By Clare French, Research Fellow in Evidence Synthesis, Health Protection Research Unit in Behavioural Science and Evaluation at the University of Bristol and Kyla Thomas, Professor of Public Health Medicine, Bristol Medical School, University of Bristol.
What’s the problem?
Chronic pain that isn’t related to cancer is very common. It affects around one third of adults worldwide. Many people living with this condition are prescribed opioids. Long-term use of opioids may lead to dependence and addiction. Widespread opioid prescribing has caused a major public health problem in the United States.
Preventing dependence in patients who are prescribed opioids is a public health priority. In response, the UK and other countries are working to reduce opioid prescriptions and prevent people who are taking these medications from becoming dependent.
What did we do?
We reviewed published medical studies to answer the question: What interventions can prevent opioid dependence among patients with chronic pain (not related to cancer) who are taking prescribed opioids?
Our review focused on studies of secondary prevention interventions that could be delivered in the community or primary care settings. Secondary prevention is a public health approach aimed at detecting diseases early. For our review, this included things like tools to predict dependence risk, screening tools for early identification of dependence, monitoring of prescriptions and medications, and access to specialist support. We excluded studies that looked solely at interventions aimed at reducing opioid dosage since these have been previously been reviewed.
We performed thorough searches of five databases and other sources, such as clinical trial registers, to find medical studies on this topic.
We gathered data from eligible studies including information about each study’s design, details of the interventions used, and numerical data on relevant outcomes. We then created a system to classify the different interventions and noted which ones were used in each study.
To understand how reliable the results of the studies in our review were, we checked for any potential bias using established tools.
What did we find?
We found 18 studies that addressed our research question. Eight were randomized controlled trials and 10 were non-randomized studies. All studies were conducted in the United States.
Types of interventions
Most studies used a mix of interventions or components. The most common type of support was from specialists: five studies included a nurse care manager, three added a clinical pharmacist, and ten offered other specialist support such as psychologists or addiction specialists.
Meanwhile, seven studies included training or education for providers, while five offered training or education for patients. Six studies used electronic patient registries or other methods to track patient populations. Other intervention types included reviewing medical records, assessing the risk of opioid misuse, and providing motivational counselling or interviewing to encourage patients to follow their treatment plans.
Types of outcomes
The studies reported various outcomes, including changes in opioid dosage, sings of opioid misuse, and whether patients stopped taking their opioid prescriptions.
Did the interventions work?
We focused our main analyses on the eight randomised controlled trials, as they provide the strongest evidence. Most of these trials used a combination of different interventions, and none applied them in a clear step-by-step way. Because of this, it is difficult to figure out which specific interventions were effective.
Of the five trials that had a lower risk of bias, four demonstrated a positive effect of the intervention on at least one relevant outcome. All four of these trials included a nurse care manager and/or other specialist support as part of their intervention. While we cannot draw firm conclusions about how effective these interventions are based on the available data, they merit further investigation.
What do our findings mean?
Our review fills an important gap in the evidence regarding how effective different methods are for preventing dependence on prescription opioids.
However, the conclusions that can be drawn about which interventions work best is limited by the lack of sufficient and consistent data.
Our findings highlight the need for more well-designed studies on this topic.
Paper
Primary care-based interventions for secondary prevention of opioid dependence in patients with chronic non-cancer pain taking pharmaceutical opioids: a systematic review, by
Clare E. French, Kly H. Tomas et al, in BJGP Open.
