Promoting Patient-Centeredness in Opioid Deprescribing: a Blueprint for De-implementation Science
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Birmingham VA Medical Center, Birmingham, AL, USA; 2Division of Preventive Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA; 3VA HSR&D Center for Healthcare Organization and Implementation Research, Boston, MA, USA; 4Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
A downward trend in opioid prescribing between 2011 and 2018 has brought per-capita opioid prescriptions below the levels of 2006, the earliest year for which the Centers for Disease Control and Prevention has published data. That trend has affected roughly ten million patients who previously received long-term opioid therapy. Any effort to reduce or replace a prior health practice is termed de-implementation. We suggest that the evaluation of opioid prescribing de-implementation has been misdirected, within US policy and health research, resulting in detrimental impacts on patients, their families and clinicians. Policymakers and implementation scientists can address these deficiencies in how we study and how we perform opioid de-implementation by applying an implementation science framework: the Consolidated Framework for Implementation Research. The Consolidated Framework lays out relevant domains of activity (internal, external, etc.) that influence implementation processes and outcomes. It can deepen our understanding of how policies are chosen, communicated, and carried out. Policymakers and researchers who embrace this framework will need a better approach to measuring success and failure in health care where both pain and opioids are concerned. This would involve shifting from a reductive focus on opioid prescription counts toward measures that are more effective, holistic, and patient-centered. J Gen Intern Med DOI: 10.1007/s11606-020-06254-7 © Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2020
downward trend in opioid prescribing has emerged in the A wake of a crisis of overdose and addiction related to opioids, coupled with a recognition that the benefits of opioids had been oversold.1 According to 2019 data from the US Centers for Disease Control and Prevention (CDC), opioid prescribing has declined 37% since its peak in 2011, while prescriptions exceeding 90 morphine milligram equivalents fell by 67% since 2008.2 This decline accelerated after a 2016 Guideline was Received February 7, 2020 Accepted September 17, 2020
issued.3 Such efforts, however, can have unintended consequences.4 By 2019, there was widespread recognition that reductions in prescribing had not been implemented in ways that consistently protected patients.5–9 Patients, media, government agencies, and professional literature acknowledged instances of worsening pain, loss of access to care, and death by suicide,7,10–13 even as others described successes in patient-centered voluntary dose reduction14 and post-operative pain management.15 By 2019, the CDC av
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