Promoting Patient-Centeredness in Opioid Deprescribing: a Blueprint for De-implementation Science

Abstract

A downward trend in opioid prescribing between 2011 and 2018 has brought per-capita opioid prescriptions below the levels of 2006, the earliest year for which the Centers for Disease Control and Prevention has published data. That trend has affected roughly ten million patients who previously received long-term opioid therapy. Any effort to reduce or replace a prior health practice is termed de-implementation. We suggest that the evaluation of opioid prescribing de-implementation has been misdirected, within US policy and health research, resulting in detrimental impacts on patients, their families and clinicians. Policymakers and implementation scientists can address these deficiencies in how we study and how we perform opioid de-implementation by applying an implementation science framework: the Consolidated Framework for Implementation Research. The Consolidated Framework lays out relevant domains of activity (internal, external, etc.) that influence implementation processes and outcomes. It can deepen our understanding of how policies a r e c h o s e n , c o m m u n i c a t e d , a n d c a r r i e d o u t . Policymakers and researchers who embrace this framework will need a better approach to measuring success and failure in health care where both pain and opioids are concerned. This would involve shifting from a reductive focus on opioid prescription counts toward measures that are more effective, holistic, and patient-centered.

Beyond pain, distress, and disability: the importance of social outcomes in pain management research and practice

“…Table 1 offers clinicians and researchers a number of options for measuring social outcomes across a variety of domains that have been demonstrated to contribute to the trajectory of chronic pain and patients' day to day quality of life. Consistent with a coproduction model of research and clinical care, 29,64,121 we recommend that clinicians and researchers take a patient-centred approach to selecting social outcome measures, engaging with patients to determine which of these social outcome domains are most relevant for the individual or study cohort. Future studies should focus on the relative importance of each of the identified outcome domains from the patient's perspective.…”

Recent trends in prescription drug misuse in the United States by age, race/ethnicity, and sex

“…These results suggest an uneven pattern of changes in past‐year PDM and poly‐PDM: large declines in young adults that are absent in adults 35 and older, inconsistent patterns of declines by race/ethnicity, and no notable change in stimulant or benzodiazepine PDM. These findings may indicate that increased restrictions on opioid prescribing contributed to declines in opioid PDM, though these declines may have had unintended harms that include increased use of illicit opioids 20 . Conversely, the lack of declines in stimulant and benzodiazepine PDM co‐occurred with recent increases in prescribing of these medications and of increased opioid‐benzodiazepine co‐prescribing.…”

Patient and Provider Perspectives on Benefits and Harms of Continuing, Tapering, and Discontinuing Long-Term Opioid Therapy

“…Improving communication efforts around LTOT might benefit from understanding patient perceptions of phrases providers use when de-prescribing LTOT since communication may impact satisfaction with care and decision-making. 26,27,[33][34][35][36][37][38] A study on general de-prescribing found that older patients preferred language about adverse effects of medications. 37 However, patients in the present study were concerned that providers focused too much on patient harms or how discontinuing LTOT benefited medical systems or monitoring requirements.…”