New opioid deprescribing guidelines – InSight+

New evidence-based clinical guidelines for opioid deprescribing were published in Medical Journal of Australia.

Australian researchers have published the first evidence-based clinical guidelines for opioid deprescribing, a crucial step to help general practitioners reduce opioid use in their patients.

Published in Medical Journal of Australia Today, Dr Aili Langford and her colleagues at the University of Sydney have formulated eleven recommendations providing advice on when, how and for whom opioid deprescribing should be considered.

One of the key findings is that evidence suggests it is possible to reduce opioid use without making pain worse, maintaining or even improving function and quality of life, lead author Dr Langford, a hospital pharmacist who led the research while working at the University of Sydney, said Insight+.

However, opioid deprescribing is complex and there is no one-size-fits-all solution.

Opioid deprescribing may not be appropriate for everyone, and as a result, the guideline also offers recommendations on when not to deprescribe.

A key component of this guideline is its emphasis on person-centered care and shared decision-making between prescribers and patients to support safe and effective opioid deprescribing.

New Opioid Deprescribing Guidelines - Featured Image
The guidelines underline the need for a shared decision-making process between prescribers and patients. sharedwutzkohphoto/Shutterstock

The Importance of Deprescribing Conversations

The researchers support the development of a deprescribing plan for people who are prescribed opioids at the time of opioid initiation.

Prior to developing this guideline, we conducted research to elicit healthcare practitioner and consumer perspectives on opioid deprescribing (here and here), said Dr. Langford.

A recurring sentiment was that it’s really hard to have conversations about opioid deprescribing. This prompted us to develop a conversation guide to help structure and facilitate these conversations in clinical practice.

GPs well positioned to discuss opioid deprescribing

General practitioners are well positioned to lead opioid deprescribing due to their ongoing relationship with patients, opportunities for shared decision-making, and ongoing monitoring and management, said Dr. Langford.

This is why general practitioners were the target audience of the guidelines.

Additional audiences who may find this guideline helpful include medical specialists (for example, general practitioners, geriatricians, pain specialists, rheumatologists, psychiatrists, addiction specialists), nurses (including nurse practitioners, registered nurses, and registered nurses), psychologists, and pharmacists. Evidence shows that a multidisciplinary approach to opioid deprescribing is optimal, so I think it is important that a range of healthcare professionals with different competencies and skills can be involved to improve pain and analgesia management.

Dr. Langford said the guidelines can also help improve communications between hospitals and community prescribers at point-of-care transfer in terms of an agreed plan of care for continuing or stopping opioids.

Fragmented healthcare system

The authors say a fragmented healthcare system is partly responsible for Australia’s lack of adequate pain management practices.

At the system level, the lack of accessible pain management services for end users in the face of a fragmented health care system and limited resources is an ongoing barrier to implementing guideline recommendations, the authors write.

Initiatives that can help their implementation include increased funding and coverage for non-drug pain management treatments, improved access to drug-assisted treatment for people with opioid use disorder, reimbursable patient counseling time, and payment models that improve geographic and financial access to multidisciplinary, coordinated interdisciplinary or multimodal care.

Seeing firsthand the challenges of pain relief

Dr. Langdon was practicing full-time as a hospital pharmacist when she saw firsthand the challenges of providing safe and effective pain relief for patients in a clinical setting.

I saw great value in the opportunity to work on a project related to optimizing opioid use, said Dr. Langford.

In 2019, Dr Langdon began her PhD at the University of Sydney, under the supervision of Associate Professor Carl Schneider, Associate Professor Danijela Gnjidic and Professor Christine Lin.

Their work was prompted by their concerns that Australia may have followed the United States and Canada, where there are rising rates of inappropriate use of prescription opioids (here and here).

During the development of the guidelines, we began to see emerging evidence of an association between opioid tapering and overdose, suicide and mental health crises, particularly when deprescribing was not required or opioids were abruptly stopped, he said.

Additionally, harms to patients from misapplication of the 2016 CDC Clinical Practice Guidelines for Prescribing Opioids in the United States it has been reported.

This got us thinking about the work we were doing and really reinforced the need and potential value of the recommendations to support evidence-based, person-centred opioid deprescribing in clinical practice.

Read the guideline summary in the Medical Journal of Australia.

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