Project Title:

Development of a service specification for deprescribing long-term opiates

Type of Research:

Realist review

Background & Scientific Rationale:

Evidence for the long-term benefits of opiates to manage chronic non-cancer pain (CNCP) is limited and evidence for harm is growing.(1) Reducing opiate prescribing is an NHS Improvement goal (2) and UEA Health partners have unanimously identified this as a regional priority. A 2018 BMJ review reported the quality of published evidence for opiate deprescribing interventions to be low, and no evidence for their efficacy or safety. The BMJ review recommendations on opioid reduction were therefore based on expert opinion rather than empirical evidence of benefit. The continuing rise in opiate prescribing for CNCP demonstrates the need for more research which can be widely implemented.(3, 4)

The result of this focus on reducing CNCP prescribing is numerous local and national activities each with varying levels of success. Realist reviews offer a structured approach to capturing the details of these local and national activities in order that we may learn from the existing research literature and the practice environment. A realist review aims to understand what elements of these attempts to reduce CNCP prescribing are effective, for whom, under which circumstances and how. Examples of circumstances include the relationships and attitudes of individuals providing the service, and environment in which the service is delivered. A realist review therefore enables the effective service elements and conducive circumstances to be identified in order to design an opiate deprescribing intervention with effective components that best fit the circumstances that can be feasibly replicated.

Research aims:

This project aimed to:

  • To identify the mechanisms by which opiate deprescribing interventions are believed to result in their intended outcomes
  • To explore the contexts which determine whether the different mechanisms produce intended outcomes
  • Identify and share materials to support opiate deprescribing in the Eastern region
  • To develop an intervention specification for opiate deprescribing suitable for feasibility testing in an NIHR RfPB or HS&DR application.


Literature for the realist review was generated through two approaches:

  1. A search of electronic databases for long-term opiate deprescribing interventions
  2. Online survey with NHS organisations and relevant stakeholders to actively provide details of any interventions together with any evaluation findings, and explore the xperiences of health organisations and individual practitioners.

Key findings and Outputs:

Following analysis of the evidence, the team have developed a theory about what elements are essential for the successful tapering of opioids.

This theory states that there needs to be a clear expectation that opioid deprescribing is the responsibility of prescribers, and programmes should incorporate:

  • information about the consequences of excess opioid use
  • information about how to taper (guidelines)
  • prescribers with appropriate knowledge and skill to initiate tapering discussions and navigate the patient pathway
  • a consistent approach by all members of the health care team
  • comprehensive education for patients
  • a pathway for patient management including access to appropriate levels of psychological and physical support

The research has contributed to the development of the ‘Toolkit for Tackling Chronic Opioid Use in Non-Cancer Pain’. This toolkit outlines seven areas of best practice to tackle chronic opioid use.

This toolkit is available on the UEA website

You can also read more in a recent Press Release about the launch of the toolkit


For further information on this project, please contact Debi Bhattacharya

1. Manchikanti L, Kaye AM, Knezevic NN, McAnally H, Slavin K, Trescot AM, et al. Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain physician. 2017;20(2s):S3-s92.
2. Faye’s story: good practice when prescribing opioids for chronic pain: NHS South region South West; 2017 [Available from:
3. Berna C, Kulich RJ, Rathmell JP. Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for Everyday Practice. Mayo Clinic proceedings. 2015;90(6):828-42.
4. Sandhu H, Underwood M, Furlan A, Noyes J, Eldabe S. What interventions are effective to taper opioids in patients with chronic pain? BMJ. 2018;362.
Share this article
Tweet about this on Twitter