Change and risk
Behaviour change
Motivational interviewing (MI) is an empathetic and supportive counselling style that encourages and strengthens a person’s motivation for change. MI uses a guiding style to engage a person, clarify their strengths and aspirations, evoke their own motivations for change, and promote autonomy in decision making. Research shows that MI techniques lead to greater participation in treatment and more positive treatment outcomes.4
Any pharmacy professionals who are involved in opioid deprescribing should familiarise themselves with the MI approach. Integrating these techniques into practice may help to support patients through this complex process.
Risks
The process of deprescribing carries risks in addition to withdrawal, which makes the process particularly complex and delicate. These include:
- An increased risk of drug overdose. This can be intentional or unintentional. If dose reductions are too rapid, a person may take a previously tolerated dose (or resort to non-prescribed opioids), which could increase the risk of overdose, as you lose tolerance to opioids
- Mental health complaints such as depression, anxiety or suicidal ideation.
These risks can be reduced through slowing down the rate of dose reduction, and carrying out frequent monitoring and regular follow-ups, especially if there is a psychiatric history or previous suicide attempts. It is essential to explain loss of tolerance to the patient, as this reduces the risk that they will ‘top up’ when they feel like their current dose (including for breakthrough pain when required) is not controlling their pain or preventing withdrawal.5,6
Conversations about withdrawal
When discussing the possibility of withdrawal, it’s important to:
- Explain that withdrawal is a physiological response by the body and not something the person can control, as this can often feel discouraging during the process of deprescribing
- Outline possible symptoms and the likely timeframe
- Highlight that pain can feel worse as part of withdrawal; it is important to emphasise that this is not a sign of what their pain will be like at the lower dose – once withdrawal has settled, they will then be able to properly assess what the pain is like at the new dose
- Discuss possible management options, sharing that no effective pharmacological options have been found for most symptoms, and that psychological approaches have been found to be more effective
- Share some ideas on how to respond to withdrawal, and discuss how being prepared for withdrawal is likely to improve the chances of persevering when the process becomes difficult
When there are recurrent withdrawal symptoms, discuss the possibility of reverting to the previous lowest dose tolerated with a view to revisiting after six to 12 weeks with a smaller reduction rate.7