There are parallels between the North American experience of escalating pharmaceutical opioid utilisation and harm and the trends being observed in Australia. In Australia, opioid utilisation has increased dramatically over the past two decades. There have been significant shifts away from the predominant prescribing of ‘weak’ and short‐acting opioids, to ‘strong’ and long‐acting opioids, for an increasing range of chronic pain indications. In concordance with escalating use, Australia is experiencing increases in opioid‐related hospital admissions and overdose, as well as opioid dependence and treatment seeking. Despite increasing concern regarding pharmaceutical opioid use and harms in Australia, responses have been limited. There have been no recent changes in regulatory systems for prescription‐only pharmaceutical opioids, opioid prescribing guidelines, limits on doctors’ prescribing, monitoring of patient or doctor access to opioids, or in access to medicines via public subsidy. Potentially abuse‐deterrent opioid formulations have entered the Australian market, with studies suggesting that these formulations are less likely to be tampered with by people who inject drugs; but to date, there have been limited impacts on opioid utilisation and harm. Additional strategies may include enhancing access to effective approaches to pain management and opioid dependence, and scaling‐up naloxone provision. There is a unique opportunity for a proactive and preventative response to pharmaceutical opioids in Australia, to avoid experiencing the scale of problems seen elsewhere.