Systematic review: managing aberrant drug behavior in primary care

Abstract

Several strategies for preventing, identifying, and responding to aberrant opioid-related behaviors are recommended in pain management guidelines. This systematic review evaluated data in support of these strategies. Risk-reduction strategies were identified via a review of available guidelines. Systematic literature searches of PubMed were conducted (May 1, 2007 to May 21, 2012) to identify articles with evidence relevant to 9 basic strategies. Reference lists from relevant articles were reviewed for additional references of interest. Levels of evidence for articles identified were graded on a 4-point scale (strongest evidence=level 1; weakest evidence=level 4) using Oxford Centre for Evidence-based Medicine Levels of Evidence criteria. Weak to moderate evidence supported the value of thorough patient assessment, risk-screening tools, controlled-substance agreements, careful dose titration, opioid dose ceilings, compliance monitoring, and adherence to practice guidelines. Moderate to strong evidence suggests that tamper-resistant opioids may help prevent misuse but also that prescribing these formulations may have the unintended consequence of prompting a migration of users to other marketed opioids, heroin, or other substances. Similarly, there is preliminary evidence that recent regulatory and legal efforts may help reduce misuse but also impose barriers to the legitimate treatment of pain. Despite an absence of consistent, strong supporting evidence, clinicians are advised to use each of the available risk-mitigation strategies in combination as an attempt to minimize the risk of abuse in opioid treatment patients. Efforts to prevent abuse should not compromise pain management or promote other forms of substance abuse. Supported by Endo Pharmaceuticals Inc. (Chadds Ford, PA), who also funded editorial support provided by Complete Healthcare Communications, Inc. (Chadds Ford, PA).