Secondary prevention of opioid painkiller dependence in chronic non cancer pain patients: A systematic review
Background: Globally, almost one third of adults with chronic non-cancer pain are prescribed opioid analgesics. The harms of long-term opioid use include dependence, misuse, overdose and death. Prevention of opioid dependence among these patients is a public health priority. Evidence on the effectiveness of interventions used in the secondary prevention of opioid dependence in primary care settings has not previously been synthesised. We aimed to synthesize the evidence on what interventions, that could be delivered in the community or primary care, are effective in the secondary prevention of opioid painkiller dependence in chronic non cancer pain patients treated with opioid painkillers.
Methods: We conducted a systematic review of randomised controlled trials (RCTs) and comparative non-randomised studies of interventions from high-income countries. We searched MEDLINE, Embase, Cumulative Index to Nursing and Allied Health (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO and ClinicalTrials.gov up to November 2022 and conducted forward citation tracking.
We included studies reporting on secondary prevention interventions such as tools for predicting dependence, screening tools for early recognition of dependence, prescribing/medication monitoring, and specialist support. We examined multiple outcomes, including reduction in opioid dosage. Primary analyses were restricted to RCTs with data synthesized using an effect direction plot. Risk of bias was assessed using the Cochrane risk of bias (RoB2) tool.
Results: Of 7102 identified reports, 18 studies were eligible for inclusion (8 RCTs). All were from the United States and most used multiple interventions/components. Of the seven RCTs at low risk of bias or ‘some concerns’, five showed a positive intervention effect on at least one relevant outcome, four of which included a nurse care manager and/or other specialist support. The remaining two RCTs showed no positive effect of automated symptom monitoring and optimized analgesic management by a nurse care manager/physician pain specialist team, or of a mobile opioid management app.
Conclusions: Our findings are of value to clinicians planning and implementing secondary prevention strategies for their patients on prescribed opioids in primary care settings. We also identify a clear need for further high quality RCTs on the topic.
