Pharmacological Strategies to Decrease Long-Term Prescription Opioid Use: A Systematic Review

Abstract

Background/Objectives: As long-term prescription opioid use is associated with increased morbidity and mortality, timely dose reduction of prescription opioids should be considered. However, most research has been conducted on patients using heroin. Given the differences between prescription and illicit opioid use, the aim of this review was to provide an overview of pharmacological strategies to reduce prescription opioid use or improve clinical outcomes for people who experience long-term prescription opioid use, including those with opioid use disorder. Methods: We conducted a systematic database search of PubMed, Embase, CINAHL, and the Cochrane Library. Outcomes included dose reduction, treatment dropout, pain, addiction, and outcomes relating to quality of life (depression, functioning, quality of life). Results: We identified thirteen studies (eight randomized controlled trials and five observational studies). Pharmacological strategies were categorized into two categories: (1) deprescribing (tapering) opioids or (2) opioid agonist treatment (OAT) with long-acting opioids. Tapering strategies decreased opioid dosage and had mixed effects on pain and addiction. OAT with buprenorphine or methadone led to improvements in pain relief and quality of life, with a slight (non-significant) preference for methadone in terms of treatment retention (RR = 1.10 [CI: 0.89-1.37]) but not for other outcomes. Most studies had high dropout rates and a serious risk of bias. Conclusions: Tapering reduced prescription opioid doses had mixed effects on pain. OAT improved clinical outcomes without dose reduction. Based on our review findings, there is no clear preference for either tapering or OAT. Tapering may be considered first as it reduces dependency, tolerance, and side effects, but is associated with adverse events and not always feasible. OAT can be a suitable alternative. Non-pharmacological interventions may facilitate tapering. Further research is needed to identify novel pharmacological strategies to facilitate opioid tapering. Registration: PROSPERO 2022 CRD42022323468.

Keywords: opioid agonist treatment; opioid rotation; opioid tapering; prescription opioid misuse; prescription opioid use disorder; prescription opioids.

Figure 1

PRISMA flowchart.

Figure 2

Risk for dropout with stable dosing compared to tapering doses after rotation [45,49,54]. Each ‘event’ is a dropout. The squares are the point estimate for each study, and square sizes corresponds to the weight they contribute to the pooled estimate. Rhomboid represents the pooled estimate.

Figure 3

Risk for dropout after rotation to maintenance doses of buprenorphine and methadone [28,51,52]. Each ‘event’ is a dropout. The squares are the point estimate for each study, and square sizes corresponds to the weight they contribute to the pooled estimate. Rhomboid represents the pooled estimate.