Consider deprescribing opioids in some patients: new guidelines

By Michael Woodhead

26 Jun 2023

The world’s first guidelines on how to deprescribe opioids have been developed by a multidisciplinary panel of Australian clinicians and academics.

Published in the MJA (link), the guidelines are based on the premise that the harms of long term opioid use must be balanced against the harms of abrupt or inappropriate cessation of opioids.

The authors advise that in specific patients  “it is possible to reduce opioid use and harms without worsening pain, while maintaining or improving function and quality of life.”

The  11 recommendations on when, how, and in what situation it may be appropriate for clinicians to reduce opioid use emphasise that any change in use must be gradual and individualised to the patient and with their shared involvement in decision making.

The University of Sydney led guidelines recommend that clinicians develop personalised deprescribing plans from the beginning for any patient being prescribed opioids.

They advise that opioid deprescribing should be considered “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.”

The guidelines also advise clinicians against abruptly stopping opioid treatment without gradually reducing the dose or transitioning to different treatments, saying it could increase risk of withdrawal symptoms. This includes people with severe opioid use disorder, as doing so without giving them access to opioid substitution therapies can lead to a higher rise of overdose related harms.

Recommendations also advise clinicians not to deprescribe opioids for people nearing end-of life unless there are side effects.

The recommendations were developed by a group of 17 authors including GPs, pain specialists, musculoskeletal medicines practitioners, addiction specialists, pharmacists, nurses, consumers, and physiotherapists.

Senior author Associate Professor Danijela Gnjidic from the School of Pharmacy noted there is emerging evidence that abruptly deprescribing opioids in patients, without support or pain management plans is associated with overdose related harms and death.

“Before the release of the guidelines, in Australia, clinical guidelines have focused on pain management and prescribing of opioids. We needed evidenced-based guidelines focused on safely reducing or stopping prescribed opioids, and individualised care for patients,” she said.

“To our knowledge, the Evidence‐based clinical practice guideline for deprescribing opioid analgesics is the first international guideline focused on opioid deprescribing,”  the authors stated.

The guidelines complement the national Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, released last year by the Australian Commission on Safety and Quality in Health Care, which aims to stop inappropriate prescribing of opioids to treat acute pain in hospitals.

“These new guidelines further support appropriate use of opioid analgesics and how to safely prescribe and stop prescribing them. They ask clinicians to consider reducing or stopping opioids when the risk of harm outweighs the benefits for the individual,” said Associate Professor Liz Marles, Clinical Director at the Commission.

“Shared decision-making and ensuring that patients have ways to manage their pain are essential when a deprescribing plan is being discussed. Ultimately, we are all working to reduce the number of Australians at risk of harm from long-term opioid use, which will have broad societal benefits,” said Associate Professor Marles.

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