Analgesic Update - 2018

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Key messages

  • Evaluate the type, cause and severity of a patient’s pain to determine which analgesics should be prescribed and if an opioid analgesic is appropriate
  • Multi-modal analgesia (concurrent use of analgesics with different modes of action) can improve analgesic effectiveness, reduce the dose of opioids if these are prescribed, reduce adverse effects and minimise the length of time that patients require opioids
  • Provide an analgesic plan that guides appropriate use of analgesics and gives information on when they should be reduced or stopped as their pain improves. This plan can be verbal but written instructions are likely to be safer and more effective.
  • Prescribe strong opioids for severe pain with morphine first-line and oxycodone as a second-line option if patients are unable to tolerate morphine

Patients presenting with pain are frequently seen in primary care in New Zealand. Treatment for pain will vary depending on the underlying cause but can usually be based on the WHO analgesic ladder. It is important that patients understand which medicines they have been prescribed to reduce their pain and how they should be taken, by providing a clear analgesic plan.

Most patients will be prescribed Step one medicines (paracetamol and/or an NSAID). Weaker opioids, e.g. codeine and tramadol are at Step 2 and strong opioids such as morphine are Step 3 on the analgesic ladder. Opioid medicines remain one of the most commonly prescribed medicine classes in New Zealand accounting for approximately 10% of all prescriptions dispensed in 2017.1

This report provides an overview of opioid analgesic prescribing trends nationally and for your practice over the last five years. We have included some key points for reflection (see side panel).

1. Ministry of Health, Pharmaceutical collection, 2017.

National data - trends in use

Overall, use of all opioid analgesics has remained relatively stable over the past five years with approximately one-fifth of the population receiving a dispensing in a year. The opioids classified as Step 2 on the WHO analgesic ladder, e.g. codeine and tramadol, had much higher overall use than the Step 3 opioids, e.g. morphine and oxycodone. Tramadol use has increased by 13% (Figure 1). Morphine use increased by 20%, while oxycodone use has levelled out after decreasing between 2013 – 2015 (Figure 2). It is difficult to state accurately why these changes have occurred because the pharmaceutical data does not include the indication for which the medicines were prescribed. It is likely that multiple factors influence prescribing and may include our ageing population, education around appropriate medicine use and subsidy changes.

Step 2 opioids prescribed nationally

Figure 1. Use of Step 2 opioid analgesics (number of patients/1000 population) from 2013-2017.*

* Methadone has been removed from the analyses because it is predominantly used for indications other than analgesia

Step 3 opioids prescribed nationally

Figure 2. Use of Step 3 opioid analgesics (number of patients/1000 population) from 2013-2017.*

* Methadone has been removed from the analyses because it is predominantly used for indications other than analgesia

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WHO analgesic ladder - Data for your practice

The World Health Organisation (WHO) analgesic ladder is widely accepted for the management of nociceptive pain. The general principle is to escalate and de-escalate through the ladder, as required until pain is negligible. See "The principals of managing acute pain in primary care" for further information.

In 2017, patients ( of your practice population) had a prescription for any opioid analgesic. Ideally, patients who received a prescription for a strong opioid would also have received a prescription for a weak opioid, as analgesic treatment was escalated or de-escalated.

Your data show that in 2017, of the patients who received a strong opioid (Step 3), % were also prescribed a weak opioid (Step 2) within three months. If this percentage is low, you may like to consider this analgesic strategy, depending on clinical circumstances; it may not be applicable for patients receiving palliative care treatment.

Step 2 analgesics prescribed at


Step 3 analgesics prescribed at


Comparing the ratio of Step 2 and Step 3 analgesics prescribed at

Your Practice (% of all opioids) Comparator Practices * National
Step 2 (%) % 90%
Step 3
(%) % 4%
Step 2 and 3 (%) % 6%

* For further information on comparator practices, see:


Download your Analgesic Update 2018 report

To download a report of your and your practice's analgesic prescribing, see:

Published: 29 March 2018

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