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  • Barriers and enablers to monitoring and deprescribing opioid analgesics for chronic non-cancer pain: a systematic review with qualitative evidence synthesis using the Theoretical Domains Framework

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Systematic review
Barriers and enablers to monitoring and deprescribing opioid analgesics for chronic non-cancer pain: a systematic review with qualitative evidence synthesis using the Theoretical Domains Framework
  1. Amanda J Cross1,2,3,
  2. Rachelle Buchbinder1,3,
  3. Stephanie Mathieson4,5,
  4. Allison Bourne1,3,
  5. Christopher G Maher4,5,
  6. Chung-Wei Christine Lin4,5,
  7. Denise A O'Connor1,3
  1. 1 Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
  2. 2 Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
  3. 3 Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  4. 4 Institute for Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
  5. 5 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Amanda J Cross, Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia; amanda.cross{at}monash.edu

Abstract

Background Understanding barriers and enablers to monitoring and deprescribing opioids will enable the development of tailored interventions to improve both practices.

Objective To perform a qualitative evidence synthesis of the barriers and enablers to monitoring ongoing appropriateness and deprescribing of opioids for chronic non-cancer pain (CNCP) and to map the findings to the Theoretical Domains Framework (TDF).

Methods We included English-language qualitative studies that explored healthcare professional (HCP), patient, carer and the general public’s perceptions regarding monitoring and deprescribing opioids for CNCP. We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO from inception to August 2020. Two authors independently selected the studies, extracted the data, assessed the methodological quality using the Critical Appraisal Skills Programme, and assessed the confidence in the findings using GRADE CERQual (Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research). We used an inductive approach to synthesis of qualitative data and mapped identified themes to TDF domains.

Results From 6948 records identified we included 21 studies, involving 209 HCPs and 330 patients. No studies involved carers or the general public. Five barrier themes were identified: limited alternatives to opioids, management of pain is top priority, patient understanding, expectations and experiences, prescriber pressures, and reluctance to change. Four enabler themes were identified: negative effects of opioids and benefits of deprescribing, clear communication and expectations for deprescribing, support for patients, and support for prescribers. 16 barrier and 12 enabler subthemes were identified; most were graded as high (n=15) or moderate (n=9) confidence. The TDF domains ‘beliefs about consequences’, ‘environmental context and resources’, ‘social influences’ and ‘emotion’ were salient for patients and HCPs. The domains ‘skills’ and ‘beliefs about capabilities’ were more salient for HCPs.

Conclusion Future implementation interventions aimed at monitoring and deprescribing opioids should target the patient and HCP barriers and enablers identified in this synthesis.

PROSPERO registration number CRD42019140784.

  • pain
  • medication safety
  • qualitative research
  • chronic disease management
  • patient safety

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

https://doi.org/10.1136/bmjqs-2021-014186

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplemental information.

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    Footnotes

    • Twitter @AmandaJCross, @CGMMaher

    • Contributors AJC, RB and DAO’C conceived the study and designed the study methods. AJC, RB, SM, AB, CM and C-WCL were involved in conducting the search, selection of studies, quality assessment and data extraction. AJC, RB, SM, AB and DAO’C analysed the data. AJC and DAO’C wrote the first draft of the manuscript. RB, SM, AB, CM and C-WCL contributed to revising subsequent drafts critically for important intellectual content. All authors approved the final version of the manuscript and agree to be accountable for its content. AJC is the guarantor.

    • Funding This study is supported by the Australian National Health and Medical Research Council (NHMRC) Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network Centre of Research Excellence (CRE) (APP1134856). RB is supported by an NHMRC Investigator Fellowship (APP1194483). SM is supported by an NHMRC Health Professional Research Early Career Fellowship (APP1158463). CM is supported by an NHMRC Investigator Fellowship (APP1194283). C-WCL is supported by an NHMRC Career Development Fellowship (APP1061400). DAO'C is supported by an NHMRC Translating Research into Practice Fellowship (APP1168749).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.