Australian compensable schemes face challenges in managing opioid prescribing. Those challenges affect claimant health outcomes and scheme sustainability.

Despite evidence from international bodies and Australian health authorities that 20 to 30% of compensable patients receive opioids and over 60% meet high-risk criteria, (4) many schemes lack comprehensive monitoring systems, medication management protocols and integrated care pathways.

Many schemes have worked hard to address this issue (see the companion article, Pain medicines cause harm — Opioids in workers’ compensation). However, healthcare and system gaps continue and suggest a framework for regulatory reform.

The global and national context

The World Health Organization has identified opioid dependence as a global public health concern, with pharmaceutical opioids now accounting for the majority of drug-related deaths in several high-income countries. The WHO’s 2023 report emphasises that while opioids remain essential medicines for severe pain, their prolonged use in chronic non-cancer pain often leads to more harm than benefit. (1)

In Australia, Department of Health research documents concerning trends. Australians consume 40 defined daily doses of opioids per 1,000 population per day — among the highest globally. (4) For compensable schemes, work-injured patients are prescribed opioids at 3 times the rate of non-compensable patients and remain on opioids for 5 times longer on average. (4)

The Royal Australian College of General Practitioners now specifically lists workers’ compensation injuries as requiring ‘additional caution or exclusion’ when considering opioid therapy (2) — guidance that many schemes have yet to operationalise.

Systemic failures in current monitoring approaches

Fragmented data systems

Most compensable schemes operate with siloed data systems that fail to capture a complete medication history. While real-time monitoring like SafeScript captures Schedule 8 medications, gaps remain: hospital dispensing may not appear immediately, interstate prescriptions stay invisible and scheme-funded medications don’t always align with PBS records. Case managers and treating teams cannot identify concerning patterns until adverse events occur.

Reactive rather than proactive management

Current approaches typically respond to problems after they manifest. Red flags such as dose escalation above 90mg morphine equivalent daily, concurrent benzodiazepine use or multiple prescriber involvement often go unnoticed until adverse events occur. At this point, intervention becomes more complex and resource-intensive.

Lack of clinical governance

Many schemes lack robust clinical governance frameworks that specifically address opioid management. Without clear protocols, prescribing limits or mandatory review points, decisions default to individual practitioners who may lack specialised knowledge in pain management or addiction medicine.

The human cost — Australian case studies

Case 1: The construction worker’s spiral

A 42-year-old Victorian construction worker sustained a back injury in 2018. Initially prescribed oxycodone 10mg twice daily, his compensation claim manager approved ongoing scripts without regular review. Over 3 years, his daily morphine equivalent dose escalated to 180mg. Despite multiple hospitalisations for opioid-related complications, no comprehensive medication review occurred. In 2021, he died from respiratory depression following an accidental overdose. The coroner’s investigation revealed he had been obtaining additional opioids through multiple doctors — a pattern that proper monitoring would have detected.

Case 2: The multi-system failure

A Queensland motor accident claimant received opioids from 3 separate sources: her scheme-approved GP, a private pain specialist and emergency departments. Each provider operated in isolation, unaware of concurrent prescribing. When she developed severe depression — a documented comorbidity with chronic opioid use (3) — her deteriorating mental health went unaddressed. She took her own life in 2022, with the coroner noting that better coordination and monitoring might have prevented the tragedy.

Case 3: The ripple effect

A New South Wales workers’ compensation claimant prescribed high-dose opioids for a shoulder injury became increasingly sedated and cognitively impaired. In 2023, while driving under the influence of prescribed opioids, he caused a fatal accident. The investigation revealed he had never been warned about driving risks, nor had his fitness to drive been assessed despite years of high-dose therapy.

International best practices — lessons for Australian schemes

International compensable schemes have implemented evidence-based approaches with documented outcomes:

Real-time prescription monitoring

U.S. workers’ compensation insurers implementing real-time prescription drug monitoring programs that flag concerning patterns immediately have achieved 40% reduction in opioid-related adverse events. (6) 

Mandatory clinical reviews

The Ontario Workplace Safety and Insurance Board requires a clinical pharmacist review for any claimant exceeding 90mg morphine milligram equivalents daily. This approach has reduced high-dose prescribing by 60% over five years. (5) 

Integrated pain management programs

Schemes in Germany and the Netherlands mandate multidisciplinary pain assessment before approving long-term opioid therapy. This investment in comprehensive care reduces long-term costs and improves functional outcomes.

Tasmania’s early adoption of real-time monitoring (DORA, 2011) provides domestic evidence. Average daily doses fell from 97mg to 35mg morphine equivalent between 2004 and 2017, with opioid-poisoning deaths shifting from 30% above the national average to 27% below. (4) 

Recommendations for Australian compensable schemes

Implement comprehensive monitoring systems

• Integrate all prescription data sources into a single monitoring platform.
• Establish automated alerts for high-risk prescribing patterns (≥90mg daily, concurrent benzodiazepines, multiple prescribers).

Create dashboards for case managers to track medication trends.

• Establish clear clinical governance
• Develop scheme-specific opioid management guidelines aligned with RACGP (2) and FPM ANZCA (3) positions.
• Mandate clinical review at 90mg morphine equivalent daily or 90 days duration.
• Require specialist pain medicine or addiction medicine input for continuation beyond these thresholds.

Invest in alternative pain management

• Ensure access to multidisciplinary pain programs within 4 weeks for workers approaching risk thresholds.
• Fund evidence-based non-pharmacological interventions upfront.
• Support psychological interventions that address pain catastrophising and fear avoidance.

Enhance case manager capability

• Provide comprehensive education on opioid risks and red flags.
• Develop decision-support tools for medication management.
• Create clear escalation pathways with clinical support.

Foster prescriber engagement

• Implement scheme-specific education programs on compensable population risks.
• Provide regular feedback to prescribers on patient outcomes.
• Create collaborative care agreements with clear role delineation.

Measure and report outcomes

• Track opioid-related adverse events as key performance indicators.
• Publicly report high-dose prevalence, prescriptions beyond 90 days and RTW rates for opioid users.
• Use data to drive continuous improvement.

The business case for change

Improved opioid management provides measurable returns:

• 30 to 50% reduction in opioid-related hospitalisations in schemes with comprehensive monitoring.(4,6) 
• 25% decrease in claim duration for properly managed cases.(5) 
• 60% reduction in high-dose prescribing with mandatory review (Ontario model).(5) 
• 40% reduction in adverse events with real-time monitoring (U.S. experience).(6) 
• Reduced litigation related to inadequate care.
• Protection from coronial criticism.

The Faculty of Pain Medicine’s evidence that ‘tapering of opioid doses most commonly leads to a reduction in pain or no change, rather than worsening’ (3) contradicts assumptions that maintain passive approaches. Initial investment in systems and processes is offset by reduced adverse events and shorter claim durations.

Conclusion — leadership is required

Current approaches to opioid management in Australian compensable schemes show systematic gaps. While clinical understanding has evolved — with peak medical bodies now warning against opioid use in compensable populations (2,3) — there are notable opportunities to reduce opioid harm.

Implementation of comprehensive monitoring, clear governance structures and investment in alternatives represents both opportunity and responsibility for compensable schemes. The evidence base is established. International examples demonstrate achievable outcomes. Regulatory leadership is now required to translate the evidence into practice.

The case studies presented have been deidentified and modified to protect privacy while maintaining essential elements that illustrate systemic issues. For clinical mechanisms and medical consensus on opioid harm in compensable settings, see the companion article Pain medicines cause harm — opioids in workers’ compensation.

References

1. World Health Organization. People with medical needs are ‘left behind in pain’: new report. Geneva: WHO; 16 Jun 2023.
2. Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice, Part C2. East Melbourne: RACGP; 2024.
3. Faculty of Pain Medicine, ANZCA. PS01(PM) Statement regarding the use of opioid analgesics in patients with chronic non-cancer pain. Melbourne: ANZCA; 2021.
4. Australian Institute of Health and Welfare. Alcohol, tobacco & other drugs in Australia. Canberra: AIHW; 2025.
5. Ontario Workplace Safety and Insurance Board. Opioid prescribing guidelines and clinical framework. Toronto: WSIB; 2024.
6. Buchmueller TC, Carey C. The effect of prescription drug monitoring programs on opioid utilization in Medicare. Am Econ J Econ Policy. 2018;1