Liam, a 34 year old warehouse picker, strained his back lifting a crate. In ED he received a short oxycodone script ‘until physio starts’.  Approvals took weeks, the pain flared and repeat scripts came from different prescribers as his appointments shifted. By week 10, he was taking 40 to 60 morphine milligram equivalents a day, with diazepam to sleep. He missed rehab sessions, felt foggy at work trials and his return to work stalled. Six months in, Liam had more pain, less activity and falls. No one had a full view of the dose, duration or combinations of his meds until a review after an ED visit. Nothing about his injury changed — only the medicines did.

Australian schemes recognise the problem. Real-time prescription monitoring, dose thresholds and review triggers have helped — national opioid dispensing fell 30% between 2016 and 2021 (4). Yet in workers’ compensation, early opioid prescribing remains common. Across Australian jurisdictions, 20 to 30% of injured workers receive opioids within 3 months of injury (5,6). Of these, over 60% meet criteria for high-risk prescribing (5). Up to one in 4 workers remains on opioids at 12 months (5).

This pattern persists across jurisdictions despite meaningful reforms and explicit medical guidance. The Faculty of Pain Medicine states: ‘Opioid therapy is not indicated in chronic non-cancer pain, with no evidence for improving chronic pain and functional outcomes’ (3). The Royal Australian College of General Practitioners specifically lists ‘workers’ compensation injuries’ as requiring ‘additional caution or exclusion’ when considering opioids (2).

Prolonged opioid therapy in compensable settings is associated with longer disability, more procedures and worse RTW outcomes (5,6). Current prescribing patterns continue despite documented mechanisms of harm.

By the numbers in research

The scope of the problem 

• Australian workers receiving opioids within 90 days of injury: 20-30% (varies by jurisdiction) (5,6). 
• Meeting criteria for high-risk prescribing: >60% of those prescribed (5).
• Still using opioids at 12 months: 15-25% (5). 
• Median disability days with early opioids: 134 days vs 21 days without (6).

Impact on recovery and return to work

• Workers on opioids >90 days: 3x longer disability duration (6) 
• High-dose users (≥90mg morphine equivalent daily): 4 x higher odds of work absence at 12 months (5).
• Co-prescription with benzodiazepines: 5 x higher hospitalisation risk (6).
• Early opioid recipients requiring surgery within 12 months: 2.3 x higher rate (6).

Evidence from intervention studies

• Schemes with mandatory review at 90mg daily: 40% reduction in high-dose prescriptions (8).
• Implementation of real-time monitoring: 23% reduction in doctor-shopping behaviours (8,10).
• Early access to multidisciplinary programs: 50% reduction in opioid use at 6 months (14).

The medical consensus — opioids are contraindicated for chronic pain

RACGP position: Workers’ compensation injuries require ‘additional caution or exclusion’ when considering opioid therapy. ‘Guidelines identify only a selective place for opioids…opioid use is not routine and is not first-line or second-line therapy’ (2).

Faculty of Pain Medicine (ANZCA): ‘Opioid therapy is not indicated in chronic non-cancer pain, with no evidence for improving chronic pain and functional outcomes in this cohort’ (3).

Evidence of harm: ‘Population studies show that people maintained on long-term opioid therapy describe more troublesome pain and greater functional interference than people not on opioids’. (FPM ANZCA 2021) (3).

Iatrogenic dependence: ‘Some patients on long-term treatment may represent de facto maintenance treatment for iatrogenic opioid dependence’ (RACGP) (2).

Tapering improves outcomes: ‘Tapering of opioid doses in patients with chronic pain most commonly leads to a reduction in their level of pain or no change in their pain, rather than a worsening of pain’ (FPM ANZCA) (3).

How opioids become the problem

The pathway from short-term relief to long-term disability follows predictable patterns. Initial prescriptions ‘while waiting’ for physiotherapy become repeat scripts when approvals are delayed. As tolerance develops, doses escalate without functional gain. The worker feels less pain relief but faces mounting side effects: sedation, cognitive fog, mood changes.

Fragmented prescribing compounds the risk. The ED provides one script, the GP another. The specialist adds something for sleep. Real-time monitoring systems, like SafeScript, now capture Schedule 8 medications (10), but gaps remain. Hospital dispensing may not appear immediately. Interstate prescriptions stay invisible. Scheme-funded medications don’t always align with PBS records in the system (11). Time-pressured clinicians may not check, or may see the alerts but feel unable to tackle inherited prescribing. By the time someone acts on the cumulative exposure — often when there’s a crisis — dependency is established.

The compensation context amplifies these mechanisms. Claim stress, repeated assessments and adversarial processes increase distress and pain perception. Sleep deteriorates. Depression emerges. Each problem gets its own medication. The worker taking 40mg of oxycodone with diazepam for sleep isn’t recovering — they’re sedated.

Meanwhile, access to alternatives remains limited. Multidisciplinary pain programs have months-long waits. Active rehabilitation requires approvals. Psychological support needs separate authorisation. While these processes unfold, opioid prescriptions continue — the path of least resistance in a time-pressured system.

The cascade effect with other healthcare patterns

Opioid prescribing rarely occurs in isolation. The same workers receiving early imaging and multiple assessments show the highest rates of opioid use. Each intervention reinforces the others:

Imaging drives medication escalation

The MRI showing ‘multilevel degeneration’ justifies stronger analgesia. The ‘objective finding’ validates subjective pain, making both doctor and patient more comfortable with pharmaceutical management.

Waiting enables dependency

While queuing for specialist appointments, approvals and procedures, opioids provide ‘interim management’. A 2-week wait becomes 6 weeks. Short-term becomes long-term. By the time definitive care arrives, withdrawal is harder than continuation.

Assessments compound distress

Each independent examination, each conflicting opinion, each request to prove incapacity increases anxiety and hypervigilance. Pain worsens. Sleep deteriorates. Medication doses creep upward to manage not just the original injury, but the distress of the claim itself.

What we’ve known — and what we overlook

The RACGP states: ‘Given the lack of evidence that long-term opioids commonly reduce pain or improve the patient’s functioning or quality of life, the harms will often outweigh the benefits’ (2). The Faculty of Pain Medicine reports: ‘Population studies show that people maintained on long-term opioid therapy describe more troublesome pain and greater functional interference than people not on opioids (3).

Research suggests that opioids may actively worsen outcomes. The RACGP acknowledges: ‘Some patients on long-term treatment with opioids for chronic non-cancer pain may represent de facto maintenance treatment for iatrogenic opioid dependence’ (2) — medical prescribing has created dependence rather than treating pain effectively.

Yet in compensable care, the standard workflow persists: repeat scripts across providers, inadequate monitoring of total exposure and delayed access to alternatives. The reasons are structural, not clinical. Time-pressured consultations make prescribing quicker than explaining. Fragmented funding obscures the total dose. Administrative delays prevent timely access to multidisciplinary care.

Opioids remain essential for acute severe pain, peri-operative care,and palliative indications.(1) The problem is their routine use for compensable musculoskeletal injuries where the evidence shows harm rather than benefit with prolonged exposure. The Ontario Workplace Safety and Insurance Board’s experience — requiring pharmacist review at 90mg daily — demonstrates that systematic intervention works (7).

Why this matters for schemes

Workers on long-term opioids have claim durations 3 times longer than those managed without (6). They undergo more procedures, have more hospitalisations and show poorer RTW rates (5,6). Analysis shows workers on high-dose opioids (>90mg morphine equivalent daily) have a median time loss of 134 days versus 21 days for similar injuries managed without opioids (6).

Beyond clinical outcomes, each prolonged claim represents someone whose confidence has been replaced by fear. Whose identity has shifted from worker to patient. Whose family bears the burden of both financial stress and personality change. Young workers exposed early in their careers face decades of increased risk.

The financial implications compound. Longer claims mean higher wage replacement, more medical costs and greater administrative burden. Each worker whose simple injury becomes chronic dependency erodes trust in the scheme’s ability to help rather than harm.

What schemes have achieved — and where gaps remain

Australian jurisdictions have implemented substantial reforms with measurable impact:

State based monitoring started with mandatory real-time prescription monitoring in Victoria (SafeScript, 2019) (10). Their workers’ compensation cohort data (2010-2019, n=30,000) shows the challenge — 20.5% received opioids within 90 days, with 67.1% of these meeting high-risk criteria and 22.8% still using at 12 months (5). Post-SafeScript implementation shows early reductions in high-risk prescribing patterns (11). 

Real-time prescription monitoring now operates across most states — QScript (Queensland, 2021), ScriptCheckWA (Western Australia, 2023), NTScript (Northern Territory, 2022). Early data shows consistent reductions in doctor-shopping and high-risk combinations (4,10).

Dose and duration thresholds trigger review in several schemes. Victoria requires justification above 90mg morphine equivalent daily (11). Queensland’s guidelines set clear escalation points (12). These mechanical triggers catch outliers, though many workers remain on concerning regimens below thresholds.

Alternative pathways have expanded, although unevenly. South Australia’s awareness campaign on opioid use had far reach. Their ReGP tele-mentoring program shows 5 of 6 participating doctors reduced opioid prescribing (14). Victoria’s multidisciplinary pain programs report functional improvements, but wait times remain long and access varies by location (13).

Tapering programs show consistent results. The Faculty of Pain Medicine reports: ‘There is evidence to show that tapering of opioid doses in patients with chronic pain most commonly leads to a reduction in their level of pain or no change in their pain, rather than a worsening of pain’ (3). This evidence contradicts common assumptions about dose reduction increasing suffering. Structured deprescribing approaches provide clear pathways for safe dose reduction (9).

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

Despite this progress, gaps remain:

• Visibility remains incomplete — real-time monitoring captures Schedule 8 drugs but may miss hospital dispensing, interstate prescriptions and timing gaps between scheme and PBS records.
• Systems don’t prevent prescribing — alerts flag risks but prescribers can override them and  inherited prescribing remains difficult to address.
• Early alternatives are limited — multidisciplinary programs have months-long waits.
• Prescriber behaviour varies widely — some check monitoring systems routinely, others sporadically.
• Young workers remain vulnerable — early exposure patterns predict long-term problems.

Questions for discussion

Immediate actions 

Should schemes implement hard stops at 90mg morphine equivalent daily or 90 days duration, requiring specialist review before continuation? How can real-time monitoring systems better integrate hospital dispensing, interstate prescriptions, and scheme-funded medications to provide truly complete visibility?

System changes 

What would guarantee access to multidisciplinary pain programs within 4 weeks for workers approaching high-risk thresholds? Should pharmacist review be mandatory at defined points rather than triggered by aberrant behaviour?

Measuring progress 

Which metric best indicates scheme performance: high-dose prevalence, prescriptions beyond 90 days or RTW rates for opioid users? How should schemes publicly report opioid-related outcomes to drive improvement?

Where this meets the assessment burden

Opioid use and repeated assessments create a particularly harmful interaction. Sedation and cognitive effects from medication complicate evaluation. Workers must appear coherent while impaired, credible while sedated. 

The stress of performing for assessments drives the escalation in medication. Each review, each examination, each moment of scrutiny increases the perceived need for pharmaceutical support. 

For a detailed examination of monitoring failures and system-level implementation strategies, see the companion article, The Hidden Crisis — How inadequate opioid monitoring in compensable schemes fails our most vulnerable, which provides specific governance recommendations and international best practices for scheme executives and regulators.

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: The role of opioids in pain management. East Melbourne: RACGP; 2024. 

3.    Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists. 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: drug-induced deaths and illicit opioids. Canberra: AIHW; updated 20 Jun 2025. 

5.    Tefera YG, Gray S, Nielsen S, Di Donato MF, Collie A. Early high-risk opioid prescribing and persistent opioid use in Australian workers with workers’ compensation claims for back and neck musculoskeletal disorders or injuries: a retrospective cohort study. CNS Drugs. 2025;39(5):499–512. doi:10.1007/s40263-025-01169-5

6.    National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention. Opioids and workers’ compensation. Atlanta (GA): CDC; 2024. 

7.    Workplace Safety and Insurance Board (Ontario). Opioids at the WSIB. Toronto: WSIB; 2024–2025.

8.    Buchmueller TC, Carey C. The effect of prescription drug monitoring programs on opioid utilization in Medicare. Am Econ J Econ Policy. 2018;10(1):77–112. doi:10.1257/pol.20160094

9.    Primary Health Tasmania. A guide to deprescribing opioids. Hobart: Primary Health Tasmania; Mar 2023. 

10.    Victorian Department of Health. SafeScript for prescribers and pharmacists. Melbourne: State of Victoria; 2025. 

11.    WorkSafe Victoria. Pharmacy policy. Melbourne: WorkSafe Victoria; 2025. 

12.    WorkSafe Victoria. Pain management (Claims Manual 4.5.33). Melbourne: WorkSafe Victoria; 2020–2025. Available from:

13.    WorkSafe Victoria. Persistent pain resources. Melbourne: WorkSafe Victoria; 2025. 

14.    Menzies Centre for Health Policy & Economics; ReturnToWorkSA. Evaluation of the SA Chronic Pain ECHO Network. Adelaide: RTWSA; 2023.