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Opioids or morphine-based pain medicines are a high-risk medicine. These medicines have led to 1180 deaths in Victoria over a 10-year period, contributing to an average of 41.3 per cent of total overdose deaths each year.

Hospitals increasingly understand the risks of supplying opioids to consumers when they are discharged. Despite this, less than 5 per cent of Australian hospitals reported having a formal program to manage opioid prescribing. In 2018, the Parliament of Victoria’s Inquiry into Drug Law Reform recommended the roll out of a sector wide stewardship trial for medicines with potential for misuse. 

The Medicines improvement program worked with Alfred Health and Clinical Excellence Queensland to test an analgesic stewardship (AGS) program in six partner health services. The program ensured appropriate use and review of opioids and other pain medicines to improve acute pain management and reduce avoidable medication-related harm.

Like other stewardship programs, such as antibiotic or antimicrobial stewardship, an AGS program includes structured approaches to governance, accountability, policy, education, monitoring, and improvement activities. 

The program has released an AGS toolkit to factsheets and adaptable resources to support health services beyond the pilot program to introduce elements of an AGS program and support the process of quality improvement. 


The AGS Toolkit has been developed and tested to support health services introduce key elements of an analgesic stewardship program. It can be used by health services to improve healthcare outcomes and align with the recently launched Australian Commission on Safety and Quality in Health Care's Opioid Analgesic in Acute Pain Clinical Care Standards. It includes factsheets and adaptable resources to support quality improvement across key quality statements including appropriate opioid analgesic prescribing, documentation, review of therapy and transfers of care .  

The program finished on 30 June 2022


All participating sites established and improved governance, policy, education, monitoring, communication and transfers of care structures within their health services using the tested toolkit.

Lead organisation

Alfred Health


  • Albury Wodonga Health
  • Barwon Health
  • Eastern Health
  • Northern Health
  • Peninsula Health
  • Royal Melbourne Hospital

Get in touch

David Nguyen
Principal Policy Advisor - Medicines
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