Global use of opioids has risen dramatically in recent years to more than 38 million partially because of pain strategies including the use of opioids.1 Opioids have been used to treat both cancer pain and chronic noncancer pain. The United States is the biggest consumer of hydrocodone and oxycodone opioids.1 The unintended consequence from the increased consumption of opioids has resulted in misuse, dependence, and overdose (OD). Public health policies are needed to address the significant increase in emergency room visits related to opioid use and admissions for opioid-related diagnoses.2,3
Opioid dependence represents a complex health condition requiring long-term intervention to be successful.1 Guidelines recommend opioid substitution treatment (OST) with methadone and buprenorphine to treat dependence.1 Opioid substitution treatment involves the administration of a long-acting opioid in conjunction with psychosocial support. It provides people time to stabilize their lives and address social factors and psychological issues. A negative aspect of OST is that the medication can be diverted. Diversion encompasses both a sale of the medication illegally and the unsanctioned use of medications.1,3 To minimize diversion and misuse of opioids by people who are dependent, it has been proposed that medications be given under strict medical supervision. Supervised OST is standard practice in managing drug dependence in treatment centers, but it is expensive to implement.1 It is important to do this review to provide evidence that may benefit patients from less restricting dosing strategies and the need to balance with potential risks to the community from possible diversion of OST medications.
A deeper understanding of OD and OST by nurses is necessary because of the increasing use of opioids and resulting OD in the community. Greater understanding of this chronic condition and its treatment can lead to improved care and more consistency when treating this population and reduce the social stigma associated with drug dependence.
OBJECTIVE/S
The objective of the review was to compare the effectiveness of OST with supervised dosing relative to dispensing of medication for off-site consumption. The primary outcomes studied in the review were retention in treatment-number of participants who complete the study protocol, abstinence from unsanctioned opioid use, diversion-inappropriate use of medication by the person(s) for whom it was intended, and frequency of unsanctioned opioid use at the end of the intervention timeframe.
INTERVENTION/METHODS
Randomized control trials (RCTs), controlled clinical trials, and prospective controlled cohort studies were included in the review. It was necessary to include trials other than RCTs because of the difficulty of conducting RCTs in this population. Inclusion criteria were participants with diagnoses of opioid dependence and receiving OST treatment with methadone or buprenorphine. Additional diagnosis of alcoholism and participants requiring methadone maintenance programs were eligible. The databases searched included Cochrane Drugs and Alcohol Group Specialized Register and Cochrane Central Register of Control trials, MEDLINE EMBASE, CINAHL, Web of Science from inception up to April 2016, ClinicalTrials.gov, World Health Organization, and the Clinical Trials Registry Platform. English and non-English publications were included. Interventions included experimental with supervised OST and a comparator of dispensing medication to be consumed away from the area of dispersion without supervision.
RESULTS
A total of 6 studies (4 RCTs and 2 prospective observational cohorts) with 7999 participants with a mean age of 35 years were included in the review. For the primary outcome of retention, there was no significant difference between supervised OST and nonsupervised consumption (relative risk, 0.88; 95% confidence interval, 0.88-1.12; n = 716). Treatment times were 3 to 12 months in duration. For the abstinence at the end of treatment outcome, there was no difference between supervised and nonsupervised therapy in self-reported heroin use at 3 months (67% vs 60%, P = .33; n = 293). For the diversion outcome, 1 study found that a total of 5% responders in the supervised group and 2% in the unsupervised group reported they permitted another person to have their medication, but it was not clear if the data referred to diversion. There were no studies that assessed days of unsanctioned opioid use.
CONCLUSIONS
The review was limited by the small number of studies resulting in only a few meta-analyses being performed. The studies also had a high risk of bias, leading to a rating of low to very low quality for the studies and subsequent outcomes measured. The applicability of the findings of the review is limited because of the small number and design of the studies. The results of this review are inconclusive, and more research is needed with longer follow-up periods to support supervised OST. There is a need for research focused on assessing the risk of diversion and safety outcomes of using supervised OST to manage opioid dependence.
IMPLICATIONS FOR PRACTICE
There is a need for more randomized trials with larger sample sizes. Efficacy of the intervention needs further exploration of replication and applicability to other settings. At this time, the decision to participate in OST with supervision versus nonsupervision should be made on a case-by-case basis, taking into consideration several factors including social and environmental. Nurses need to engage the patient in a dialog encompassing all factors when developing a treatment plan for opioid-dependent patients and to reduce the social stigma associated with the condition.
The Mission of Cochrane Nursing (CN) is to support Cochrane's work by increasing the use of their library and provide an international evidence base for nurses and related healthcare professionals involved in delivering, leading or researching nursing care. The CN produces 'Cochrane Corner' columns (summaries of recent nursing-care-relevant Cochrane reviews) that are regularly published in the group's collaborating nursing-care-related journals. The original authors and full citations of the Cochrane reviews are noted in each published column. These published summaries reach a much wider group of nurses and related healthcare agencies internationally and allow direct access to highly relevant evidence outcomes that frontline healthcare workers might not otherwise have access to. Information on the processes this group has developed can be accessed at: https://nursing.cochrane.org/.
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