How to get your patient off opioids safely

3 minute read

World-first guidelines from the University of Sydney go through the who, what and how of deprescribing for general practitioners.

Patient buy-in is key to designing an effective opioid deprescribing regimen, according to new Australian guidelines.

The set of 11 recommendations was put together by a panel of 17 researchers, doctors, pharmacists and people with lived experience, most of whom were affiliated with the University of Sydney.

“People taking opioids, we all know, can fear that deprescribing will result in worse pain or reduced quality of life,” guideline co-author Associate Professor Carl Schneider told The Medical Republic.

“The evidence is that, in studies, when people are able to reduce their opioids, they’re able to generally maintain a level of pain and functioning or potentially even improve in terms of pain management and function with the reduction in opioids.”

This comes with a catch.

“However, primarily these interventions have been performed when the person taking opioids is working together with the prescriber to create deprescribing plan that takes into consideration a person’s values, preferences and goals.”

The guidelines focus on the cohort of opioid users who are prescribed the medicines for pain, rather than those using opioids like methadone for maintenance therapy, given that deprescribing was more relevant for the pain cohort.

The guideline authors do, however, acknowledge the subset of people who use opioids for pain while also having an addiction.

Professor Schneider said one important takeaway was that there were scenarios where people shouldn’t be taken off opioids.

“There are some populations where opioid deprescribing should not be undertaken,” he said.

“For example, at end-of-life care or in circumstances where people may have an opioid use disorder.”

For the subset of patients with a potential use disorder, the guidelines recommend referral to an evidence-based, medication-assisted opioid misuse treatment program rather than a deprescribing regimen.

At the Australian Pain Society Annual Scientific Meeting in Canberra this April, lead author and Sydney pharmacist Aili Langford told audiences that the unexpected advice on when not to deprescribe was driven by overwhelming public demand in the consultation phase of the guidelines.

Another recommendation, with low-certainty evidence, warns not to cease opioids abruptly.

There are separate suggestions pertaining to people with chronic non-cancer pain, chronic cancer-survivor pain and chronic pain.

For patients with non-cancer pain, the researchers made a very low-certainty conditional recommendation to deprescribe if there is a lack of clinically meaningful improvement from baseline, a lack of progress toward agreed goals or if they are experiencing intolerable adverse effects.

They made the same recommendation for patients with cancer-survivor pain, but in the form of a consensus recommendation.

For the chronic pain cohort, the researchers made a consensus recommendation suggesting deprescribing for people with specific co-morbidities like sleep apnoea or COPD, as well as people who have concomitant use of substances with sedating effects or who are on a high dose of prescribed opioids.

MJA 2023, online 26 June

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