Promoting Patient-Centeredness in Opioid Deprescribing: a Blueprint for De-implementation Science

Abstract

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.

Fig. 1

The figure offers selected examples of actors and agencies that, collectively, influence opioid prescribing in the USA, grouped into the following domains: “Governmental,” “Guidelines and Metrics,” “Framing Voices,” and “Providers and Payers.” The four domains are offered with illustrative intent and are not necessarily exhaustive or mutually exclusive. For example, a government agency may produce a guideline and also influence how the guideline is understood through collaboration with a journalist (i.e., a Framing Voice). CMS, The Centers for Medicare & Medicaid Services; CDC, Centers for Disease Control and Prevention; DEA, Drug Enforcement Agency; VA, Department of Veteran Affair’s; DoD, Department of Defense; NCQA, National Committee for Quality Assurance.