Chronic pain and opioid misuse: a review of reviews

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Abstract

Objective

The crisis of prescription opioid (PO) related harms has focused attention toward identifying and treating high-risk populations. This review aims to synthesize systematic reviews on the epidemiology and clinical management of comorbid chronic pain and PO or other substance misuse.

Methods

A systematic database search was conducted to identify systematic reviews published between 2000 and 2016. Eligible studies were systematic reviews related to chronic non-cancer pain and PO or other substance misuse. Evidence from the included reviews was synthesized according to epidemiology and clinical management themes.

Results

Of 1908 identified articles, 18 systematic reviews were eligible for final inclusion. Two meta-analyses estimated the prevalence of chronic non-cancer pain in individuals using POs non-medically to be approximately 48% to 60%, which is substantially higher than the prevalence of chronic non-cancer pain in general population samples (11% to 19%). Five systematic reviews estimated the rates of PO or other opioid use in chronic pain populations with substantial variation in results (0.05% to 81%), likely due to widely varying definitions of dependence, substance use disorder, misuse, addiction, and abuse. Several clinical assessment and treatment approaches were identified, including: standardized assessment instruments; urine drug testing; medication counts; prescription drug monitoring programs; blood level monitoring; treatment agreements; opioid selection; dosing and dispensing strategies; and opioid agonist treatment. However, the reviews commonly noted serious limitations, inconsistencies, and imprecision of studies, and a lack of evidence on effectiveness or clinical utility for the majority of these strategies.

Conclusion

Overall, current systematic reviews have found a lack of high-quality evidence or consistent findings on the prevalence, risk factors, and optimal clinical assessment and treatment approaches related to concurrent chronic pain and substance misuse. Given the role of systematic reviews in guiding evidence-based medicine and health policy, there is an urgent need for high-quality primary research to guide future systematic reviews to address the escalating epidemic of harms related to chronic pain and substance misuse.

Electronic supplementary material

The online version of this article (doi:10.1186/s13011-017-0120-7) contains supplementary material, which is available to authorized users.

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Most cited references 31

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Systematic reviews: synthesis of best evidence for clinical decisions.

D J Cook, C D Mulrow, R B Haynes (1997)

Systematic reviews can help practitioners keep abreast of the medical literature by summarizing large bodies of evidence and helping to explain differences among studies on the same question. A systematic review involves the application of scientific strategies, in ways that limit bias, to the assembly, critical appraisal, and synthesis of all relevant studies that address a specific clinical question. A meta-analysis is a type of systematic review that uses statistical methods to combine and summarize the results of several primary studies. Because the review process itself (like any other type of research) is subject to bias, a useful review requires clear reporting of information obtained using rigorous methods. Used increasingly to inform medical decision making, plan future research agendas, and establish clinical policy, systematic reviews may strengthen the link between best research evidence and optimal health care.

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Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis.

Kevin Vowles, Mindy L McEntee, Peter Julnes … (2015)

Opioid use in chronic pain treatment is complex, as patients may derive both benefit and harm. Identification of individuals currently using opioids in a problematic way is important given the substantial recent increases in prescription rates and consequent increases in morbidity and mortality. The present review provides updated and expanded information regarding rates of problematic opioid use in chronic pain. Because previous reviews have indicated substantial variability in this literature, several steps were taken to enhance precision and utility. First, problematic use was coded using explicitly defined terms, referring to different patterns of use (ie, misuse, abuse, and addiction). Second, average prevalence rates were calculated and weighted by sample size and study quality. Third, the influence of differences in study methodology was examined. In total, data from 38 studies were included. Rates of problematic use were quite broad, ranging from <1% to 81% across studies. Across most calculations, rates of misuse averaged between 21% and 29% (range, 95% confidence interval [CI]: 13%-38%). Rates of addiction averaged between 8% and 12% (range, 95% CI: 3%-17%). Abuse was reported in only a single study. Only 1 difference emerged when study methods were examined, where rates of addiction were lower in studies that identified prevalence assessment as a primary, rather than secondary, objective. Although significant variability remains in this literature, this review provides guidance regarding possible average rates of opioid misuse and addiction and also highlights areas in need of further clarification.

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Opioids in chronic non-cancer pain: systematic review of efficacy and safety.

Eija Kalso, Jayne E Edwards, Andrew R. Moore … (2004)

Opioids are used increasingly for chronic non-cancer pain. Controversy exists about their effectiveness and safety with long-term use. We analysed available randomised, placebo-controlled trials of WHO step 3 opioids for efficacy and safety in chronic non-cancer pain. The Oxford Pain Relief Database (1950-1994) and Medline, EMBASE and the Cochrane Library were searched until September 2003. Inclusion criteria were randomised comparisons of WHO step 3 opioids with placebo in chronic non-cancer pain. Double-blind studies reporting on pain intensity outcomes using validated pain scales were included. Fifteen randomised placebo-controlled trials were included. Four investigations with 120 patients studied intravenous opioid testing. Eleven studies (1025 patients) compared oral opioids with placebo for four days to eight weeks. Six of the 15 included trials had an open label follow-up of 6-24 months. The mean decrease in pain intensity in most studies was at least 30% with opioids and was comparable in neuropathic and musculoskeletal pain. About 80% of patients experienced at least one adverse event, with constipation (41%), nausea (32%) and somnolence (29%) being most common. Only 44% of 388 patients on open label treatments were still on opioids after therapy for between 7 and 24 months. The short-term efficacy of opioids was good in both neuropathic and musculoskeletal pain conditions. However, only a minority of patients in these studies went on to long-term management with opioids. The small number of selected patients and the short follow-ups do not allow conclusions concerning problems such as tolerance and addiction.

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Author and article information

Contributors

Pauline Voon:

ORCID: http://orcid.org/0000-0003-4766-4296

+1 (604)-806-8477 , pvoon@cfenet.ubc.ca

Mohammad Karamouzian: pvoon@cfenet.ubc.ca

Thomas Kerr: uhri-tk@cfenet.ubc.ca

Journal

Journal ID (nlm-ta): Subst Abuse Treat Prev Policy

Journal ID (iso-abbrev): Subst Abuse Treat Prev Policy

Title: Substance Abuse Treatment, Prevention, and Policy

Publisher: BioMed Central (London )

ISSN (Electronic): 1747-597X

Publication date (Electronic): 15 August 2017

Publication date PMC-release: 15 August 2017

Publication date Collection: 2017

Volume: 12

Electronic Location Identifier: 36

Affiliations

[1 ]ISNI 0000 0001 2288 9830, GRID grid.17091.3e, British Columbia Centre for Excellence in HIV/AIDS, , University of British Columbia, St. Paul’s Hospital, ; 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada

[2 ]ISNI 0000 0001 2288 9830, GRID grid.17091.3e, , School of Population and Public Health, Faculty of Medicine, University of British Columbia, ; 2206 East Mall, Vancouver, BC V6Z 1Z3 Canada

[3 ]ISNI 0000 0001 2092 9755, GRID grid.412105.3, HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, , Institute for Futures Studies in Health, Kerman University of Medical Sciences, ; Kerman, Iran

[4 ]ISNI 0000 0001 2288 9830, GRID grid.17091.3e, Department of Medicine, , University of British Columbia, St. Paul’s Hospital, ; 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada

Author information

Pauline Voon http://orcid.org/0000-0003-4766-4296

Article

Publisher ID: 120

DOI: 10.1186/s13011-017-0120-7

PMC ID: 5558770

PubMed ID: 28810899

SO-VID: 73f16fd1-82b0-4654-a2a4-9ff8011ab5fc

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 13 December 2016

Date accepted : 6 August 2017

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100000024, Canadian Institutes of Health Research;

Award ID: Vanier Canada Graduate Scholarship

Award Recipient : Pauline Voon

Funded by: FundRef http://dx.doi.org/10.13039/501100000101, Pierre Elliott Trudeau Foundation;

Award ID: Trudeau Doctoral Scholarship

Award Recipient : Pauline Voon

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ScienceOpen disciplines: Health & Social care

Keywords: chronic pain,prescription opioid,substance use,addiction,systematic review (3–10 keywords required)

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ScienceOpen disciplines: Health & Social care

Keywords: chronic pain, prescription opioid, substance use, addiction, systematic review (3–10 keywords required)

Chronic pain and opioid misuse: a review of reviews

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Tobacco Prevention & Cessation

Most cited references 31

Systematic reviews: synthesis of best evidence for clinical decisions.

Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis.

Opioids in chronic non-cancer pain: systematic review of efficacy and safety.

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