Systematic Review of Opioids for Pain and Opioid Dependence: The Risks Cannot be Estimated

The epidemic of prescription opioid dependence in the United States has raised concern about whether management of non-cancer pain with opioids is to blame. This systematic review examined 135 potentially relevant studies of this association. Data were extracted from 17 studies that reported the incidence or prevalence of opioid dependence in patients prescribed opioids for treatment of acute or chronic pain. Most studies included adult patients with chronic non-malignant pain; two also included patients with cancer pain.

• Studies were very heterogeneous and of very low quality.
• Only one study included patients with a previous history of drug dependence.
• Incidence ranged from 0 to 24% (median 0.5%).
• Prevalence ranged from 0 to 31% (median 4.5%).

Comments:

The authors conclude that “available evidence suggests that opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence,” but admit that the quality of the evidence is very weak. A scathing critique (McAuliffe, 2013) emphasizes that “studies with very low methodological quality undermine the scientific and medical value of a systematic review.” Unfortunately for clinicians, the existing literature is unable to estimate the incidence of iatrogenic opioid dependence among patients receiving treatment for pain. Better primary research is clearly needed.

Peter D. Friedmann, MD, MPH

Reference:

Minozzi S, Amato L, Davoli M. Development of dependence following treatment with opioid analgesics for pain relief: a systematic review. Addiction. 2013;108(4):688–698.
McAuliffe WE. A critique of Minozzi et al.’s pain relief and dependence systematic review. Addiction. 2013;108(6):1162–1169.