Deprescribing Can Mean Fewer Opioids, More Grateful Patients

[Virginia McIntyre]

I have been invited to join a small working group regarding opioid reduction pilot project. Is anyone involved in a similar project?

[Carolyn Canfield]

Hi Virginia,

Although I'm not involved in this area, I just came across this topic in a favourite email newsletter for translating medical research into succinct clinical guidance.

Tools for Practice from the Alberta College of Family Physicians:

"Location, Location, Location: Treating patients with opioid use disorder in primary care", October 9, 2018

Clinical Question: How well is opioid agonist therapy managed in primary care?

Perhaps you'll find this interesting?

The short summaries are aimed at Family physicians, but usually patients can find them understandable. The authors (some of whom I know) are scrupulous about interpreting research findings accurately, including identifying reliability and remaining uncertainty.

I read the short reports in part to understand better "knowledge translation", the gap between new findings and present practice. Also it's useful to see the need for plain language communications.

You can sign up for these biweekly emails here.

Best regards, Carolyn

[Virginia McIntyre]

Hello Carolyn

The pilot project is in primary health care setting so this will help.

I read everything I can so thanks for this, I did not have it.

Thank you

Virginia

[Carolyn Canfield]

Hi again, Virginia. Just found another excellent resource. It's a recorded talk about an article on opioid tapering in the BMJ (formerly the British Medical Journal). Here is the link. Below is the introduction. One of the authors is at University of Toronto (other two from UK and Australia). BMJ Talk Medicine is open access, so no subscription is needed to listen.

Really glad to help out.

Best wishes, Carolyn

There is very little guidance on withdrawing or tapering opioids in chronic pain (not caused by cancer). People can fear pain, withdrawal symptoms, a lack of social and healthcare support, and they may also distrust non-opioid methods of pain management.

This can mean that patients receive repeat opioid prescriptions for extended periods of time.

In this podcast, Harbinder Sandhu, health psychologist in pain management at Warwick Medical School, Andrea Furlan, associate professor of medicine at University of Toronto, and Sam Eldabe, consultant in pain medicine at The James Cook University Hospital join us to set out the evidence on tapering opioids - and give practical advice on how to support patients. We're also joined by Colin, who was prescribed opioids for a decade, before he decided to reduce his usage.

What you need to know:

For people with chronic pain and who do not have cancer, the benefits of long term opioids are outweighed by the issues of tolerance, dependence, and the requirement for higher doses

Tapering is the gradual reduction of opioids with the aim of limiting withdrawal symptoms; it may target complete discontinuation of the opioid, or on occasion a reduction of the dose

It is not clear how best to support people to taper their opioids; whether it is best done by interdisciplinary pain management programmes, buprenorphine substitution, or behavioural interventions

Read the full uncertainties paper:
www.bmj.com/content/362/bmj.k2990

[Virginia McIntyre]

Thank you for this. I am listening to the talk now, it is informative.

Virginia

[Carolyn Canfield]

And yet another, this from the USA, a blog on IHI website. I hope it is useful.

Deprescribing Can Mean Fewer Opioids, More Grateful Patients

This Institute for Healthcare Improvement has an abundance of reading to introduce patient safety and improvement science to practitioners and students. Accessible style and good references to drill deeper make the content really great for patient advisors. However, there are sections closed except by subscription, so you may feel frustrated. Please get in touch with me, as many years ago I was given access -- it seems it's perpetual!! I'd be happy to share.

Best wishes, Carolyn

[Virginia McIntyre]

Hi Carolyn,

Would love to have access to full article. The first meeting is not till November so I have time.

My email is V.mcintyre14@hotmail.com

Thank you for your help with this.

Virginia

[Carolyn Canfield]

Hi Virginia,
I wasn't sure if you would encounter a subscription barrier. Happy to paste the blog post below. I will email a Word version of the blog and the 14-page case study (2017) as linked at the foot of the blog.

Interesting that this is an adaptation of a Canadian protocol to a US setting. The article is well written. Please share it with your team, if you think they would find it helpful.

Cheers, Carolyn

Deprescribing Can Mean Fewer Opioids, More Grateful Patients

By Leslie Pelton | Monday, September 10, 2018

Deprescribing means reducing or stopping medications that may no longer benefit or may harm a patient. In other words, by definition, it means taking something away that has previously been given. In the middle of the opioid epidemic, deprescribing now may arguably be more complicated than ever.

For example, many providers assume that prescribing fewer opioid medications for acute pain in the emergency department (ED) will lead to patients experiencing prolonged pain. Or more complaints. Or requests for more medications. Maybe we fear that we — and our colleagues, our teams, or our health systems — will not be able to handle these responses. Maybe we fear our patients will not be able to handle their pain without the opioids.

And, so, we do not deprescribe. But maybe it doesn’t have to be this way. Maybe some of our fears are unfounded. The experience of a team of ED physicians in Jacksonville, Florida, may surprise many.

According to Travis Smith, DO, of Ascension St. Vincent’s, “We started using a multimodal approach [in the ED] that involved prescribing opioids only as a last resort to help reduce the incidence of adverse events.” An early champion of deprescribing, Smith reports, “I received many thank you notes from my patients in the weeks and months following my first tests of deprescribing opioids, which validated our approach. This was, most likely, because I spent time with patients and their families explaining the reasons for deprescribing opioids and assuring them that our focus was on treating pain safely and effectively.”

Smith’s efforts were part of a targeted, patient-focused analgesic approach that supports utilization of non-opioid medication combinations. It involved a more judicious use of opioids to achieve better pain control, fewer side effects, and reduced dosing of individual medications.

Prior to developing their opioid deprescribing protocol, Ascension St. Vincent’s participated in community discussions about the opioid crisis. They administered Naloxone, the opioid reversal agent, when someone needed it. And they were like just about every other hospital using opioids as the main modality to manage pain.

“We knew we had to do our part to address the national opioid crisis,” said Florian Daragjati, PharmD, BCPS, then the pharmacy clinical manager at Ascension St. Vincent’s. “But, quite honestly, we did not know where to begin. In addition to being a national crisis, it was an issue that was truly affecting our own patients on a daily basis.”

Then, in 2017, Ascension St. Vincent joined the IHI International Innovations Network, funded by the Commonwealth Fund, and tested an approach to deprescribing that originated in Ottawa, Canada (deprescribing.org). “We were motivated by the [results of the] innovation from Canada and joined a network of US health systems to apply the Model for Improvement to test the innovation in their systems,” Daragjati reported. “The results were dramatic enough to lead Ascension to spread the practice across all its 150+ hospitals nationwide.”

Ascension St. Vincent reduced their use of opioids significantly over time with incrementally broader tests of change and involving more and more physicians as their belief in their results increased.

Ascension St. Vincent’s pain scores help to explain the thank you notes from patients. Pain scores improved as opioid use declined.

To learn more about how you might implement this approach in your health system, review the IHI Evidence-Based Medication Deprescribing Innovation Case Study.

Leslie Pelton is Senior Director for IHI Innovation and leads IHI’s Age-Friendly Health Systems initiative.

[Virginia McIntyre]

Thank you Carolyn.

I have scanned this, looks very informative. I will sit with it on the week end.

Virginia

[Carolyn Canfield]

Hi again, Virginia.

Here is a research systematic review, just published today by the Alberta College of Family Physicians' "Tools for Practice" newsletter.

"Clinical Question: Is buprenorphine (with or without naloxone) effective as maintenance therapy in pharmaceutical opioid use disorder?"

The evidence is weak but important to report, given high mortality and social impact. Negative and confusing results from trials are also critical to report, not just the successes!

I hope this is a useful contribution to your project group.

Best regards, Carolyn