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Deprescribing Opioids in Chronic Non-cancer Pain: Systematic Review of Randomised Trials

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A Correction to this article was published on 29 September 2020

This article has been updated

Abstract

Background

Deprescribing, the process of reducing or discontinuing unnecessary or harmful medicines is an essential part of clinical practice.

Objective

To evaluate the efficacy of interventions designed to deprescribe opioid analgesics for pain relief in patients with chronic non-cancer pain.

Methods

We searched electronic databases, including clinical trial registries, from database inception to 13th January 2020 without restrictions, and conducted citation tracking. Our systematic review included randomised controlled trials (RCTs) evaluating interventions reducing the prescription, or use of opioid analgesics in patients with chronic pain versus control. Inventions could be aimed at the patient, clinician, or both. We excluded trials enrolling patients with cancer or illicit drug use. Two authors independently screened and extracted data. Outcome follow-up timepoints were short (≤ 3 months), intermediate (> 3 but < 12 months) or long (≥ 12 months) term. Primary outcome was the reduction in opioid dose [morphine milligram equivalent (MME) mg/day]. Methodological quality was assessed using the Cochrane Risk of Bias Tool.

Results

We included ten patient-focused RCT interventions (n = 835; median 37 participants) and 2 testing clinician-focused interventions (n = 291 clinicians); none at low risk of bias. Patient-focused interventions did not reduce opioid dose in the intermediate term [e.g. dose reduction protocol, mean difference (MD) − 19.9 MME, 95% CI − 107.5 to 67.7], nor did they increase the number of participants who ceased their dose, or increase the risk of serious adverse events or adverse events. One clinician intervention of education plus decision tools versus decision tools alone reduced the number of opioid prescriptions (risk difference (RD) − 0.1, 95% CI − 0.2 to − 0.1), dose (MD − 5.3 MME, 95% CI − 6.2 to − 4.5) and use (RD − 0.1, 95% CI − 0.1 to − 0.0) in the long term.

Limitations

Study heterogeneity prevented meta-analysis.

Conclusion

The small number of studies and heterogeneity prevented firm conclusions to recommend any one opioid-analgesic-deprescribing strategy in patients with chronic pain.

Systematic review registration number

PROSPERO CRD42017068422.

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Change history

  • 29 September 2020

    Page 9, Fig. 2, which originally appeared as.

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Acknowledgements

SM holds a Health Professional Research Early Career Fellowship (APP1158463) from Australia’s National Health and Medical Research Council. CM holds a Principal Research Fellowship (APP 1103022) from Australia’s National Health and Medical Research Council, GF holds a PhD scholarship from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) Brazil (88881.127942/2016-01). JJ holds a Career Development Fellowship (APP1162149) from Australia’s National Health and Medical Research Council. CL holds a Career Development Fellowship (APP1061400) from Australia’s National Health and Medical Research Council.

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Authors and Affiliations

  1. Institute for Musculoskeletal Health, Level 10 North, King George V Building, Missenden Road, Camperdown, Sydney, Australia

    Stephanie Mathieson, Christopher G. Maher, Giovanni E. Ferreira, Melanie Hamilton & Chung-Wei Christine Lin

  2. Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia

    Stephanie Mathieson, Christopher G. Maher, Giovanni E. Ferreira, Melanie Hamilton, Jesse Jansen & Chung-Wei Christine Lin

  3. Sydney Health Literacy Lab, ASK-GP Centre for Research Excellence, Sydney, Australia

    Jesse Jansen

  4. Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia

    Andrew J. McLachlan

  5. Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL, UK

    Martin Underwood

  6. University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK

    Martin Underwood

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  1. Stephanie Mathieson
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Contributions

All authors contributed to the review design. The search was performed by Stephanie Mathieson. Screening was conducted by Stephanie Mathieson, Giovanni Ferreira, Melanie Hamilton. All authors contributed to data collection, analysis and interpretation. The first draft of the manuscript was written by Stephanie Mathieson. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Stephanie Mathieson.

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Funding

SM and JJ received funding from the Sydney Medical School, The University of Sydney, from a Public Health Research Collaboration Scheme to assist in data extraction to the value of $4000.

Conflict of interest

SM, GF, MH, JJ report no conflicts of interest. CM is funded by an NHMRC Senior Research Fellowship. He is chief investigator or co-investigator on multiple previous and current research grants from government agencies and charities in Australia and internationally. He has received travel expenses for speaking at conferences from the professional organisations hosting the conferences. He is an investigator on the SHaPED trial which received heat wraps at no cost from Flexeze. AM has received untied research funding from GlaxoSmithKline to the Sydney Pharmacy School for a postgraduate student scholarship under his supervision. MU is chief investigator or co-investigator on multiple previous and current research grants from the UK National Institute for Health Research, Arthritis Research UK and is a co-investigator on grants funded by the Australian NHMRC; he is an NIHR Senior Investigator. MU has received travel expenses for speaking at conferences from the professional organisations hosting the conferences. MU is a director and shareholder of Clinvivo Ltd that provides electronic data collection for health services research and is part of an academic partnership with Serco Ltd related to return to work initiatives. MU is a co-investigator on two NIHR funded studies receiving support in kind from Stryker Ltd. MU has accepted honoraria for teaching/lecturing from CARTA; was an editor of the NIHR journal series, and a member of the NIHR Journal Editors Group, for which he received a fee; and a co-investigator on an NIHR funded trial of opioid withdrawal ISRCTN49470934.

Data availability

All data generated or analysed during this study are included in this published article (and its supplementary information files).

Ethics approval

No ethics approval required.

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Not applicable.

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Not applicable.

Code availability

Not applicable.

Additional information

The original version of this article was revised: Due to Figure 2 update.

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Mathieson, S., Maher, C.G., Ferreira, G.E. et al. Deprescribing Opioids in Chronic Non-cancer Pain: Systematic Review of Randomised Trials. Drugs 80, 1563–1576 (2020). https://doi.org/10.1007/s40265-020-01368-y

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