Opioids, deprescribing, and the management of medicine-related harm

In Australia, about 400,000 people go to emergency departments each year because of medication problems, with at least half of this harm deemed preventable.

On a more granular level, opioids are Australia’s most common drug class identified in toxicology for drug-induced deaths, with deaths and hospitalisations due to opioid poisoning far more common from legally prescribed opioids such as codeine and oxycodone than the illegal variety, such as heroin.

The issue of medicine-related harm is immense, and how to tackle it is an area of growing interest to governments and healthcare systems alike.

At Monash University, researchers from the Centre for Medicine Use and Safety, which sits within the Monash Institute of Pharmaceutical Sciences, have been concentrating their efforts on how to address Australia’s opioid problem and, more broadly speaking, how best to “deprescribe” or taper prescribed medications that may be harmful or unnecessary. This might include opioids; however, deprescribing applies to many classes of medications.

An article by Caroline Sirois, CADeN member and professor at Laval University’s Faculty of Pharmacy, gives a simple overview of polypharmacy, its risks and 3 potential strategies to avoid them.

This article is written for a lay audience and is a great resource to raise awareness… pic.twitter.com/pLsBABsXVK

— CADeN (@DeprescribeNet) July 16, 2024

Educational intervention is needed

Writing in The Canberra Times in June, CMUS researcher Dr Justin Turner called for a direct-to-patient education campaign regarding opioids, drawing his evidence from a new Canada-based randomised controlled trial he led.

In the trial, people who had opioid medications dispensed from their pharmacy for more than three months were mailed educational brochures, resulting in reduced opioid use and deaths from all causes.

In the opinion piece, Dr Turner highlights that even though Australia’s regulatory regime was making concerted efforts to reduce harm, more had to be done.

“Ongoing public education should be at the forefront of Australia’s strategy to ensure patients receive the best treatments to manage pain, while making sure the harms caused by opioids in the US do not happen here.”

Ninety Americans die by opioid overdose every day, on average, usually young or middle-aged adults, in an opioid crisis that has been partly attributed to aggressive tactics by pharmaceutical companies.

“America’s opioid crisis is one of the most significant public health catastrophes of our time, and while Australia has made concerted efforts to avoid this level of detrimental damage, more can be done,” Dr Turner wrote.

In Australia it’s more frequently described as “the crisis of misuse versus appropriate use”, and Dr Turner says for some using opioids for pain at their lowest effective dose makes sense, but many people may not need opioids at all.

“It’s important to note that the aim of our study was not to stop everyone from taking opioids, but rather to spark conversation between patients and healthcare professionals about an individual's pain management strategy … to reach those where opioids are not providing adequate pain relief, or where the adverse effects outweigh the benefits, and provide them with better strategies for managing their pain.”

What else is being done to tackle the opioid issue?

In August 2023, Lens reported on the recently developed Guideline for Deprescribing Opioid Analgesics, based on research on the best way to reduce opioid doses, and led by Dr Aili Langford, Dr Emily Reeve, and others from both Monash University and the University of Sydney.

Clinical practice guideline for deprescribing opioid analgesics: summary of recommendations https://t.co/R7GGvyKRqs

— MJA (@theMJA) December 28, 2023

Learning from the harms observed in the US, and acknowledging challenges faced by people who take opioids for pain management, the researchers said these guidelines have quite a different focus.

The new guideline specifically recommends that opioids be tapered gradually, and that doctors make plans alongside their patients, which consider their goals and preferences.

Importantly, the guideline recognises that stopping opioids is not for everyone.

While studies looking at the guideline’s impact aren’t yet complete, this guideline is a critical step toward helping healthcare providers and patients create a personalised plan to help people safely taper off opioids.

What about other medications?

Meanwhile, CMUS researchers have also led a study now published in the British Medical Journal (BMJ) Quality and Safety revealing, alarmingly, that 71% of clinical practice guidelines do not contain any guidance on deprescribing – the process by which people and their healthcare providers work together to reduce the dose of a medication, or work toward stopping altogether.

The study looked at guidelines from Europe, North America, Australia, Asia, and Africa published in the past 10 years.

Co-first author Dr Aili Langford says medicines are important and necessary for treating and preventing diseases, along with improving symptoms, but the review shows a huge omission in clinical practice guidelines internationally – a universal trend.

Clinical practice guidelines are designed to help those dealing with patients in the health system diagnose, treat and prescribe. Dr Langford believes in many cases, deprescribing can be as important as prescribing. Only 29% of guidelines examined contained recommendations about deprescribing, and many guidelines did not contain recommendations about how to deprescribe.

The Australian reported on the international study, saying it was “clear” some medicines such as opiates and benzodiazepines are overused and can be addictive, and linked to another of its reports on the “extreme difficulty” some patients experience while trying to stop taking more common medications such as selective serotonin reuptake inhibitors (SSRIs) for depression or anxiety, or both. One in seven Australians is taking an SSRI medication daily.

Senior author and Chair of the Australian Deprescribing Network (ADeN), Dr Emily Reeve, says the team is conducting ongoing research to help determine how it can best-support the development of actionable and evidence-based deprescribing recommendations.

“While more comprehensive deprescribing recommendations may facilitate the implementation of deprescribing in practice, there remains a need for recommendations to be simple and digestible,” Dr Reeve says.

“Guideline language, for example, is integral – recommendations should be uncomplicated, clear and persuasive. Although clinician expertise and discretion can be used to bridge the gap between recommendations and practice, in the absence of clear deprescribing recommendations, there’s concern that recommendations will be misapplied, leading to unintended harm.”

Dr Langford says the potential benefits and harms of medicines can change over time as a person ages, acquires new medical conditions, takes new medicines, and changes their care goals.

“Therefore, medicines should be regularly reviewed to make sure they’re still of benefit, and not causing harm. If recommendations are unclear, they’re unlikely to be implemented as intended.”

Previous research has suggested prescribers want more information on when and how to safely and effectively deprescribe.