Abstract

Hospital-initiated opioid analgesics that extend beyond discharge can lead to long-term use and adverse outcomes. Despite a growing understanding of opioid-related harms, there is a lack of published protocols for structured deprescribing in Europe. We aimed to develop an actionable opioid deprescribing framework that builds on trialed reduction protocols with patient-centered determinants for systematic implementation in tertiary care. We conducted a multi-level consensus study to bridge evidence, clinician expertise, and patient perspectives. Initial framework development included focus group discussions with multidisciplinary clinicians (n=5). The framework was validated for our institution via a two-round Delphi survey across six medical specialties (n=11). An opioid reduction calculator was developed in Python (version 3.12.3), incorporating clinical parameters to determine reduction trajectories for prespecified starting and end doses. Final refinement included interviews with patients receiving opioid therapy (n=11) to optimize understandability of the reduction plan as a patient handout and for developing a patient pamphlet on opioids with patients (n=13). The framework identified four critical domains for successful opioid deprescribing: interventional reduction strategies, patient-specific physiological variables, environmental enablers, and procedural elements. Reduction strategies categorized patients into chronic and new users, incorporating grace periods for dose stabilization, with particular attention given to patients exhibiting pain catastrophizing behavior and frailty. Environmental and procedural factors included shared responsibility and interdisciplinarity, ensuring that follow-up is facilitated by a coordinated care team. These findings were operationalized into the reduction calculator, proposing initial individualized reduction plans (10-25%) based on key patient-specific variables with built-in stabilization periods. Delphi validation achieved full consensus (87.8% first-round agreement; 100% final consensus) on all framework components. Patient involvement refined the handout to improve understandability and actionability, and yielded comprehensive information on opioids. We developed an actionable opioid deprescribing framework that bridges published evidence with patient-centered care for our institution, providing other healthcare institutions with a practical blueprint for their own implementation. Our multi-level consensus identified critical patient-specific and environmental determinants, and established individualized reduction protocols, addressing a critical gap in transitional care while facilitating safe opioid deprescribing practices.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This study was supported by an external research grant (Forschungsprojekt nationaler Tragweite 2023) from the Swiss Association of Public Health Administration and Hospital Pharmacists (GSASA).

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Institutional ethical approval was obtained from the ETH Zurich Ethics Commission (EK-2024-N-37; Project 24 ETHICS-270). All research was performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all study participants.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

Data Availability

All data generated or analyzed during this study are included in this published article and its supplementary materials, except for the interview transcripts and Delphi survey data. Due to the potential risk of participant identification, access to the transcripts and Delphi survey data will be provided only upon reasonable request to protect their anonymity.

List of abbreviationsCFIRConsolidated framework for implementation researchCIConfidence intervalCOREQConsolidated criteria for reporting qualitative researchGPGeneral practitionerOEPOpioid exit plan