Clinical practice guideline for deprescribing opioid analgesics: summary of recommendations

Abstract

Introduction Long term opioids are commonly prescribed to manage pain. Dose reduction or discontinuation (deprescribing) can be challenging, even when the potential harms of continuation outweigh the perceived benefits. The Evidence‐based clinical practice guideline for deprescribing opioid analgesics was developed using robust guideline development processes and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, and contains deprescribing recommendations for adults prescribed opioids for pain. Main recommendations Eleven recommendations provide advice about when, how and for whom opioid deprescribing should be considered, while noting the need to consider each person's goals, values and preferences. The recommendations aim to achieve: implementation of a deprescribing plan at the point of opioid initiation; initiation of opioid deprescribing for persons with chronic non‐cancer or chronic cancer‐survivor pain if there is a lack of overall and clinically meaningful improvement in function, quality of life or pain, a lack of progress towards meeting agreed therapeutic goals, or the person is experiencing serious or intolerable opioid‐related adverse effects; gradual and individualised deprescribing, with regular monitoring and review; consideration of opioid deprescribing for individuals at high risk of opioid‐related harms; avoidance of opioid deprescribing for persons nearing the end of life unless clinically indicated; avoidance of opioid deprescribing for persons with a severe opioid use disorder, with the initiation of evidence‐based care, such as medication‐assisted treatment of opioid use disorder; and use of evidence‐based co‐interventions to facilitate deprescribing, including interdisciplinary, multidisciplinary or multimodal care. Changes in management as a result of these guidelines To our knowledge, these are the first evidence‐based guidelines for opioid deprescribing. The recommendations intend to facilitate safe and effective deprescribing to improve the quality of care for persons taking opioids for pain.

Survey content validation evaluating the dissemination and implementation of deprescribing guidelines

“…This study involved the development of a survey targeting organisations involved in deprescribing guideline endorsement, dissemination, implementation, modification or translation of deprescribing guidelines 8–13 . Survey development is reported in accordance with the Checklist for Reporting of Results of Internet E‐Surveys (CHERRIES), as outlined in Table S1 29,30 .…”

“…Medication class‐specific deprescribing guidelines, such as those developed by the Bruyère Research Institute in Canada, have the capacity to empower clinicians by providing evidence‐based recommendations on when and how to safely and effectively reduce medications 6,7 . At present, there are six deprescribing guidelines focusing on specific drug classes, including antipsychotics (APs), 8 proton pump inhibitors (PPIs), 9 antihyperglycemic agents (AHs), 10 benzodiazepine receptor agonists (BZRAs), 11 cholinesterase inhibitors (ChEIs) and memantine, 12 with and opioids being the latest guideline 13 …”

“…Although the implementation science literature provides evidence for effective implementation strategies, 26,27 there is a lack of consensus on an optimal strategy. Hence, there is a need to examine current dissemination and implementation efforts for deprescribing guidelines and their outcomes 8–13 …”

Standard of practice in pain management for pharmacy services

“…21 Where clinically appropriate, the pain management pharmacist may engage in shared decision-making with patients to provide guidance on the safe deprescribing of opioids. 22…”

Opioid characteristics and nonopioid interventions associated with successful opioid taper in patients with chronic noncancer pain

“…7,15,17,21 In Australia, a National Health and Medical Research Council (NHMRC) endorsed Evidence-Based Clinical Practice Guideline for Deprescribing Opioid Analgesics was published in September 2022 to guide clinicians on when and how to taper opioids. 35 Further efforts to advocate for opioid deprescribing were made by national and institutional bodies. 22,41 Despite the focus on deprescribing opioids, guidance on specific aspects of how to taper patients off opioids are lacking nuance.…”