BackgroundChronic prescription opioid use is a major international public health issue associated with significant harms, including increased risk of hospitalisation, morbidity and death. Guidance for healthcare professionals on when and how to deprescribe or reduce opioids is required. A key step for guideline development for deprescribing pharmacotherapy is to understand the perspectives of stakeholders. The aim of this study was to explore the perspectives of healthcare professional stakeholders on the challenges associated with opioid deprescribing and factors to be considered in the development of opioid deprescribing guidelines.MethodsA qualitative study was undertaken with a purposive sample of healthcare professionals including prescribers, pharmacists and nurses. An initial cohort of participants was identified at the 2018 Australian Deprescribing Network annual meeting and two focus groups were conducted (n=20). Individual interviews were conducted with a further 11 healthcare professionals. Focus groups and interviews were audio-recorded and transcribed verbatim. Data underwent inductive thematic analysis using a phenomenological perspective.ResultsHealthcare professionals viewed opioid deprescribing as a challenge and identified several key barriers to deprescribing in clinical practice. Medication, patient, prescriber and health system level challenges were identified. Participants requested evidence-based guidance on the withdrawal of opioid therapies and suggested that prospective opioid deprescribing guidelines require a multitarget, multimodal intervention strategy that addresses patient psychosocial factors and incorporates behavioural change techniques.ConclusionOpioid deprescribing was perceived as a complex and challenging practice with continued prescribing the default behaviour. Evidence-based opioid deprescribing guidelines may be a valuable resource for clinicians to support clinical decision-making and reduce suboptimal opioid use.

Deprescribing opioids has been identified as an intervention to mitigate opioid harm; however, it is often challenging to implement interventions and communicate deprescribing decisions to consumers. The development of opioid deprescribing guidelines may provide guidance and support on when and how to reduce or cease opioids in routine care. This study aimed to explore the perspectives of opioid consumers on opioid deprescribing and determine factors to be considered in the development of opioid deprescribing guidelines. A purposive sample of 20 consumers using opioids for pain was recruited. Semistructured interviews were conducted, audio recorded, and transcribed verbatim. Inductive thematic analysis was undertaken, followed by a framework analysis informed by Bandura's Social Cognitive Theory. Behavioral, cognitive, and environmental factors influence consumers' attitudes and actions regarding opioid deprescribing. Significant barriers to opioid deprescribing were identified, including fears of pain and withdrawal effects, opioid-related stigma, and perceived inadequacies of the healthcare system. Improved communication between healthcare professionals and consumers regarding expectations of deprescribing and goals of care, as well as the provision of greater opportunities for consumer engagement in decision making were identified as avenues to improve the success of opioid deprescribing. For opioid deprescribing guidelines to be effective and achieve the intended goal of optimizing opioid use, consumers need to feel empowered to engage in opioid reduction or cessation. The findings of this study may facilitate a patient-centred approach for practitioners and guideline developers in creating recommendations and interventions to enable opioid deprescribing through targeting behavioral change.

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Background Caregivers often undertake medication management for people living with dementia without formal training. There is a need to evaluate caregiver medication management practices for people living with dementia to identify and address the key issues that contribute to caregiver burden. Objectives This study aimed to identify and summarize approaches that evaluate medication management for caregivers of people living with dementia and appraise caregiver's involvement in aspects of medication management. Search Strategy A systematic search was undertaken in five databases: Medline, Embase, PsycINFO, Scopus and International Pharmaceutical Abstracts. Studies written in English that contained tools and surveys that evaluated aspects of medication management for caregivers of PWD were included. Results A total of 10 studies were included. Medication selection was assessed in six studies, supply and monitoring/review was captured in seven studies, with administration assessed in nine studies. Caregivers were commonly involved in decision‐making for medication changes (77.1%–86.8%) and in the ordering (55.9%–86.0%) and collection (87.0%–92.4%) of medications. Reported caregiver involvement in medication administration showed a wide range (44%–94.7%) between the studies. Challenges in administration were commonly related to polypharmacy and dosage regimen complexity. Conclusions Current tools capture specific aspects of medication management, with medication administration the most evaluated aspect of medication management. Future research is needed to develop a tool to holistically evaluate the complexities of medication management for caregivers of people living with dementia to minimize adverse events at transitions of care. Public Contribution From the authors' previous research, caregivers highlighted the need to address key issues in medication management for people living with dementia.

Introduction Long term opioids are commonly prescribed to manage pain. Dose reduction or discontinuation (deprescribing) can be challenging, even when the potential harms of continuation outweigh the perceived benefits. The Evidence‐based clinical practice guideline for deprescribing opioid analgesics was developed using robust guideline development processes and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, and contains deprescribing recommendations for adults prescribed opioids for pain. Main recommendations Eleven recommendations provide advice about when, how and for whom opioid deprescribing should be considered, while noting the need to consider each person's goals, values and preferences. The recommendations aim to achieve: implementation of a deprescribing plan at the point of opioid initiation; initiation of opioid deprescribing for persons with chronic non‐cancer or chronic cancer‐survivor pain if there is a lack of overall and clinically meaningful improvement in function, quality of life or pain, a lack of progress towards meeting agreed therapeutic goals, or the person is experiencing serious or intolerable opioid‐related adverse effects; gradual and individualised deprescribing, with regular monitoring and review; consideration of opioid deprescribing for individuals at high risk of opioid‐related harms; avoidance of opioid deprescribing for persons nearing the end of life unless clinically indicated; avoidance of opioid deprescribing for persons with a severe opioid use disorder, with the initiation of evidence‐based care, such as medication‐assisted treatment of opioid use disorder; and use of evidence‐based co‐interventions to facilitate deprescribing, including interdisciplinary, multidisciplinary or multimodal care. Changes in management as a result of these guidelines To our knowledge, these are the first evidence‐based guidelines for opioid deprescribing. The recommendations intend to facilitate safe and effective deprescribing to improve the quality of care for persons taking opioids for pain.

We commend Hallvik et al. 4 on their recent cohort study of Oregon Medicaid recipients on high-dose chronic opioid treatment, in which an increased risk of serious patient harms after both opioid continuation and discontinuation was observed. The increased incidence of suicide and illicit opioid use after opioid reduction is concerning, as is the increased risk of fatal overdose for individuals with stable or increasing opioid doses.As outlined in the article, patients on chronic opioid therapy require careful risk assessment and supportive interventions when considering opioid discontinuation or deprescribing, to minimise the risk of serious harm. The reality of clinical practice means that this is not always the case, and significant barriers to successful opioid deprescribing have been identified by both healthcare professionals 5 and patients. 6 Barriers to opioid deprescribing may be further exacerbated by the fact that healthcare professionals and patients have differing perspectives and priorities in goals of care. Differing expectations support the authors' recommendation for healthcare professionals to consider opioid deprescribing in partnership with patients to optimise outcomes. 4 We note that the authors have stated that "even when dose reduction is the best identified clinical course, clinical caution is merited". 4 We agree that there may be insufficient guidance readily available to clinicians regarding the parameters of caution and the factors that need to be considered during the deprescribing process. The authors refer to the Centers for Disease Control guideline 2 for prescribing opioids for chronic pain and the unintended consequences of the applications of these guidelines in the context of inciting involuntary and inappropriate opioid tapering. 4 It is likely that clinicians were exercising clinical caution when attempting to comply with these prescribing guidelines, potentially resulting in unintended harms. Conversely, studies such as the present one from Hallvik et al. can increase the reluctance of clinicians to engage in opioid deprescribing with their patients, in fear of causing harm. This further highlights the need for specific guidance for clinicians on when and how to stop opioids.To aid the efforts of supporting deprescribing in clinical practice, a deprescribing guideline framework has been established by the Bruy ère Deprescribing Guidelines Research Team in Canada, with guidelines developed for a range of drug classes. 3 We are currently in the process of finalising evidence-based opioid deprescribing guidelines in Australia. 1 We hope that these guidelines and resources to support clinicians in opioid tapering discussions, 7 can directly address difficulties encountered when opioid tapering through promotion of shared decision-making processes and improvements in prescriber and patient deprescribing self-efficacy.The development and effective implementation of evidencebased deprescribing guidelines is one strategy to encourage a more collaborative and evidence informed appro...

BackgroundDeprescribing (reduction or cessation) of prescribed opioids can be challenging for both patients and healthcare professionals.ObjectiveTo synthesize and evaluate evidence from systematic reviews examining the effectiveness and outcomes of patient‐targeted opioid deprescribing interventions for all types of pain.MethodsSystematic searches were conducted in five databases with results screened against predetermined inclusion/exclusion criteria. Primary outcomes were (i) reduction in opioid dose, reported as change in oral Morphine Equivalent Daily Dose (oMEDD) and (ii) success of opioid deprescribing, reported as the proportion of the sample for which opioid use declined. Secondary outcomes included pain severity, physical function, quality of life and adverse events. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.FindingsTwelve reviews were eligible for inclusion. Interventions were heterogeneous in nature and included pharmacological (n = 4), physical (n = 3), procedural (n = 3), psychological or behavioural (n = 3) and mixed (n = 5) interventions. Multidisciplinary care programmes appeared to be the most effective intervention for opioid deprescribing; however, the certainty of evidence was low, with significant variability in opioid reduction across interventions.ConclusionsEvidence is too uncertain to draw firm conclusions about specific populations who may derive the greatest benefit from opioid deprescribing, warranting further investigation.

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