Preventing and managing aberrant drug-related behavior in primary care: Systematic review of outcomes evidence

Abstract

Several strategies for preventing, identifying, and responding to aberrant opioid-related behaviors are recommended in pain management guidelines. This systematic review evaluated data supporting basic strategies for addressing aberrant opioid- related behaviors. Risk reduction strategies were identified via a review of available guidelines. Systematic literature searches of PubMed (May 1, 2007- January 18, 2013) identified articles with evidence relevant to nine basic strategies. Reference lists from relevant articles were reviewed for additional references of interest. Levels of evidence for articles identified were graded on a four-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 supports 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 prescribing tamper-resistant opioids may help prevent misuse but may also have the unintended consequence of prompting a migration of users to other marketed opioids, heroin, or other substances. Similarly, preliminary evidence suggests that although recent regulatory and legal efforts may reduce misuse, they 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 in an attempt to minimize the risk of abuse in opioid treatment patients. Physicians must critically evaluate their opioid prescribing and not only increase their efforts to prevent substance