acting μ-opioid receptor antagonist (PAMORA)

Adult dose 25 mg PO once daily in the morning (12.5 mg if moderate hepatic impairment or with CYP3A4 inhibitors)

Renal adjustment No adjustment required (not renally cleared)

Caution Contraindicated with strong CYP3A4 inhibitors (ketoconazole, clarithromycin). Avoid in known/suspected GI obstruction.

PBS status Authority Required — opioid-induced constipation refractory to laxatives

💊

Naloxone nasal spray

Nyxoid® · Opioid overdose reversal (take-home naloxone)

Dose 1.8 mg (1 spray) into one nostril; may repeat with second device after 2–3 minutes if no response

Indication Co-prescribe for MEDD ≥ 50 mg/day, concurrent benzodiazepines, SUD history, or patient/carer request

PBS status Authority Required

Special Populations

🤰

Pregnancy & Breastfeeding

Opioids in pregnancy

Neonatal abstinence syndrome (NAS) risk with any opioid used in third trimester — duration of exposure correlates with severity.
Codeine: avoid — active metabolite morphine crosses the placenta; unpredictable CYP2D6 metabolism.
If opioid-dependent, maintain on supervised methadone or buprenorphine-naloxone (Suboxone®) per opioid pharmacotherapy guidelines — withdrawal is contraindicated in pregnancy due to fetal distress risk.
Short-acting opioids (oxycodone) preferred if opioids absolutely required for acute flares; lowest effective dose, shortest duration.

Breastfeeding

Codeine: contraindicated in breastfeeding (TGA 2018). Morphine in low doses is preferred but monitor infant for drowsiness, poor feeding.
Tramadol: caution — avoid in CYP2D6 ultra-rapid metabolisers; monitor infant.
Paracetamol and ibuprofen are safe breastfeeding-compatible analgesics; maximise non-opioid strategies.

👶

Paediatrics (< 18 years)

General principles

Opioids for chronic noncancer pain in children and adolescents have no robust evidence base and are generally not recommended.
Multidisciplinary paediatric pain services (e.g., Children's Pain Management Centres in tertiary hospitals) should be involved early.
Non-pharmacological approaches (graded physiotherapy, CBT, family-based interventions) are first-line.
If opioids are considered, only under specialist supervision with strict dose limits and duration constraints.

👴

Older Adults (≥ 65 years)

Key considerations

Increased sensitivity to opioids (reduced clearance, increased receptor sensitivity, altered volume of distribution).
Falls risk significantly increased — combine with fall-risk assessment and mitigation (home modifications, physiotherapy, vision check).
Start at 25–50% of the standard adult dose and titrate slowly ("start low, go slow").
Avoid codeine (constipation, unpredictable metabolism) and tramadol (seizure risk, serotonin syndrome risk with SSRIs — commonly co-prescribed in this age group).
Check Beers Criteria (AGS) — opioids are potentially inappropriate medications in older adults.
Cognitive effects (delirium, worsening dementia) must be monitored; opioids can mimic or exacerbate cognitive decline.

🫘

Renal Impairment

Dose adjustments

eGFR 30–60: Reduce starting dose by 25–50%; avoid morphine (active metabolite M6G accumulates). Prefer oxycodone or hydromorphone.
eGFR < 30 or dialysis: Avoid morphine entirely. Buprenorphine (transdermal) is renally safe and preferred. Oxycodone at reduced dose if needed. Tramadol dose reduction required.
Fentanyl is hepatically metabolised — no active renally-excreted metabolites — but caution with dosing in severe renal failure due to altered pharmacodynamics.
Codeine: avoid — active metabolite morphine accumulates, causing prolonged sedation and respiratory depression.

🫁

Hepatic Impairment

Key considerations

Child-Pugh A (mild): reduced starting doses, careful titration.
Child-Pugh B–C (moderate–severe): avoid or use with extreme caution. Morphine and codeine have reduced hepatic clearance and increased bioavailability due to reduced first-pass metabolism.
Fentanyl (transdermal) and buprenorphine (transdermal) may be relatively safer in moderate hepatic impairment, but specialist advice is essential.
Paracetamol hepatotoxicity risk amplified — limit to ≤ 2 g/day in chronic liver disease.

🛡️

Immunocompromised

Key considerations

Opioids have immunosuppressive effects (reduced NK cell activity, T-cell function); clinical significance uncertain but relevant in patients with HIV, transplant recipients, or active malignancy (non-palliative).
Drug interactions with immunosuppressants: tramadol lowers seizure threshold (relevant with ciclosporin); methadone interacts with antiretrovirals (ritonavir, efavirenz).
Pain assessment in immunocompromised patients must rule out infection, malignancy progression, or drug-related pain before attributing to a chronic noncancer mechanism.

Non-Pharmacological & Non-Opioid Pharmacological First-Line Approaches

Australian guidelines uniformly recommend that non-pharmacological therapies and non-opioid medications be trialled before opioids. These interventions should continue even if opioids are initiated, as they enhance outcomes and support opioid dose minimisation.

Non-Pharmacological

Graded exercise therapy — supervised physiotherapy, hydrotherapy, walking programmes
Cognitive-behavioural therapy (CBT) — pain catastrophising, acceptance and commitment therapy (ACT)
Mindfulness-based stress reduction (MBSR)
Interdisciplinary pain rehabilitation — Australian pain clinics offer 2–8 week programmes
Physiotherapy — manual therapy, active exercise, taping, dry needling
TENS (transcutaneous electrical nerve stimulation) — limited evidence for selected neuropathic presentations
Sleep hygiene and management

Non-Opioid Pharmacological

Paracetamol 1 g QID (max 4 g/day; 2 g/day in liver disease)
NSAIDs — ibuprofen, naproxen, celecoxib; shortest duration, lowest effective dose; GI and CV risk assessment
SNRIs — duloxetine 30–60 mg daily (first-line for neuropathic pain, fibromyalgia, osteoarthritis)
TCAs — amitriptyline 10–75 mg nocte (neuropathic pain)
Gabapentinoids — gabapentin, pregabalin (neuropathic pain; caution dependence potential)
Topical agents — capsaicin 8% patch (Qutenza®), lidocaine 5% patch (Versatis®), topical NSAIDs
Interventional procedures — nerve blocks, radiofrequency ablation, spinal cord stimulation (specialist referral)

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Chronic pain prevalence

Aboriginal and Torres Strait Islander Australians experience chronic pain at 1.5–2 times the rate of the non-Indigenous population (AIHW, 2022). Musculoskeletal conditions, injury-related pain, and diabetes-related neuropathy are disproportionately represented. Despite higher prevalence, access to multidisciplinary pain services is significantly lower, particularly in regional and remote communities.

Opioid-related harm

Aboriginal and Torres Strait Islander Australians are 1.5–2 times more likely to be dispensed pharmaceutical opioids and experience higher rates of opioid-related hospitalisation and death compared with non-Indigenous Australians (AIHW, 2022). Factors include higher pain burden, comorbidity, reduced access to non-pharmacological alternatives, and historical prescribing patterns.

Access to multidisciplinary care

Most specialist pain management centres are located in metropolitan areas. Aboriginal and Torres Strait Islander people in remote and very remote areas may have no access to physiotherapy, psychology, or specialist pain medicine. Aboriginal Community Controlled Health Organisations (ACCHOs) provide culturally safe primary care but may lack specialist pain medicine support. Telehealth services (including those funded under MBS telehealth items) can partially bridge this gap.

Cultural safety & communication

Pain is experienced and expressed within cultural frameworks. Concepts of pain, disability, and stoicism may differ across communities. Clinicians should use culturally appropriate communication, employ Aboriginal Health Workers and Aboriginal Health Practitioners as key members of the care team, and avoid deficit-framing language. Respect for family structures, country, and community decision-making processes is essential.

PBS co-payment & Close the Gap

Eligible Aboriginal and Torres Strait Islander patients can access PBS medicines at a reduced co-payment under the Closing the Gap PBS co-payment measure (currently .70 per script vs. .60 general patient co-payment). Eligibility requires identification as Aboriginal and/or Torres Strait Islander, registration with Medicare, and a valid Medicare number. This significantly reduces cost barriers to non-opioid analgesics, duloxetine, pregabalin, and topical agents.

ACCHOs & shared-care models

Aboriginal Community Controlled Health Organisations (e.g., AMSANT in the NT, VACCHO in Victoria, AHCWA in WA) are best placed to deliver culturally safe chronic pain management. Shared-care models involving ACCHOs, regional hospitals, and specialist pain services via telehealth are recommended. The Royal Australasian College of Physicians' Indigenous Health Strategy and RHDAustralia provide frameworks for opioid stewardship in these settings.

Naloxone access in remote communities

Take-home naloxone (Nyxoid®) should be proactively offered to patients in remote communities on opioids for CNCP, given: (1) delayed emergency medical response times (often hours rather than minutes), (2) higher baseline opioid dispensing rates, and (3) community-level opioid exposure. Training of family members and community health workers in naloxone administration is recommended.

📚 References

1. Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017;189(18):E659–E666. doi:10.1503/cmaj.170363
2. Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872–882. doi:10.1001/jama.2018.0899
3. Royal Australian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice: Part B — Opioids. Melbourne: RACGP; 2022.
4. Australian and New Zealand College of Anaesthetists (ANZCA) Faculty of Pain Medicine. Position Statement on the Use of Opioid Analgesics in Chronic Non-Cancer Pain. Melbourne: ANZCA; 2023.
5. Australian Institute of Health and Welfare (AIHW). Pain in Australia. Cat. no. PHE 282. Canberra: AIHW; 2022.
6. NPS MedicineWise. Opioids, chronic non-cancer pain and the bigger picture. NPS Radar. Sydney: NPS MedicineWise; 2020.
7. Penington Institute. Australia's Annual Overdose Report 2022. Melbourne: Penington Institute; 2022.
8. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep. 2022;71(No. RR-3):1–95. doi:10.15585/mmwr.rr7103a1
9. Therapeutic Goods Administration (TGA). Prescription opioids: what changes are being made and why. Canberra: Department of Health and Aged Care; 2023.
10. Australian Government Department of Health and Aged Care. PBS — Pharmaceutical Benefits Scheme: Closing the Gap co-payment measure. Canberra: DoHA; 2024. Available from: pbs.gov.au
11. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019. Lancet. 2020;396(10258):1204–1222. doi:10.1016/S0140-6736(20)30925-9
12. Sun EC, Dixit A, Humphreys K, Darnall BD, Baker LC, Mackey S. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ. 2017;356:j760. doi:10.1136/bmj.j760

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).