MNP-POL-002: Opioid stewardship

Policy · MNP-POL-002 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 3.2

At a glance

Opioids are prescribed for the lowest effective dose and the shortest effective duration.
Non-opioid alternatives are considered and recorded before an opioid is started.
A designated clinician leads stewardship, or a physician champion where no dedicated person exists.
Signs of diversion or misuse are monitored and reported.
Stop and get help straight away if: an opioid is prescribed with no review and no stewardship record, or misuse is seen and not reported.

1. Purpose

To use opioids safely: effective for pain, short in duration, and not misused (3.2).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

Opioids can relieve pain but they also cause harm when they are over-prescribed, given for too long, or not monitored. A stewardship approach keeps the dose and duration to what the patient needs.

5. Responsibilities

Role	Responsibility	Competence
Designated opioid steward (or physician champion)	Leads review and audit	Clinician
Prescribers	Consider alternatives and record the review	Doctor
Pharmacy	Checks dose, duration and controlled drug records	Pharmacist

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Prescribe.

Consider non-opioid alternatives and record the reason for an opioid (MNP-FRM-001).
Set the lowest effective dose and a stop or review date.

Key point: Dose and duration are set at the start.

Step 2. Review.

Review each opioid at the review date and stop it when it is no longer needed.

Key point: A stop date is a standard.

Step 3. Monitor.

Check the controlled drug register for early or unusual use and report concerns to the steward.

Key point: Diversion is looked for.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Opioid prescriptions with a stop or review date	100%	Monthly	Designated steward	Escalate to clinical director
Opioid prescriptions reviewed on time	At least 90%	Monthly	Designated steward	Escalate to clinical director

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
MNP-SOP-001	Opioid prescribing review and diversion monitoring	Procedure
HOS-REG-001	Controlled drugs register	Register

17. Evidence

Reference	Note
E-009	Based on the CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022).
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

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References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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