‘A very challenging space’: Opioid deprescribing guide released

Jolyon Attwooll

26/06/2023 3:14:35 PM

Work for guidelines was led by researchers at the University of Sydney and includes 11 recommendations with general practice in mind.

Woman taking opioid tablet
Around 1.9 million Australians are initiated on opioids every year.

New guidelines aimed at helping GPs decide when and how to deprescribe opioid analgesics have been published.
The guidance, which authors describe as the first international guideline focused on opioid deprescribing, includes 11 recommendations, leading with the suggestion that clinicians have a deprescribing plan in place from the moment opioid treatment starts.
Another recommendation advises opioids not to be deprescribed for patients near the end of life unless there are side effects.
The study was published in the Medical Journal of Australia (MJA) today (26 June), with authors describing input from GPs, pain specialists, addiction specialists, pharmacists, registered nurses, consumers and physiotherapists.
Associate Professor Liz Marles, a former RACGP President, and a current clinical director at the Australian Commission on Safety and Quality in Health Care (ACSQHC), says the guidelines are timely for GPs.
‘We all have patients who are in pain, who really want pain relief and expect a tablet to be part of that,’ she told newsGP.
‘It’s a very challenging space.
‘I know GPs want to have evidence-based guidance, and these guidelines are providing that.’
The guidance details the tools at the disposal of general practice for deprescribing, as well advice on messaging to use with patients, the approach to deprescribing and when it should be done.
For Associate Professor Marles, one of the key points is having a deprescribing process outlined from the beginning, citing the process involved for those prescribed opioids for post-operation pain relief.
‘Two and a half million people have operations each year, and they’re often commenced on opioids at that point,’ she said.
‘At the same time as they’re commenced, they should have a weaning plan, which as GPs we should be receiving in the discharge summary.
‘We should expect a discharge summary if someone’s had surgery and they’ve been commenced on an opioid, that there is a clear weaning plan for the GP to follow, and that the patient is also informed.’
Lead author Dr Aili Langford told InSight+ that recent studies indicate opioid deprescribing can be put in place without compromising pain management.
‘One of the main takeaways is that evidence suggests that it is possible to reduce opioid use without worsening pain, while maintaining or even improving function and quality of life,’ she said.

‘However, opioid deprescribing is complex and there is no one-size-fits-all solution.
‘Opioid deprescribing may not be appropriate for everyone and accordingly, the guideline also offers recommendations about when not to deprescribe.
‘A key component of this guideline is its emphasis on person-centred care and shared decision making between prescribers and patients to support safe and effective opioid deprescribing.’
Another author, Associate Professor Danijela Gnjidic from the University of Sydney’s School of Pharmacy, said the guidelines address a gap. 
‘Internationally we were seeing significant harms from opioids, but also significant harms from unsolicited and abrupt opioid cessation,’ she said.  
‘It was clear that recommendations to support safe and person-centred opioid deprescribing were required.
‘Before the release of the guidelines, in Australia, clinical guidelines have focused on pain management and prescribing of opioids.’
Around 1.9 million people in Australia are prescribed opioid-based therapies each year according to a 2019 study published in the British Journal of Pharmacology.
Approximately three million adults use opioids each year, the same study indicates, with authors expressing concern over the impact.
‘The initiation of strong opioids has increased, reinforcing concerns about increased use and the harms associated with strong opioids in the community,’ they wrote.
An estimated 5% of patients prescribed opioids end up using them long term, with around four in five of those taking opioids for three months or longer experiencing adverse effects, according to a 2004 study cited in MJA.
The harm long-term opioid use can cause has been flagged as an international public health concern by the World Health Organization (WHO).
In 2020, the ACSQHC identified opioids as one of four medicines to focus on to reduce medication-related harms in Australia in its publication, Medication without Harm.
In the MJA article published this week, authors say there is currently ‘a lack of accessible pain management services’ and expressed concern that ‘limited resources’ could act as a barrier for the guidelines to be put in place.
They wrote that increased funding and coverage for non‐pharmacological pain management treatments, as well as improved access to medication‐assisted treatment for individuals with opioid use disorder, and reimbursable time for patient counselling could help address those barriers.
They also advocated ‘payment models that improve geographical and financial access to multidisciplinary, interdisciplinary or multimodal coordinated care’.  
The authors acknowledge that some of the guideline’s recommendations are based on low certainty evidence and advise that ‘additional high certainty evidence is needed to strengthen existing recommendations and inform future recommendations’.
The RACGP has guidelines for prescribing opioids available on its website.
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Dr Peter James Strickland   27/06/2023 11:08:34 AM

Reducing opioids in patients is largely dependent on the patients themselves. The secret is to review them frequently, and adjust dose on the subjective and objective parameters at each consultation. Having been a methadone prescriber for years there is NO guideline to follow, apart from the patient and doctor's perception of how things are going. Opioid addicts are deceptive and manipulative by nature, and tend to take a higher dose than recommended, if allowed. The best controllers of opioid dose I have seen are children with iv lines, and who seem to be excellent with the dose they give themselves for advancing intermittent severe pain, and only naive adult patients to opioids after surgery etc are good at controlling and reducing their dose on any guideline, and simply because they want to avoid addiction. Terminal patients should be free to take the dose they need for quality of life, and without restriction. It is all up to the attitude of the patient and doctor!