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Opioid Management Practices for the Prevention of Drug Diversion and Misuse: A Review of the Clinical Evidence and Guidelines

Last updated: April 13, 2012
Project Number: RC0347-000
Product Line: Rapid Response
Research Type: Drug
Report Type: Summary with Critical Appraisal
Result type: Report

Report in Brief

Context
Chronic pain affects 15% to 30% of Canadians. It persists for longer than three months and is frequently related to back pain, osteoarthritis, fibromyalgia, and headaches. Opioids are commonly used to manage pain, but are also associated with harms such as overdose, addiction, and opioid diversion. Diversion can include sharing, selling, and misusing opioids obtained via prescription, or the theft of opioids from manufacturing plants - while in transit or from pharmacies. Misuse is a non-judgmental term which refers to the deliberate or unintentional use of an opioid in any manner other than for which it was prescribed.

Technology
Opioid pain medications available in Canada include codeine (e.g., Tylenol No. 3), tramadol, buprenorphine, morphine, hydromorphone (e.g., Dilaudid), oxycodone (e.g. OxyContin, OxyNEO, or Percocet), fentanyl, and methadone.

Issue
The number of opioid prescriptions has substantially increased in Canada in recent years, accompanied by increases in addiction and fatal overdoses. The challenge for decision-makers is to minimize opportunities for misuse and diversion, while ensuring access to opioid-based pain treatments for those who may benefit from them. This review examines the available evidence regarding practices to reduce opioid diversion and misuse to help inform decisions on their use.

Methods
A limited literature search of key resources was conducted, and titles and abstracts of the retrieved publications were reviewed. Full-text publications were evaluated for final article selection according to predetermined selection criteria (population, intervention, comparator, outcomes, and study designs).

Key Messages
Practices to prevent opioid misuse:

  • Prescription-monitoring programs
    • May be effective
  • Clinical practice strategies (patient contracts, urine drug screening, sole dispensing pharmacy, etc.)
    • Unknown impact
  • Use of prescribing patterns (dose escalation) or patient characteristics to predict misuse
    • Limited, inconclusive evidence

Results
The literature search produced 419 citations, with 6 additional studies identified from the grey literature. Of these, 35 articles were deemed potentially relevant, with 11 meeting the criteria for inclusion in this review ? 1 randomized controlled trial, 5 non-randomized studies, and 5 evidence-based guidelines.

Question

  1. What is the clinical evidence regarding opioid management practices to reduce drug diversion and misuse?
  2. What are the evidence based guidelines for opioid management practices to reduce opioid diversion and misuse?
  3. What is the clinical evidence regarding opioid use patterns for prediction of substance abuse disorder?

Key Message

There is no one set of policies or practices that have been consistently associated with a reduction in opioid diversion and misuse. There is some evidence to suggest increased monitoring of patients and governmental prescription monitoring programs could have some impact on reducing opioid diversion and misuse. Evidence-based guidelines suggest frequently monitoring and assessing patients, using a diverse battery of techniques to prevent opioid diversion and misuse. There may be distinct patterns of opioid use associated with substance abuse and guideline recommended opioid prescription practices may reduce substance abuse.