Opioid misuse, abuse and diversion

Misuse, abuse and diversion can occur with all opioids, including tramadol and tapentadol. Opioids that are full mu-receptor agonists with high receptor affinity and a short duration of action may have a greater abuse potential. Prevalence of opioid abuse is influenced by opioid availability.

Unintended consequences of opioid prescription are interrelated and occur on a spectrum of severity; see Opioid misuse definitions for opioid misuse definitions.

Table 1. Opioid misuse definitions
Term	Definition
misuse	opioid use that differs to the prescribed regimen (eg using a higher dose or frequency, using an opioid for a different indication [such as managing stress or inducing sleep]) sometimes includes abuse and diversion
abuse	intentional use of opioids for nonmedical effects (eg euphoria, altered consciousness) may be a single episode or a pattern of continued use; see opioid-use disorder (addiction)
diversion	transfer of the opioid to other people
opioid-use disorder (addiction)	aberrant behaviours, such as compulsive opioid use for nonmedical effects, or to avoid withdrawal continued opioid use despite risks of physical, psychological or social harm to the patient or others
chemical coping	tendency to use opioids to cope with stress aberrant behaviours may be seen, but are not consistently exhibited
poisoning	deliberate or accidental opioid overdose, either in the patient or a household member

Increased opioid prescribing rates have been associated with a significant increase in the number of fatalities involving opioids. There is a lack of robust evidence comparing the relative fatality risk associated with opioid misuse; however, epidemiological studies in adults suggest fewer fatalities result from misuse of buprenorphine patches, tramadol or tapentadol, compared to other opioids.

Misuse and abuse are significant concerns if opioids are prescribed for chronic conditions. Conduct an individual risk assessment (see Opioid risk assessment tool for adults ) before prescribing an opioid. Studies report that 20% of patients with chronic noncancer pain are at risk of opioid abuse.

Risk mitigation strategies may minimise opportunity for misuse, abuse and diversion. These strategies include checking the following resources before prescribing:

Also prescribe the lowest effective dose, limit the duration of supply and dispense smaller pack sizes for patients at risk of misuse, abuse and diversion of opioids. Provide the patient and their healthcare providers clear instructions on tapering and withdrawal of opioids. Advise patients on safe storage and transport of opioids, particularly those with children in their care.