Table 2.

Four key domains described as needed for successful opioid dose reduction in hospitalized patients, derived from focus group discussions and a Delphi survey conducted with local clinicians. For an improved overview, the respective domain contents are divided in subheadings. The corresponding supporting quotations are numbered and detailed in the supplement (Sect. 1.4). (GPs = general practitioners, NSAIDs = non-steroidal anti-inflammatory drugs, SQ-Nr = supporting quotations numbers from supplementary table 2 [Sect. 1.4]).

Domain	Condensed recommendations	SQ-Nr
(D1) Opioid reduction strategies
Structured reduction plan components	• Plan for opioid reduction whenever opioids are initiated or doses increased. • Target either return to prehospitalization dose or complete cessation based on patient’s prehospital opioid status (user vs. naïve). • Commence reduction once patient stabilizes on regimen (minimal back-up opioid use and stable pain for 24–48 h) and base starting deprescribing dose on patient’s last 24-hour consumption of both fixed and back-up opioids. • Adjust reduction rates (5–25%) based on pain type and nature of injury/surgical procedure to minimize withdrawal symptoms and maintain functionality: o Acute pain: 25% reduction with 2-day stabilization periods. o Chronic pain: 10% reduction with 3-day stabilization periods. • For musculoskeletal injuries/surgeries, align reduction with mobilization process and use physical therapist input to guide reduction rates. • Identify high-pain periods (e.g., morning activation) to prioritize which doses to reduce last, while maintaining back-up opioids at 1/10 to 1/6 of initial dose throughout reduction process. • Reduce or stop opioids before discontinuing non-opioid analgesics (NSAIDs, acetaminophen, metamizole). There is reportedly a tendency to discontinue non-opioids first due to the higher pill burden required for adequate pain control in musculoskeletal conditions.	1, 2, 5, 6, 7, 15, 19
Barriers and solutions	• Large pack sizes and dosage forms of commercially available opioids, such as excessively high tablet counts or inconvenient administration routes, impede reduction efforts. • Solutions include offering smaller, customized pack sizes and switching opioids to weaker agents or more manageable forms, such as tablets or capsules.	10, 27, 28
Patient education priorities	• Patient education should focus on encouraging physical activity and setting realistic functional goals rather than abstract pain levels. • Patients should be advised that occasional pain spikes are normal and that back-up opioids are intended for these situations to enhance adherence to the reduction process.	13, 16
(D2) Patient-specific variables
Pain-related variables	• Patient-specific variables, including the type and source of pain, significantly influence the approach to reducing opioid analgesics. • While short-term analgesic therapy for acute pain permits a rapid reduction rate and long-term analgesic therapy for chronic pain often necessitates a slower reduction, reduction speed may still need further adjustment based on individual circumstances. • The nature of the injury or patient’s frailty; for instance, fractures in elderly patients may require a slower reduction rate due to prolonged healing times. • In patients with chronic pain who experience acute pain episodes (e.g., postoperative), additional opioids may be required temporarily, which should be reduced in a tiered approach. Doses above the maintenance dose can be reduced more rapidly, followed by a more gradual reduction once acute pain subsides and maintenance dose is reestablished.	1, 2, 17, 19, 22
Patient-centered factors	• Adjust reduction strategy based on opioid exposure length: o Even opioid-naïve patients may require slower reduction if exposed to high doses for extended periods (e.g., following treatment in critical care). o Monitor closely for withdrawal symptoms or pain exacerbation during the reduction. • Adjust the reduction process for organ function, such as renal or hepatic impairment. • Behavioral factors, such as pain catastrophizing, may necessitate closer monitoring during the reduction process and a slower reduction rate. • For cognitively impaired patients, deprescribing should involve a simplified regimen with a single dosage strength to minimize intake errors.	12, 20, 24
Assessment challenges	• Clinicians should remain vigilant for other pain sources, such as infections or hematomas, when patients report increased pain levels. • Numeric pain rating scales should be interpreted cautiously, as patient misconceptions may often distort their utility. • A critical barrier may arise from the shared goal of patients and clinicians to achieve pain-free states, which may inadvertently hinder the reduction process and mask opportunities for reducing opioids.	23, 25, 29, 40, 48
(D3) Environmental enablers
Core enablers	• Implement shared decision-making, particularly involving discussions on patient confidence and mobility progress during hospitalization. • Develop straightforward, adaptable reduction protocols, recognizing that complex or rigid schemes may impede adoption in clinical practice. • Place primary responsibility for reducing opioids on prescribing clinicians, supported by the involvement of a collaborative, interdisciplinary care team. • Recognize GPs as critical “gatekeepers” in deprescribing hospital-initiated opioids. However, they may face systemic challenges such as high workloads, limited time, and insufficient resources. • Clear referral pathways to specialists (e.g., pain medicine specialists) support deprescribing efforts.	35, 51, 45, 46, 53, 56, 57
System-level enablers	• Institutional support and interdisciplinary collaboration are critical to achieve sustainable opioid reduction and improve patient outcomes. • Systemic inefficiencies, including a lack of standardized protocols and poor care coordination, may impede institutional implementation. • Integrate a unified, evidence-based deprescribing strategy into clinical workflows through institutional policies and standardized efforts.	38, 57
(D4) Procedural factors
Hospital-to-community procedures	• Regular pain medication reviews are vital to prevent uninformed continuation of opioids and manage adverse drug reactions. • A two-day grace period before continuing to reduce opioids may support adherence when patients transition from hospital to community. • Detailed assessments, including a thorough medical history to understand the nature, timing, and triggers of the pain, ensure a personalized and safe reduction process. • Structured follow-up of patients discharged with opioids is essential, including phone calls and clear deprescribing instructions for both patients and GPs.	8, 30, 34, 41
System-level factors	• Operational challenges include uncertainty in managing escalating doses and adverse drug reactions, often leading to continued prescribing without clear guidance. • Coordinated transitions between hospital and outpatient settings are needed to ensure appropriate referrals and alignment of pain management with rehabilitation goals. • Barriers include staff shortages, fragmented care, and time constraints during transitions, particularly for chronic pain patients. A cohesive, patient-centered strategy is needed to address these challenges.	37, 39, 41