Deprescribing long-term opioid therapy in patients with chronic pain

Barriers and facilitators to opioid deprescribing among Advanced Nurse Practitioners: A qualitative interview study

AIM

To explore the experiences primary care Advanced Nurse Practitioners have had in relation to deprescribing opioids in chronic non-malignant pain.

DESIGN

A qualitative interview study.

METHODS

Primary care Advanced Nurse Practitioners were recruited from across the Northern Ireland GP Federations. Data collection for this study took place between April and June 2022. In total, 10 semi-structured online interviews were conducted. Interviews were audio and visually recorded, transcribed verbatim and interpreted using a thematic analysis framework. The COREQ criteria were used to guide the reporting of this study.

RESULTS

The Advanced Nurse Practitioners experienced several challenges associated with opioid deprescribing and the implementation of current chronic pain guidelines. The main barriers identified were difficulties engaging patients in deprescribing discussions, a lack of availability of supportive therapies and poor access to secondary care services. The barriers identified directly impacted on their ability to deliver best practice which resulted in a sense of professional powerlessness.

CONCLUSION

The experiences of the Advanced Nurse Practitioners demonstrate that opioid deprescribing in patients with chronic pain is challenging, and implementation of current chronic pain guidelines is difficult.

IMPACT

This study contributes to existing literature on the topic of reducing opioid prescribing and as far as the authors are aware, is the first study to examine the experiences of primary care advanced nurse practitioners in this context. These findings will be of interest to other primary care practitioners, and prescribers involved in the management of chronic non-malignant pain.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Opioid characteristics and nonopioid interventions associated with successful opioid taper in patients with chronic noncancer pain

ABSTRACT

Current research indicates that tapering opioids may improve pain and function in patients with chronic noncancer pain. However, gaps in the literature remain regarding the choice of opioid and nonopioid interventions to support a successful taper. This study used an Australian primary care data set to identify a cohort of patients on long-term opioid therapy commencing opioid taper between January 2016 and September 2019. Using logistic regression analysis, we compared key clinical factors associated with differing taper outcomes. Of a total of 3371 patients who commenced taper, 1068 (31.7%) completed taper within 12 months. In the 3 months after commencement of taper, compared with those who did not complete taper, patients who successfully completed opioid taper were less likely to be prescribed buprenorphine (odds ratio [OR] 0.691; 95% CI: 0.530-0.901), fentanyl (OR, 0.429; 95% CI: 0.295-0.622), and long-acting (LA) opioids, including methadone (OR, 0.349; 95% CI: 0.157-0.774), oxycodone-naloxone (OR, 0.521; 95% CI: 0.407-0.669), and LA tapentadol (OR, 0.645; 95% CI: 0.461-0.902), but more likely to be prescribed codeine (OR, 1.308; 95% CI: 1.036-1.652). Compared with those who did not complete taper, patients who successfully tapered were less likely to be prescribed any formulations of oxycodone (short-acting [SA]: OR, 0.533; 95% CI: 0.422-0.672, LA: OR, 0.356; 95% CI: 0.240-0.530) and tramadol (SA: OR, 0.370; 95% CI: 0.218-0.628, LA: OR, 0.317; 95% CI: 0.234-0.428). The type of opioid prescribed in the months after commencement of taper seems to influence the taper outcomes. These findings may inform prospective studies on opioid taper.

Trajectories of prescription opioid tapering in patients with chronic non-cancer pain: a retrospective cohort study, 2015-2020

OBJECTIVE

To identify common opioid tapering trajectories among patients commencing opioid taper from long-term opioid therapy for chronic non-cancer pain and to examine patient-level characteristics associated with these different trajectories.

DESIGN

A retrospective cohort study.

SETTING

Australian primary care.

SUBJECTS

Patients prescribed opioid analgesics between 2015 and 2020.

METHODS

Group-based trajectory modeling and multinomial logistic regression analysis were conducted to determine tapering trajectories and to examine demographic and clinical factors associated with the different trajectories.

RESULTS

A total of 3369 patients commenced a taper from long-term opioid therapy. Six distinct opioid tapering trajectories were identified: low dose / completed taper (12.9%), medium dose / faster taper (12.2%), medium dose / gradual taper (6.5%), low dose / noncompleted taper (21.3%), medium dose / noncompleted taper (30.4%), and high dose / noncompleted taper (16.7%). A completed tapering trajectory from a high opioid dose was not identified. Among patients prescribed medium opioid doses, those who completed their taper were more likely to have higher geographically derived socioeconomic status (relative risk ratio [RRR], 1.067; 95% confidence interval [CI], 1.001-1.137) and less likely to have sleep disorders (RRR, 0.661; 95% CI, 0.463-0.945) than were those who didn't complete their taper. Patients who didn't complete their taper were more likely to be prescribed strong opioids (eg, morphine, oxycodone), regardless of whether they were tapered from low (RRR, 1.444; 95% CI, 1.138-1.831) or high (RRR, 1.344; 95% CI, 1.027-1.760) doses.

CONCLUSIONS

Those prescribed strong opioids and high doses appear to be less likely to complete tapering. Further studies are needed to evaluate the clinical outcomes associated with the identified trajectories.

Deprescribing potential of commonly used medications among community-dwelling older adults: insights from a pharmacist's geriatric assessment

Pharmacist's geriatric assessment can provide valuable insights into potential deprescribing targets, while including important information on various health-related domains. Data collected from a geriatric assessment questionnaire, for 388 patients, from the Croatian cohort of the EuroAgeism H2020 ESR 7 international project, along with guideline-based deprescribing criteria, were used to analyse potentially inappropriate prescribing of four medication groups (benzodiazepines (BZN), proton pump inhibitors (PPI), opioids, and non-steroidal anti-inflammatory drugs (NSAID)), and to assess the deprescribing potential. Binary logistic regression was used to explore the effects of age, gender, number of medicines and diagnoses, self-reported health, frailty score, and healthcare utilization on the likelihood of needing deprescribing. More than half of participants (n = 216, 55.2%) are candidates for deprescribing, with 31.1% of PPI, 74.8% of NSAID, 75% of opioid, and 96.1% of BZN users meeting at least one criterion. Most common criteria for deprescribing were inappropriately long use and safety concerns. Women (aOR = 2.58; p < 0.001), those reporting poor self-reported health (aOR = 5.14; p < 0.001), and those exposed to polypharmacy (aOR = 1.29; p < 0.001) had higher odds of needing to have medicines deprescribed. The high rate of deprescribing potential warrants prompt action to increase patient safety and decrease polypharmacy. Pharmacist's geriatric assessment and deprescribing-focused medication review could be used to lead a personalised approach.

Dose Changes for Long-term Opioid Patients Following a State Opioid Prescribing Policy

BACKGROUND

In 2018, Nevada implemented opioid prescribing legislation (AB474) to support the uptake of CDC pain care guidelines. We studied the law's association with doses over threshold levels of morphine milligram equivalents (MMEs) and with time to dose increases and decreases, among long-term opioid patients.

METHODS

A difference-in-difference study examined dosing changes across opioid prescription episodes (ie, prescriptions within 30 day and within the same dosing threshold). Patients with at least 120 days supply over 6 months in Nevada and Colorado Medicaid pharmacy claims were included. Using a logistic regression model, we compare the predicted probabilities that opioid episodes exceeded 50 MME before and after implementation of the law, in both states. Adjusted hazard ratios (aHR) from a gap time survival model estimated time to escalate above 50 MME among low-dose episodes (<50 MME), and time to de-escalate below 50 MME among high-dose episodes (≥50 MME).

RESULTS

Among 453,577 episodes (74,292 patients), the Nevada law was associated with a 2.9% reduction in prescriptions over 50 MME (95% CI: -3.5, -2.3) compared with Colorado. While the law was also associated with slower escalation (Nevada: aHR = 0.75; 95% CI: 0.72, 0.77, Colorado: aHR = 1.04; 95% CI: 1.01, 1.06), it was also associated with slower de-escalation (Nevada: aHR = 0.87; 95% CI: 0.84, 0.89, Colorado: aHR = 0.97; 95% CI: 0.96, 0.99).

CONCLUSIONS

Slower dose escalations, rather than faster dose de-escalation, likely explain post-law reductions in doses over 50 MME. Slower dose de-escalations may be due to longer days supply post-policy.

Opioid deprescribing in patients with chronic noncancer pain: a systematic review of international guidelines

ABSTRACT

In response to the overuse of prescription opioid analgesics, clinical practice guidelines encourage opioid deprescribing (ie, dose reduction or cessation) in patients with chronic noncancer pain. Therefore, this study evaluated and compared international clinical guideline recommendations on opioid deprescribing in patients with chronic noncancer pain. We searched PubMed, EMBASE, PEDro, National Institute for Health and Care Excellence (United Kingdom), and MAGICapp databases from inception to June 4, 2021, with no language or publication restrictions. In addition, we searched the National Guideline Clearinghouse and International Guideline Network databases from inception to December 2018. Two independent reviewers conducted the initial title and abstract screening. After discrepancies were resolved through discussion, 2 independent reviewers conducted the full-text screening of each potentially eligible reference. Four independent reviewers completed the prepiloted, standardized data extraction forms of each included guideline. Extracted information included bibliographical details; strength of recommendations; and the outcomes, such as when and how to deprescribe, managing withdrawal symptoms, additional support, outcome monitoring, and deprescribing with coprescription of sedatives. A narrative synthesis was used to present the results. This study found that clinical practice guidelines agree on when and how to deprescribe opioid analgesics but lack advice on managing a patient's withdrawal symptoms, outcome monitoring, and deprescribing with coprescription of sedatives. Quality assessment of the guidelines suggests that greater discussion on implementation and dissemination is needed.

What are the research priorities for optimising the safe and effective use of opioids in Australian general practice?

INTRODUCTION

Persistent high rates of prescription opioid use and harms remain a concern in Australia, Europe and North America. Research priority setting can inform the research agenda, strategic responses and evidence-based interventions. The objective of this study was to establish research priorities related to the safe and effective use of prescription opioids in general practice.

METHODS

Consumers, clinicians and policy makers were invited to participate in a structured consensus workshop in May 2021. A modified nominal group technique was used to explore research priorities for the safe and effective use of opioids in Australian general practice. Research priorities were identified, consolidated and prioritised using a structured process.

RESULTS

Seventeen consumer, medical, pharmacy, nursing, allied health and policy participants generated 26 consolidated priorities across three domains: (i) consumer-focused priorities; (ii) clinician and practice-focused priorities; and (iii) system and policy-focused priorities. The highest ranked research priorities in each of the domains were consumer characteristics that influence opioid prescribing and outcomes, opioid deprescribing strategies, and system-level barriers to prescribing alternatives to opioids, in the consumer, clinician and practice, and system and policy domains, respectively.

DISCUSSION AND CONCLUSION

The priorities reflect opportunities for research priority setting within Australian general practice. The priorities provide a map for future qualitative and quantitative research that will inform safe and effective opioid prescribing.

Prescription of potentially addictive medications after a multilevel community intervention in general practice

OBJECTIVE

To evaluate the long-term effects of a multilevel community intervention to improve the quality of prescription practice of potentially addictive medications (PAMs).

DESIGN

We conducted a retrospective study, using anonymized data from the Norwegian prescription registry.

SETTING

Based on an initiative from the GPs in Molde Municipality in Norway, a multilevel community intervention was initiated by the municipal chief physician in 2018. The intervention targeted GPs, patients, and the public.

SUBJECTS

We retrieved prescription data from 26 of 36 GPs.

MAIN OUTCOME MEASURES

By using the standardized defined daily dose (DDD), we compared prescription of three groups of PAMs from before the intervention (2017) throughout the intervention in 2018, and through 2020 to determine long-term effects.

RESULTS

Three years after the intervention, the GPs in our study sample prescribed 26% less opioids, 38% less benzodiazepines, and 16% less z-hypnotics. Overall prescription of PAMs decreased by 27%. The number of individuals receiving at least 90 DDD of benzodiazepines and z-hypnotics were reduced from 9 to 7 and 34 to 24 per 1000, respectively. Also, the number of individuals receiving two and three PAMs concomitantly were reduced.

CONCLUSION

Addressing prescription practice among GPs in a community as a joint intervention, combined with addressing patients and the public may be a feasible method to obtain long-term reduction of PAM prescriptions.Key pointsNon-therapeutic prescriptions of potentially addictive medications (PAMs) are both a public health concern and a frequent challenge in general practice.A multilevel community intervention, targeting general practitioners, patients, and the public, led to 27% reduction in prescription of PAMs.Both the number of daily users and concomitant use of several PAMs were reduced.The reduction in prescription persisted for three years.

Appropriate use of tapentadol: focus on the optimal tapering strategy

OBJECTIVE

Due to its opioid and non-opioid mechanism of action, tapentadol is considered an atypical opioid with improved gastrointestinal tolerability versus traditional opioids. As for all opioid analgesics it is important to understand how to discontinue a treatment when it is not needed anymore. The aim of this article was to provide an overview of opioid therapy in non-cancer pain, with a specific focus on tapering of tapentadol in patients with chronic non-cancer pain, and suggestions on how to achieve tapering.

METHODS

Studies for this narrative review were identified via PubMed using a structured search strategy, focusing on management of chronic non-cancer pain with opioids, and the efficacy, tolerability, and pharmacology of tapentadol prolonged release. Publications were limited to English-language articles published within the last ∼10 years.

RESULTS

The review discusses the use and discontinuation of opioids in general, as well clinical data on discontinuation of tapentadol specifically. We provide a flow chart, which can be used by clinicians in the context of their own clinical experience to appropriately taper tapentadol in patients with chronic non-cancer pain. The flow chart can be easily tailored to individual patient characteristics, duration of tapentadol treatment, response to progressive dosage reduction, and likelihood of withdrawal symptom occurrence.

CONCLUSIONS

While tapentadol is associated with a low frequency of opioid withdrawal symptoms after abrupt discontinuation, use of a tapering strategy is prudent. Tapering strategies developed for opioids in general can potentially be safely individualized in tapentadol-treated patients, although research on tapering strategies for tapentadol is required.

Raising Awareness on the Clinical and Social Relevance of Adequate Chronic Pain Care

Appropriate pain care should be regarded as a right and effectively guaranteed to people with chronic pain (CP). Law 38, enacted in Italy in 2010, establishes the citizen's right not to suffer. Twelve years later, such right appears still disregarded in Italy and the current access to adequate pain care reveals significant shortcomings. In addition, a mismatch between CP-associated burden and the available healthcare resources in the framework of our national health system has been observed. This article gathers the perspectives of a Board of Italian anesthesiologists on the state of the art of CP management in Italy and aims at strengthening the scientific rationale and clinical relevance of pursuing the enforceability of the right not to suffer and at promoting widespread multidisciplinary care of patients with CP.

Evaluating acceptability and feasibility of a mobile health intervention to improve self-efficacy in prescription opioid tapering in patients with chronic pain: protocol for a pilot randomised, single-blind, controlled trial

INTRODUCTION

Opioid medications are no longer recommended as long-term therapy for chronic non-cancer pain, and many patients are advised to reduce or discontinue opioid medications. Many patients report difficulties in tapering opioid medications, necessitating supporting interventions. This protocol describes a pilot randomised controlled trial (RCT) to investigate the acceptability, feasibility and potential efficacy of a mobile health intervention to improve the opioid tapering self-efficacy of patients with chronic non-cancer pain.

METHODS AND ANALYSIS

The trial will be a single-blind (clinician, data collector and statistician-blinded) pilot RCT with two parallel arms. Forty adult patients with chronic non-cancer pain who are voluntarily reducing their prescribed opioid medications under medical guidance will be recruited from two tertiary pain clinics (Start date 25 August 2021). Participants will be randomly assigned to an intervention or control group. Both groups will receive usual care, including multidisciplinary pain management. In addition to usual care, the intervention group will receive a short informational and testimonial video about opioid tapering and will receive two specifically text messages per day for 28 days. The intervention is codesigned with patients and clinicians to provide evidence-based informational, motivational and emotional support to patients with chronic pain to taper opioid medications. Feasibility of the intervention and a future definitive RCT will be evaluated by measuring patient acceptability, delivery of the intervention, rates and reasons of exclusions and drop-outs, completion rates and missing data in the study questionnaires, and obtaining estimates for sample size determination. Potential efficacy will be evaluated by comparing changes in opioid tapering self-efficacy between the two groups.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by the Northern Sydney Local Health District (Australia). Study results will be published in peer-reviewed journals and presented at scientific and professional meetings.

TRIAL REGISTRATION NUMBER

ACTRN12621000795897.

Characteristics of opioid prescribing to outpatients with chronic liver diseases: A call for action

Background

Chronic liver disease (CLD) is among the strongest risk factors for adverse prescription opioid-related events. Yet, the current prevalence and factors associated with high-risk opioid prescribing in patients with chronic liver disease (CLD) remain unclear, making it challenging to address opioid safety in this population. Therefore, we aimed to characterize opioid prescribing patterns among patients with CLD.

Methods

This retrospective cohort study included patients with CLD identified at a single medical center and followed for one year from 10/1/2015-9/30/2016. Multivariable, multinomial regression was used identify the patient characteristics, including demographics, medical conditions, and liver-related factors, that were associated with opioid prescriptions and high-risk prescriptions (≥90mg morphine equivalents per day [MME/day] or co-prescribed with benzodiazepines).

Results

Nearly half (47%) of 12,425 patients with CLD were prescribed opioids over a one-year period, with 17% of these receiving high-risk prescriptions. The baseline factors significantly associated with high-risk opioid prescriptions included female gender (adjusted incident rate ratio, AIRR = 1.32, 95% CI = 1.14–1.53), Medicaid insurance (AIRR = 1.68, 95% CI = 1.36–2.06), cirrhosis (AIRR = 1.22, 95% CI = 1.04–1.43) and baseline chronic pain (AIRR = 3.40, 95% CI = 2.94–4.01), depression (AIRR = 1.93, 95% CI = 1.60–2.32), anxiety (AIRR = 1.84, 95% CI = 1.53–2.22), substance use disorder (AIRR = 2.16, 95% CI = 1.67–2.79), and Charlson comorbidity score (AIRR = 1.27, 95% CI = 1.22–1.32). Non-alcoholic fatty liver disease was associated with decreased high-risk opioid prescriptions (AIRR = 0.56, 95% CI = 0.47–0.66).

Conclusion

Opioid medications continue to be prescribed to nearly half of patients with CLD, despite efforts to curtail opioid prescribing due to known adverse events in this population.

A pharmacist-led intervention to improve the management of opioids in a general practice: a qualitative evaluation of participant interviews

Background Opioid prescribing has escalated, particularly long-term in chronic noncancer pain. Innovative models of care have been recommended to augment regulatory and harm-minimisation strategies and to review the safety and benefits of opioids for the individual patient. Medication stewardship and pharmacist integration are evolving approaches for general practice. Aim To explore enablers, barriers, and outcomes of a pharmacist-led intervention to improve opioid management in general practice, from the perspectives of general practitioners (GPs) and practice personnel. Method The study was part of a mixed-methods investigation into a general practice pharmacist pilot. Qualitative data relevant to opioids were analysed. Data from 13 semi-structured interviews were coded, analysed iteratively and thematically, and interpreted conceptually through the framework of Opioid Stewardship fundamentals proposed by the National Quality Forum. Results Seven themes and 14 subthemes aligned with stewardship fundamentals. Participants considered organisational policy, supported by leadership and education, fostered collaboration and consistency and improved practice safety. Patient engagement with individualised resources, 'agreements' and 'having the conversation' with the pharmacist enabled person-centred opioid review and weaning. GPs reported greater accountability and reflection in their practices, in the broader context of opioid prescribing and dilemmas in managing patients transitioning through care. Receiving feedback on practice deprescribing outcomes encouraged participants' ongoing commitment. Patient communication was deemed an early barrier; however, learnings were applied when transferring the model to other high-risk medicines. Conclusion Improved opioid management was enabled through implementing pharmacist-led coordinated stewardship. The findings offer a practical application of guideline advice to individualise opioid deprescribing.

Clinical factors associated with increased length of stay and readmission in patients with medication-related hospital admissions: a retrospective study

BACKGROUND

Adverse drug events (ADEs) remain a key contributor to hospitalisations, resulting in long hospital stays and readmissions. Information pertaining to the specific medications and clinical factors associated with these outcomes is limited. Hence, a better understanding of these factors and their relationship to ADEs is required.

OBJECTIVES

To investigate medications involved, clinical manifestations of ADE-related hospitalisations, and their association with length of stay and readmission.

METHODS

A retrospective medical record review of patients admitted to a major, tertiary referral hospital in NSW, Australia, from January 2019 to August 2020 was conducted. ADEs were identified using Australian Refined Diagnosis Related Group (AR-DRG) codes: X40, X61, X62 and X64. Medications were classified per the Anatomical Therapeutic Chemical (ATC) classification system and clinical symptoms were classified per the International Classification of Disease (ICD) 9-CM. Logistic regression was performed to assess the relationship between medication and presentation classes with length of stay (≥2 days vs <2 days) and readmission.

RESULTS

There were 125 patients who met inclusion criteria (median age = 64 [interquartile range, 45-75] years; 53.6% male). Anti-thrombotic agents, opioids, antidepressants, antipsychotics, insulins and NSAIDs were the most implicated pharmacological classes. Neurological medications and falls were associated with a length of stay ≥2 days (adjusted odds ratio [aOR] 3.92, 95% confidence interval [CI] 1.48-10.33 and aOR 3.24, 95% CI 1.05-10.06, respectively). Neurological medications and neurological and cognitive disorders were associated with an increased likelihood of 90-day readmission (aOR 2.63, 95% CI 1.05-6.57 and aOR 3.20, 95% CI 1.17-8.75, respectively).

CONCLUSION

This study identified neurological medications as high-risk for increased length of stay and readmission in those hospitalised due to ADEs. This highlights the need for judicious prescribing and monitoring of these medications.