Primary care- based interventions for secondary prevention of opioid dependence in patients with chronic non- cancer pain taking pharmaceutical opioids: a systematic review

Background: Globally, almost one- third of adults with chronic non- cancer pain (CNCP) are prescribed opioids. Prevention of opioid dependence among these patients is a public health priority. Aim: To synthesise the evidence on the effectiveness of primary care- based interventions for secondary prevention of opioid dependence in patients with CNCP who are taking pharmaceutical opioids. Design & setting: Systematic review of randomised controlled trials (RCTs) and comparative nonrandomised studies of interventions from high- income countries. Method: We searched five databases for studies on non- tapering secondary prevention interventions, such as tools for predicting dependence, screening tools for early recognition of dependence, monitoring of prescribing or medication, and specialist support. We examined multiple outcomes, including reduction in opioid dosage. Primary analyses were restricted to RCTs with data synthesised 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 (eight of which were RCTs). Most used multiple interventions or components. Of the seven RCTs at low risk of bias or with '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 optimised analgesic management by a nurse care manager or a physician pain specialist team, or of a mobile opioid management app. Conclusion: We identify a clear need for further adequately powered high- quality studies. The conclusions that can be drawn on the effectiveness of interventions are limited by the sparsity and inconsistency of available data.