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The six Rs of managing high‑risk opioid prescribing

High-dose opioid prescribing is associated with an increased risk of harms, including death.

Box 1. The six Rs of managing high‑risk opioid prescribing

• Rotation of opioids

• Reduction (tapering)

• Replacement pharmacotherapy

• Reversal with naloxone

• Referral to allied health practitioners/ other specialists

• Restriction of supply

Box 2. Opioid taper

• All opioids (both short- and long-acting) are converted into one long-acting opioid (may involve opioid rotation).

• The dose of the long-acting opioid is decreased at a rate of 10% of the starting dose per week or fortnight.

• The use of short-acting opioids or as-needed doses is strictly limited.

• Non-opioid analgesics are used to manage pain flares.

• Opioid withdrawal symptoms are managed by reducing the taper rate.

In Australia, Pharmaceutical Benefits Scheme (PBS)–subsidised opioid prescriptions rose from 2.4 million in 1992 to 7.5 million in 2012, with associated increases observed in pharmaceutical opioid-related deaths.


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