August 31, 2020
New guidelines developed by the RACP’s Chapter of Addiction Medicine as part of the Evolve program, say that healthcare providers should seriously consider the impacts of opioid cessation before de-prescribing patients, as de-prescribing opioids can sometimes be more harmful than the side effects from the drug itself.
The recommendations are especially relevant in light of today’s International Overdose Awareness Day. The new recommendation states: Do not deprescribe or stop opioid treatment in a patient with concurrent chronic pain and opioid dependence without considering the impact on morbidity and mortality from discontinuation of opioid medications.
Royal Australasian College of Physicians spokesperson and President of the Chapter of Addiction Medicine Professor Nicholas Lintzeris said, “For a long-time the debate around opioids has been framed by the importance of de-prescribing opioid use – and there is strong evidence to support this approach. But we are also finding that in some cases, patients with chronic pain who get turned away from opioids are actually ending up in more harm.
“We need to recognise that some patients with long term opioid use can develop dependence to their medications – meaning they struggle to stop or reduce their use of opioids. This represents a minority of patients – perhaps no more than 10 or 20 per cent of patients using long term opioid medication for pain. Yet for these patients, stopping opioid medication can result in increased pain and mental health problems, reduced quality of life and suicide attempts.
“Some seek more dangerous sources of pain relief, such as illicit drugs, alcohol or polypharmacy, which can in turn result in accidental overdoses. Opioid dependence is a chronic, relapsing condition, and we cannot expect that all patients will easily transition to being opioid free.
“Our new recommendation asks physicians to weigh up the potential consequences of de-prescribing for each patient, and to tailor the treatment plan accordingly.
“Patients with features of opioid dependence require additional support, and we need to remove the stigma around opioid use and dependence. Whilst a trial of withdrawal from opioid medications should always be considered, for many, structured longer-term opioid medication as part of their treatment plan may be required, together with non-opioid approaches to pain management, and attention to comorbidities.
“Consultation with pain and addiction medicine specialists should be considered for patients who encounter difficulties controlling their use of opioid medications or have other substance use conditions.
“Physicians must act within the relevant legal framework for practice but there shouldn’t be undue pressure on doctors to stop opioid prescribing in patients who would otherwise be in chronic pain and are dependent on opioids.
“These recommendations have been developed to support clinicians in making decisions to ease the suffering of their patients in the context of ongoing pressures to deprescribe.”
The RACP, in partnership with the Australasian Chapter of Addiction Medicine, has launched the latest Evolve Top-5 recommendations on low-value practices.
Practitioners of all disciplines, not just addiction medicine specialists, will come across patients who experience substance addiction and may play a substantial role in their management.
Enhance the safety and quality of your care for people affected by addiction by using the latest RACP Evolve Top-5 recommendations. Learn more at evolve.edu.au/recommendations/AChAM.