Communities across North America continue to struggle to contain the opioid epidemic. Last year, there were 3,996 opioid-related deaths in Canada—surpassing the 2016 death toll of 3,005 which itself was a record at the time. Similarly, in the U.S., the 2016 record of 64,000 deaths was also overtaken by the 2017 toll of 72,000 opioid deaths.
Although a growing share of this death toll (73 per cent in Canada) can be attributed to the proliferation in recent years of highly potent synthetic opioids (e.g., fentanyl), the misuse and abuse of prescribed opioids has been identified as a root cause of this crisis and continues to be an important cause of opioid overdose deaths.
Since the epidemic began in the late 1990s, efforts to prevent this misuse and abuse have taken many different forms across North America. To help decision-makers in Canada tap into the lessons they offer, a team at the Institute for Work & Health (IWH) conducted a systematic review, now available as an open-access paper in the Canadian Journal of Pain (doi:10.1080/24740527.2018.1479842).
The review, published in July 2018, provides a comprehensive assessment of the studies evaluating strategies that have been tried for promoting the appropriate prescribing of opioids, reducing their misuse and abuse, and preventing overdose deaths. It also describes any unintended consequences of such strategies reported in the reviewed studies.
The systematic review found 65 articles published between the late 1990s and 2015 that examined the effectiveness of 66 interventions or programs. From among these, the review identified eight promising strategies cutting across the various interventions, namely:
- education aimed at health professionals and/or opioid users;
- clinical practice changes;
- naloxone distribution;
- prescription monitoring programs;
- regulatory changes;
- collaborations across different disciplines and professions;
- public health campaigns; and
- opioid substitution treatments.
The programs that worked most effectively were those that combined multiple strategies, according to the review.
Many of the studies we found looked at interventions that combined more than one type of strategy and examined many different outcomes, says Emma Irvin, IWH director of research operations and head of the Institute’s systematic review program.
We see this as a good sign of wide recognition that this is a complex public health problem, one that should involve multi-pronged strategies that cut across the system.
A comprehensive synthesis
Systematic reviews conducted elsewhere have examined the effectiveness of specific strategies, such as medical treatments for opioid use disorders, supervised consumption sites, and community naloxone distribution programs, among others. In contrast, the IWH review aimed for a more comprehensive synthesis. It set out to include all existing strategies that could be implemented in North America. To that end, the review included only studies implemented and evaluated in North America, Europe and Australia/New Zealand.
In recognition that many studies would not be published in peer-reviewed journals, the review team also looked beyond academic journals and included the grey literature (i.e., conference proceedings, white papers, reports and the like). It focused on content aimed at health professionals and health regulators, governments, public health and health promotion agencies, prevention and treatment organizations, workers’ compensation boards, private insurance companies and law enforcement agencies. Due to limitations on the time and resources to conduct the review, the team excluded research produced by military organizations, pharmaceutical companies or for-profit organizations.
And in recognition that answers are urgently needed, the team modified an integral part of the IWH systematic review method: the quality appraisal. Although the review did flag limitations and potential biases in the studies included, it did not filter out studies due to quality issues (e.g. methodological problems).
We understand that it takes time to build up a body of quality evidence, says Dr. Andrea Furlan, IWH scientist and one of the co-leads on the review.
We don’t have the luxury of time when it comes to this issue.
Eight promising strategies
The 65 studies included in the review are all worth reading by anyone developing a program to prevent the misuse and abuse of prescription opioids. Each outlines a unique approach reflecting a specific context, involving particular sets of system actors, and integrating the distinct needs and available resources of the affected communities. Not surprisingly, the review revealed considerable diversity, even within each of the following categories of promising strategies.
Education: These strategies involved formal teaching to improve knowledge or training to impart specific skills. Examples of educational strategies included workshops or continuing medical education aimed at health professionals on managing chronic pain or safe opioid prescribing. They also included community-based education aimed at raising awareness among pain patients and those who use drugs about the risks of opioids. Of the 66 interventions examined, more than half included an education strategy.
Clinical practice: These strategies involved changes in how health care was delivered, such as the implementation of recommendations from clinical practice guidelines, the adoption of a tool to improve opioid prescribing, the introduction of urine drug tests, or the implementation of disease management programs. As with education, about half of the intervention programs included a clinical practice change.
Naloxone distribution: Naloxone is a prescribed medication that reverses the effects of opioids in the brain and restores breathing. In this review, only four studies found a large positive effect for an intervention on reducing opioid overdoses and deaths; in three of these four studies, the intervention involved some type of naloxone distribution—for example, with the use of collaborative practice agreements between pharmacies and prescribers, or via programs that train individuals who use opioids on the use of take-home naloxone kits.
Prescription monitoring programs: Prescription monitoring programs involve the use of electronic databases meant to help pharmacists detect patients who fill multiple prescriptions of the same drug from many different providers, engage in “doctor shopping” to find willing prescribers, or divert prescribed opioids to the illicit street market.
Regulations: Many of the interventions included in the review involved some kind of regulatory change. One example was a state requirement that emergency room (ER) doctors check the prescription monitoring program before giving opioid prescriptions to ER patients; another was a regulatory change to allow pharmacists to dispense naloxone on a doctor’s standing order.
Collaborations: Ten of the included interventions involved collaboration across disciplinary or professional groups. For example, in a health department program to treat people with opioid use disorder using buprenorphine, patients were monitored for an average of 20 weeks by a physician and pharmacist pair; the goal of the collaboration was to reduce the costs involved when maintenance is done only by physicians.
Public health: Public health campaigns were included in five of the studies. One example was a multi-pronged public health program that included prescribing guidelines, one-on-one educational visits with prescribers, timely dissemination of prescribing and mortality data to local media, public service announcement broadcasts, town halls and stakeholder meetings.
Opioid substitution treatments: Opioid substitution therapies involved the use of prescribed methadone or buprenorphine for opioid use disorder and dependence. This type of strategy was usually combined with clinical or educational strategies.
Studies about supervised consumption sites, a strategy that has garnered quite a bit of public attention, were not included in this review. The studies that were done on this strategy within the timeframe of this review were mostly focused on illicit drug use—not prescription opioids, Irvin explains. In addition, they were primarily interested in outcomes such as the transmission of communicable diseases such as HIV/AIDS—outcomes that were beyond the scope of this review, she adds.
The systematic review also highlighted several unintended consequences of implemented strategies, which were reported in 19 of the 65 studies. Examples of unintended consequences for health-care providers included additional burden on staffing and workload. For the target population, examples included patients not receiving necessary prescriptions, increased stigma and police harassment due to the carrying of naloxone kits, and increased use of, and overdoses on, other substances such as morphine, hydromorphone and heroin.
The IWH team is now working on a follow-up synthesis of the studies that came out after 2015, the cut-off point of this systematic review. The team is encouraged that many of the promising strategies in this review have already been implemented in Canada in recent years, says Irvin.
As communities across Canada develop responses to this still-growing public health crisis, the IWH systematic review team hopes decision-makers will consult this synthesis—and the studies upon which it is based—when planning and implementing interventions.