Background: Canada and the United States have the highest levels of prescription opioid consumption
in the world. In an attempt to curb the opioid epidemic, a variety of interventions have been implemented.
Thus far, evidence regarding their effectiveness has not been consolidated.
Objectives: The objectives of this study were to: 1) identify interventions that target opioid prescribing;
2) assess and compare the effectiveness of interventions on opioid prescription and related harms; 3)
determine the methodological quality of evaluation studies.
Study Design: The study involved a systematic review of the literature including bibliographical
databases and gray literature sources.
Setting: Systematic review including bibliographical databases and gray literature sources.
Methods: We searched MEDLINE, Embase, and LILACS databases from January 1, 2005 to September 23,
2016 for any intervention that targeted the prescription of opioids. We also examined websites of relevant
organizations and scanned bibliographies of included articles and reviews for additional references. The
target population was that of all health care providers (HCPs) or users of opioids with no restriction on
indication. Endpoints were those related to process (implementation), outcomes (effectiveness), or impact.
Sources were screened independently by 2 reviewers using pre-defined eligibility criteria. Synthesis of
findings was qualitative; no pooling of results was conducted.
Results: Literature search yielded 12,278 unique sources. Of these, 142 were retained. During full-text
review, 75 were further excluded. Searches of the gray literature and bibliographies yielded 49 additional
sources. Thus, a total of 95 distinct interventions were identified. Over half consisted of prescription
monitoring programs (PMPs) and mainly targeted HCPs. Evaluation studies addressed mainly opioid
prescription rate (30.6%), opioid use (19.4%), or doctor shopping or diversion (9.7%). Fewer studies
considered overdose death (9.7%), abuse (9.7%), misuse (4.2%), or diversion (5.6%). Study designs
consisted of cross-sectional surveys (23.3%), pre-post intervention (26.7%), or time series without a
comparison group (13.3%), which limit the robustness of the evidence. Although PMPs and policies
have been associated with a reduction in opioid prescription, their impact on appropriateness of use
according to clinical guidelines and restriction of access to patients in need is inconsistent. Continuing
medical education (CME) and pain management programs were found effective in improving chronic pain
management, but studies were conducted in specific settings. The impact of interventions on abuse and
overdose-death is conflicting.
Limitations: Due to the very large number of publications and programs found, it was difficult
to compare interventions owing to the heterogeneity of the programs and to the methodologies of
evaluation studies. No assessment of publication bias was done in the review.
Conclusions: Evidence of effectiveness of interventions targeting the prescription of opioids is scarce in
the literature. Although PMPs have been associated with a reduction in the overall prescription rates of
Schedule II opioids, their impact on the appropriateness of use taking into consideration benefits, misuse,
legal and illegal use remains elusive. Our review suggests that existing interventions have not addressed
all determinants of inappropriate opioid prescribing and usage. A well-described theoretical framework
would be the backdrop against which targeted interventions or policies may be developed.
Key words: Opioid, prescription, abuse, misuse, diversion, interventions, prescription monitoring
programs
A Systematic Review of Interventions and
Programs Targeting Appropriate Prescribing of
Opioids