• Anaesthesia
• Healthcare quality improvement
• Medication safety
• Pain

Pain is a leading cause of disease burden and ill health globally, affecting approximately one in five people.1 Opioid analgesics are deemed essential medicines owing to their ability to relieve pain and dyspnoea.2 However, they are also recognised as high-risk medicines due to their propensity for harm, including adverse effects, dependence, non-medical use and overdose.3 Globally, significant variations in opioid access and usage have been observed. In 2018–2020, many countries in Asia and Africa consumed fewer than 200 standard defined daily doses of opioids per million inhabitants per day.4 Yet, in the same period, the USA consumed an average of over 20 000 standard defined daily doses per million inhabitants per day.4 While medical needs will inevitably vary between countries according to their epidemiological profiles, the magnitude of disparity in consumption indicates potential unmet need in some countries and overuse in others, constituting two different but equally concerning global health problems.

In many countries with high opioid consumption, postsurgical opioid prescribing has been identified as a major contributor to overuse.5 This has prompted calls for the implementation of strategies to ensure judicious opioid prescribing and deprescribing (medication dose reduction or cessation) following surgery.5 Previous evidence syntheses have indicated that opioid deprescribing is feasible and may lead to improved or unchanged pain outcomes for patients.6 7 However, to date, they have focused predominantly on people living with chronic non-cancer pain and have examined interventions implemented in primary care settings.6–8 In this issue of BMJ Quality and Safety, Bansal et al synthesised data on the effectiveness of interventions that aimed to reduce postoperative opioid consumption,9 an important research question considering the current dearth of high certainty evidence in this space.6 Both randomised controlled trials and observational studies were included, focusing on diverse interventions targeting healthcare professionals and patients undergoing various surgical procedures. Effect sizes varied considerably, and heterogeneity in interventions and populations made it difficult to draw definitive conclusions about any particular opioid-deprescribing approach.9 Importantly, the authors identified 23 distinct behaviour change techniques employed in opioid-deprescribing interventions, including behaviour instructions, goal setting and social support. By linking these techniques to the effect sizes observed in the studies, their findings provide insights for designing strategies to reduce opioid use after surgery.

While reducing opioid use after surgery is a subject of substantial interest in regions experiencing negative health and social consequences of opioid overprescribing,5 10 only ~10% of the global population consumes 90% of the world’s opioids.11 In contexts where many suffer unnecessarily due to the unavailability of lifesaving and life-enhancing opioid medicines for pain and anaesthesia in the perioperative period,10 opioid deprescribing is likely a distant priority. This is reflected in the fact that all studies from the systematic review originated from the USA, Australia or Germany, with none from low- or middle-income countries.9 At its core, deprescribing is a patient-centred process of medication optimisation and intends to enhance medication safety and appropriateness,12 a sentiment that would likely achieve international agreement and support. However, how can deprescribing be relevant for regions with limited or no opioid access? Intuitively, you cannot deprescribe something that is not there.

Addressing the duality of equitable opioid access, while minimising negative health and societal consequences of opioid overuse, will inevitably be complex. It will likely require a shift in the global conversation, from deprescribing opioids in high-access contexts to a broader focus on quality use of medicines. In Australia, ‘Quality Use of Medicines’ refers to a set of principles advocating for the judicious, appropriate, safe and effective use of medicines.13 Internationally, similar concepts are captured by terms such as ‘Rational Use of Medicines’, ‘Appropriate Use of Medicines’, ‘Medicines Optimisation’ or ‘Good Prescribing Practices’, forming key components of countries’ National Medicines Policies.14 Specifically, quality use of medicines involves;

1. selecting management options wisely by considering the place of medicines in treating illness and maintaining health, recognising that there may be better ways than medicine to manage many disorders.

2. choosing suitable medicines if a medicine is considered necessary so that the best available option is selected. This involves considering the individual, the clinical condition, risks and benefits, dosage and length of treatment, co-existing conditions, other therapies, monitoring considerations, costs for the individual, the community and the health system.

3. using medicines safely and effectively to get the best possible results by monitoring outcomes, minimising misuse, over-use and under-use, and improving people’s ability to solve problems related to medication, such as negative effects or managing multiple medications.13

To achieve worldwide quality use of opioids, more and higher certainty evidence on mechanisms to achieve safe and equitable opioid prescribing and deprescribing is required. The review by Bansal et al contributes one piece to this large and complex puzzle, yet many critical evidence gaps remain. For example, there is a need to determine whether certain opioids present more favourable benefit–risk profiles compared with others. If so, it should be determined whether these can be produced and distributed in formulations that are convenient and affordable for people with clinical needs. At a national level, it will be necessary to assess resource requirements to effectively deliver quality use of medicine initiatives, for example, via opioid stewardship programmes. This includes ensuring that workforces are adequately staffed and trained to support such efforts. From a regulatory perspective, countries will likely require specific and actionable guidance to implement policies that achieve these goals. The release of the WHO’s guideline on ensuring balanced national policies for access to and safe use of controlled medicines is highly anticipated for this reason.15

To translate opioid prescribing and deprescribing evidence into clinical practice, it will be critical that research studies measure and report patient-centred outcomes. In the review by Bansal et al, only six of 22 included studies reported on pain intensity, one examined patient satisfaction and one measured healthcare utilisation.9 Without measuring patient-reported outcomes, it cannot be determined whether reductions in opioid use result in worse pain or other adverse effects (eg, reduced function, increased hospitalisations and therapeutic substitution to an alternate but equally high-risk medicine). Such information is required to ensure that singular efforts to solve one problem do not in turn inadvertently create another. In attempts to reduce opioid-related harm in countries such as the USA and Australia, unintended consequences have been observed, including unsolicited opioid deprescribing resulting in unmanaged pain, abrupt opioid cessation and refusal of care.16 17 This has resulted in serious harm, including mental health crises and increased rates of suicide.18 19 Conversely, neglecting to implement harm prevention measures when increasing opioid access may result in downstream overprescription and subsequent harm. For example, there is growing concern that pharmaceutical companies are employing opioid marketing techniques in low- and middle-income countries to incentivise opioid prescribing, a strategy known to have contributed to the North American opioid crisis.11 20

In conclusion, current global disparities in opioid consumption highlight a critical need for balanced approaches to ensure opioid access and safety. While opioid-deprescribing research predominantly originates from high-income countries, its relevance may extend beyond borders if considered within a broader quality use of medicines framework and if relevant patient-centred outcomes are examined. The adage of ‘prevention is better than cure’ resonates strongly, both to prevent inappropriate long-term opioid use following initiation and also to put safeguards in place that proactively reduce preventable harm and suffering from overuse as countries expand opioid access. Addressing the dual challenges of ensuring adequate pain relief while preventing overuse will ultimately contribute to the realisation of WHO’s goal of all people achieving their right to health; a state of complete physical, mental and social well-being not merely the absence of disease.21