Guidelines to help clinicians on safer opioid deprescribing

Australian and international experts have released 11 recommendations on when, how, and in what situation it may be appropriate for clinicians to reduce opioid use, by placing the patient at the center of the equation.

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

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 and summary of the guidelines are published in the Medical Journal of Australia. The guidelines were led by 17 experts which includes general practitioners, pain specialists, addiction specialists, pharmacists, registered nurses, consumers, and physiotherapists.

The Evidence-based Guidelines for Deprescribing Opioid Analgesics is the first international guideline focused on helping general practitioners to safely reduce opioid use for adults with pain, and aims to improve quality of care for patients.

Opioids are commonly prescribed to manage pain, with over 1.9 million adults starting opioid therapies each year in Australia. Approximately five percent of patients who fill an opioid prescription transition to long-term use.

Senior author Associate Professor Danijela Gnjidic from the School of Pharmacy says opioid deprescribing may not be appropriate for every single person with emerging evidence that abruptly deprescribing opioids in patients, without support or pain management plans is associated with overdose related harms and death.

"It is possible to reduce opioid use and harms without worsening pain, while maintaining or even improving quality of life. However, pain management should not be one-dimensional," says Associate Professor Gnjidic.

"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 individualized care for patients."

Pain management should not be 'one size fits all'

"Opioids can be effective in pain management. However, over the longer-term, the risk of harms may outweigh the benefits," says fellow senior author Associate Professor Carl Schneider from the School of Pharmacy.

"Reducing the dose or discontinuing (deprescribing) opioids can be challenging, with additional complexity for Aboriginal and Torres Strait Islander Peoples and culturally and linguistically diverse communities. We received strong feedback on the need for specific resources for those communities on how to seek advice from healthcare professionals and be actively involved in decisions."

Lead author Dr. Aili Langford says the best available evidence that was interpreted and informed by expert opinion, and refined following extensive public consultation with healthcare professionals, organizations, policymakers and people who take opioids for pain.

"Internationally we were seeing significant harms from opioids, but also significant harms from unsolicited and abrupt opioid cessation. It was clear that recommendations to support safe and person-centered opioid deprescribing were required," says Dr. Langford, who worked on the report during her doctorate at the University of Sydney and is now based at Monash University.

Pain management a national and international priority

Pain and pain-related conditions are a leading cause of disability and disease burden globally. In Australia one in five adults report having chronic pain.

Escalating opioid use and subsequent harm has been recognized as an international public health concern. The World Health Organization has set a global goal of reducing severe avoidable medication related harms. In 2020, Australia responded by identifying opioids as one of the four medicines of focus in the country.

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.

"It is incredibly important that we prescribe opioids safely and appropriately so that we don't compromise the future health of Australians," says Associate Professor Liz Marles, Clinical Director at the Commission and a general practitioner.

"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.

"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," says Marles.