Deprescribing Opioids in Chronic Non-cancer Pain: Systematic Review of Randomised Trials
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SYSTEMATIC REVIEW
Deprescribing Opioids in Chronic Non‑cancer Pain: Systematic Review of Randomised Trials Stephanie Mathieson1,2 · Christopher G. Maher1,2 · Giovanni E. Ferreira1,2 · Melanie Hamilton1,2 · Jesse Jansen2,3 · Andrew J. McLachlan4 · Martin Underwood5,6 · Chung‑Wei Christine Lin1,2
© Springer Nature Switzerland AG 2020
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 3 but 50%) prevented conducting a metaanalysis. Continuous outcomes are presented as mean differences between the intervention and control groups, and dichotomous outcomes are presented as absolute risk differences between the intervention and control groups. Heterogeneity prevented the assessment of the overall quality of evidence using a Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach [16]. We were also unable to perform the pre-planned sensitivity analysis (i.e. explain potential sources of heterogeneity and differences in risk of bias) and subgroup (i.e. chronic low back pain population) analyses due to the low number of studies.
3 Results The search retrieved 37,406 records, of which 12 trials were included in this review plus 10 ongoing clinical trials (NCT02737826, NCT03521960; NCT03743402, NCT03889418, NCT03916276, NCT03950791, NCT04013529, NCT04097743, NCT04184362, ISRCTN49470934) (Online Appendix 3). All studies were published from 2010 onwards, were published in English
and were all conducted in the USA except one study from Australia [17] and one from Denmark [18].
3.1 Study Characteristics 3.1.1 Patient‑focused Interventions A total of 835 adult participants with chronic non-cancer pain were randomised, with a mean age of 48.0 years [standard deviation (SD) 16.9]. Most trials were of small size (median 37 participants with chronic pain range 12–411) (Table 1). There were ten studies of patient-focused interventions [17–26] including: • Dose reduction protocols [18, 23, 24]. Two studies speci-
fying dose reduction targets as part of the protocol such as starting with a 10% reduction of daily dose every week [18, 24]. One study initiated dose reduction by sending a letter to both patients an
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