New evidence-based clinical guidelines for opioid deprescribing have been published in the Medical Journal of Australia

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

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

“One of the main take-aways is that evidence suggests that it is possible to reduce opioid use without worsening pain, whilst maintaining or even improving function and quality of life,” lead author Dr Langford, a hospital pharmacist who conducted the research while working at University of Sydney, told InSight+.

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

“Opioid deprescribing may not be appropriate for everyone and accordingly, the guideline also offers recommendations about when not to deprescribe.

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

New guidelines for opioid deprescribing - Featured Image
The guidelines emphasise the need for shared decision making between prescribers and patients. sharedwutzkohphoto/Shutterstock

The importance of conversations about deprescribing

The researchers argue for the development of a deprescribing plan for people being prescribed opioids at the point of opioid initiation.

“Prior to developing this guideline, we conducted research to elicit health care professional and consumer perspectives about opioid deprescribing (here and here),” Dr Langford said.

“One reccurring sentiment was that it’s really difficult 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 conduct opioid deprescribing due to their ongoing relationship with patients, opportunities for shared decision making, and ongoing monitoring and management,” Dr Langford said.

“That is why general practitioners were the guideline’s target audience.

“Additional audiences that may find this guideline useful include specialist physicians (eg, general physicians, geriatricians, pain specialists, rheumatologists, psychiatrists, addiction specialists), nurses (including nurse practitioners, registered nurses and enrolled 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 health care professionals with varying expertise and skills can be engaged to improve pain and analgesia management.”

Dr Langford said the guideline may also help improve communications between hospitals and community prescribers at the point-of-care transfer in terms of an agreed care plan for opioid continuation or discontinuation.

Fragmented health care system

The authors say a fragmented health care system is partly to blame for the lack of proper pain management practices in Australia.

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

“Initiatives that may assist their implementation include increased funding and coverage for non-pharmacological pain management treatments, improved access to medication-assisted treatment for individuals with opioid use disorder, reimbursable time for patient counselling and payment models that improve geographical and financial access to multidisciplinary, interdisciplinary or multimodal coordinated care.”

Seeing first-hand the challenges of pain relief

Dr Langdon was practising full time as a hospital pharmacist when she saw first-hand the challenges of providing safe and effective pain relief for patients in a clinical environment.

“I saw great value in an opportunity to work on a project relating to optimising opioid use,” Dr Langford said.

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

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

“During guideline development, we started to see emerging evidence of an association between opioid tapering and overdose, suicide and mental health crises, particularly when deprescribing was unsolicited or opioids were ceased abruptly,” she said.

“Additionally, patient harm resulting from the misapplication of the 2016 CDC Clinical Practice Guideline for Prescribing Opioids in the United States was being reported.

“This made us reflect on the work we were doing and really reinforced to us the need for, and potential value of, recommendations to support evidence-based and person-centred opioid deprescribing in clinical practice.”

Read the guideline summary in the Medical Journal of Australia.

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