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There is growing interest in strategies to improve patient safety with prescription opioids, collectively known as opioid stewardship (OS). This study aimed to develop a framework to facilitate the implementation of OS in the Australian acute hospital setting. Using a Modified Delphi Technique, a diverse stakeholder panel (including patient representatives and multidisciplinary healthcare professionals) was selected. A survey based on the results of a literature review was sent to the panel for appraisal. In line with standard Delphi methodology, the primary outcome for each element was reaching consensus of at least 70% of the participants on the importance of its inclusion in the framework. The survey allowed the participants to suggest new items for inclusion in subsequent rounds or rephrase existing items. Of the 29 participants who completed the survey, the majority (23/29) were regularly involved in providing direct patient care. Twenty-six of 27 items reached the 70% threshold for agreement for importance after the first round. The remaining item not agreed on in the initial round was modified based on comments received and reached 100% agreement on importance at the second round. There was greater than 85% agreement on importance of 24 of 27 items for inclusion in a framework with 8 of 27 reaching a 100% level of agreement. We have developed a framework for OS in the Australian acute hospital settings that may be used to guide health services to prioritise and plan strategies to improve opioid use., (© 2021 Royal Australasian College of Physicians.)