Interventions to optimize prescribed medicines and reduce their misuse in chronic non-malignant pain: a systematic review

Purpose Sub-optimal opioid prescribing and use is viewed as a major contributor to the growing opioid crisis. This study aims to systematically review the nature, process and outcomes of interventions to optimize prescribed medicines and reduce their misuse in chronic non-malignant pain (CNMP) with a particular focus on minimizing misuse of opiates. Methods A systematic review of literature was undertaken. Search of literature using Medline, EMBASE and CINAHL databases from 2000 onwards was conducted. Screening and selection, data extraction and risk of bias assessments were undertaken by two independent reviewers. Narrative synthesis of the data was conducted. Results A total of 21 studies were included in the review, of which three were RCTs. Interventions included clinical (e.g. urine drug testing, opioid treatment contract, pill count), behavioural (e.g. electrical diaries about craving), cognitive behavioural treatment and/or educational interventions for patients and healthcare providers delivered as a single or as a multi-component intervention. Medication optimization outcomes included aspects of misuse, abuse, aberrant drug behaviour, adherence and non-adherence. Although all evaluations showed improvement in medication optimization outcomes, multi-component interventions were more likely to consider and to have shown improvement in clinical outcomes such as pain intensity, quality of life, psychological states and functional improvement compared to single-component interventions. Conclusions A well-structured CNMP management programme to promote medicines optimization should include multi-component interventions delivered by a multidisciplinary team of healthcare professionals and target both healthcare professionals and patients. There was heterogeneity in definitions applied and interventions evaluated. There is a need for the development of clear and consistent terminology and measurement criteria to facilitate better comparisons of research evidence.