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Deprescribing opioids in people with chronic pain: part four

Discussing deprescribing
A complex process

module menu icon A complex process

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module menu icon A complex process

A complex process

Looking at the steps

Step 1 Step 2 Step 3

Step 1: Identifying appropriate patients 

The principles of opioid stewardship require the evaluation of opioid use to support and protect human health. Anyone receiving an opioid prescription should have a regular review to ensure their use remains appropriate, weighing up the benefits of likely efficacy versus current side effect burden. 

NICE [NG193] advises that healthcare professionals should not initiate opioids in the treatment of chronic primary pain, as there is insufficient evidence for their efficacy. They also advise that healthcare professionals should aim to deprescribe opioids in those established on opioids for chronic primary pain, if the patient reports little benefit or significant harm.6 

The Faculty of Pain Medicine advises a more pragmatic approach, stating that some people may achieve good pain relief with opioids in the long-term if the dose can be kept low and if use is intermittent, but note that it is difficult to identify those people at the point of opioid initiation.7

The risk of harm increases substantially at doses above an oral morphine equivalent (OME) of 120mg/day, but there is no increased benefit. If a patient has pain that remains severe despite opioid treatment, then the opioids are not working and should be stopped, even if no other treatment is available – however, tapering or stopping needs careful planning and collaboration.9 

The NHS Business Services Authority (NHSBSA) has produced an opioid comparator tool that highlights how many patients are taking these medicines, and identifies those potentially most in need of support to improve the way their pain is managed.6 

Step 2: Initiating a conversation with the person 

The next step is to share this information with the person concerned using a joint decision-making approach. The aim as a pharmacy professional is to provide information about the risks, benefits and potential consequences of opioid use specific to the person, as well as to listen to their perspective and experiences. 

Conversation around this topic may be difficult and each person will be different. However, there are several useful things you can consider when planning a conversation around opioid deprescribing, including: 

  • Considering how the conversation will come about
  • Establishing the person’s current opioid use – accept this and do not express any judgement
  • Exploring their thoughts about their opioid medication. Do they think it helps? Do they think they have any side effects? 
  • Exploring their thoughts about reduction 
  • Being aware of any coexisting conditions that may complicate the reduction, especially mental health issues
  • Exploring and identifying their goals and values 
  • Determining whether the person has any experience of reducing their dosage
  • Sharing reasons for deprescribing, for example, lack of efficacy or side effects associated with long-term use
  • Sharing the expected benefits of reducing the dosage and/or deprescribing
  • Discussing that if the opioids are not being effective, they should be discontinued, even if there is no other medicine to offer
  • Encouraging the person to share any concerns they have
  • If any specific barriers are identified, working together to find solutions 
  • Working together to explore other treatment options, including behavioural therapies 
  • Considering how to communicate with other healthcare teams involved in the person’s care.

Consider whether the opioids are meeting the patient’s needs or whether they are exposing them to greater risk of serious side effects, or to developing opioid use disorder. Ask the question: do the benefits outweigh the risks? Each decision must be based on the individual patient’s situation.

Step 3: Producing a reduction plan 

When a person has made the decision to move forward with opioid reduction, you can come to a shared decision about their opioid reduction strategy. General principles:

  • Individualise the reducing schedule 
  • Consider the duration of therapy and the person’s preference for speed of reduction 
  • If deprescribing for a person on a transdermal opioid patch, reduce to the lowest tolerable patch strength, then consider switching to an alternative oral modified release (MR) opioid to continue deprescribing with frequent monitoring10 
  • Consider ease of access to medication for prescription changes 
  • If the person is anxious about how they might cope with an increase in their pain, or if they are concerned about experiencing withdrawal, then make a very small reduction initially in order to build their confidence in the process
  • Reductions can be made either in the dose taken or through increasing the interval between doses
  • Discuss the possibility of withdrawal 
  • Provide ongoing support to monitor progress 
  • Recognise any reduction in dose as a success
  • Consider if the person would benefit from contact with other services
  • Signpost to any useful resources, e.g., Flippin’ Pain and Live Well with Pain 
  • Be realistic about outcomes.
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