"The Lesser of Two Evils": A Framework Analysis of Consumers' Perspectives on Opioid Deprescribing and the Development of Opioid Deprescribing Guidelines

Aili V. Langford; Danijela Gnjidic; Chung-Wei Christine Lin; Lisa Bero; Fiona Blyth; Jonathan Penm; Carl R. Schneider


Pain. 2021;162(11):2686-2692. 

In This Article

Abstract and Introduction


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.


Use of prescription opioids has escalated over the past 3 decades,[10,32] accompanied by increases in opioid-related harms and overdoses.[8,17,31] Ubiquitous opioid use does not align with the recommendations of international clinical practice guidelines, which caution on the lack of safety and efficacy data for opioids in chronic pain management.[9,11] Utilization of opioids for acute pain, although indicated, is associated with increased risks of long-term use,[38] further amplifying the potential for opioid-related harms.

Despite concerns related to long-term opioid therapy, almost one-third of individuals with chronic noncancer pain are prescribed opioids.[25] The United States, United Kingdom, Canada, and Australia are among nations who have identified opioid harms as a significant public health concern,[2,27] implementing numerous system-level strategies to promote judicious use.[7,28,42] From a public health perspective, regulatory approaches such as prescription drug monitoring programs are central in curtailing inappropriate use, yet at an individual level, strategies such as opioid deprescribing remain challenging. Deprescribing is the process of withdrawal of an inappropriate medication, with the goal of managing polypharmacy and improving outcomes.[33] Healthcare professionals acknowledge that opioid deprescribing should be considered when the risk of continuation outweighs the benefit[22] and existing deprescribing literature suggests that most individuals are willing to have medications deprescribed.[36] However, barriers to deprescribing exist, including fear of withdrawal effects and the lack of alternative treatment options.[13,19,35] Furthermore, current pain practice guidelines provide insufficient decision support in identifying populations who may benefit from deprescribing interventions, and evidence-based opioid deprescribing guidelines are yet to be developed.

Although healthcare professionals' perspectives on opioid deprescribing have been elicited,[22] it is paramount that the perspectives of opioid consumers are explored and reflected in guideline development. Consumers are best placed to ensure that recommendations made for, or about, them are consistent with their values and preferences, thereby enhancing guideline acceptability and legitimacy.[3] Consumers may offer different and complementary perspectives to those of healthcare professionals and may be able to challenge assumptions that are made about the values used for making recommendations.[37] This study aimed to explore the perspectives of Australian opioid consumers on opioid deprescribing and determine factors to be considered in the development of opioid deprescribing guidelines. By identifying factors that influence consumers' self-efficacy and decision making to deprescribe opioids, interventions may be designed that address and account for consumer needs and preferences. The use of a theoretically informed model to contextualize perspectives may allow for a conceptual understanding of factors that influence consumers' motivation, attitudes, and actions.