Trends in high-dose opioid prescribing in Canada

Objective

To describe trends in rates of prescribing of high-dose opioid formulations and variations in opioid product selection across Canada.

Design

Population-based, cross-sectional study.

Setting

Canada.

Participants

Retail pharmacies dispensing opioids between January 1, 2006, and December 31, 2011.

Main outcome measures

Opioid dispensing rates, reported as the number of units dispensed per 1000 population, stratified by province and opioid type.

Results

The rate of dispensing high-dose opioid formulations increased 23.0%, from 781 units per 1000 population in 2006 to 961 units per 1000 population in 2011. Although these rates remained relatively stable in Alberta (6.3% increase) and British Columbia (8.4% increase), rates in Newfoundland and Labrador (84.7% increase) and Saskatchewan (54.0% increase) rose substantially. Ontario exhibited the highest annual rate of high-dose oxycodone and fentanyl dispensing (756 tablets and 112 patches per 1000 population, respectively), while Alberta’s rate of high-dose morphine dispensing was the highest in Canada (347 units per 1000 population). Two of the highest rates of high-dose hydromorphone dispensing were found in Saskatchewan and Nova Scotia (258 and 369 units per 1000 population, respectively). Conversely, Quebec had the lowest rate of high-dose oxycodone and morphine dispensing (98 and 53 units per 1000 population, respectively).

Conclusion

We found marked interprovincial variation in the dispensing of high-dose opioid formulations in Canada, emphasizing the need to understand the reasons for these differences, and to consider developing a national strategy to address opioid prescribing.     

A changing landscape of opioid prescribing in emergency medicine

Emergency Medicine providers are grappling with the dual challenges of adequately treating pain while avoiding the risks associated with opioid pain relievers. The aggressive treatment of pain with opioids for the last three decades has resulted in an epidemic of opioid use disorder and opioid related mortality. This editorial discusses the findings in a study of emergency department (ED) opioid prescribing by Yang et al. and explores the changing landscape of opioid prescribing in emergency medicine. We specifically discuss risks associated with opioid prescribing, strategies to reduce risks while improving pain management, the role of advanced practice providers in ED opioid prescribing, and the importance of further education on opioid sparing pain management strategies.     

Eight principles for safer opioid prescribing and cautions with benzodiazepines

The provision of long-term opioid analgesic therapy for chronic pain requires a careful risk/benefit analysis followed by clinical safety measures to identify and reduce misuse, abuse, and addiction and their associated morbidity and mortality. Multiple data sources show that benzodiazepines, prescribed for comorbid insomnia, anxiety, and mood disorders, heighten the risk of respiratory depression and other adverse outcomes when combined with opioid therapy. Evidence is presented for hazards associated with coadministration of opioids and benzodiazepines and the need for caution when initiating opioid therapy for chronic pain. Clinical recommendations follow, as drawn from 2 previously published literature reviews, one of which proffers 8 principles for safer opioid prescribing; the other review presents risks associated with benzodiazepines, suggests alternatives for co-prescribing benzodiazepines and opioids, and outlines recommendations regarding co-prescribing if alternative therapies are ineffective.     

Survey of Ontario primary care physicians' experiences with opioid prescribing

Objective

To measure physicians’ experiences with opioid-related adverse events and their perceived level of confidence in their opioid prescribing skills and practices.

Design

Mailed survey.

Setting

The province of Ontario.

Participants

A total of 1000 primary care physicians randomly selected from the College of Physicians and Surgeons of Ontario registration database.

Main outcome measures

Opioid-related adverse events and concerns (eg, number of patients, type of opioid, cause of the event or concern); physicians’ confidence, comfort, and satisfaction with opioid prescribing; physicians’ opinions on strategies to optimize their prescribing; and physicians’ perspectives of their interactions with pharmacists and nurses.

Results

The response rate was close to 66%, for a total of 658 participants. Almost all respondents reported prescribing opioids for chronic pain in the past 3 months. Eighty-six percent of respondents reported being confident in their prescribing of opioids, but 42% of respondents indicated that at least 1 patient had experienced an adverse event related to opioids in the past year, usually involving oxycodone, and 16.3% of respondents did not know if their patients had experienced any opioid-related adverse events. The most commonly cited factors leading to adverse events were that the patient took more than prescribed, the prescribed dose was too high, or the patient took alcohol or sedating drugs with the opioids. Most physicians had concerns about the opioid use of 1 or more of their patients; concerns included running out of opioids early, minimal access to pain and addiction treatment, and addiction and overdose. The reported number of physicians’ patients taking opioids was positively associated with their confidence and comfort levels in opioid prescribing and negatively associated with their belief that many patients become addicted to opioids.

Conclusion

Most physicians have encountered opioid-related adverse events. Comprehensive strategies are required to promote safe prescribing of opioids, including guidelines and comprehensive office-system materials.     

Computational opioid prescribing: a novel application of clinical pharmacokinetics

We implemented a pharmacokinetics-based mathematical modeling technique using algebra to assist prescribers with point-of-care opioid dosing. We call this technique computational opioid prescribing (COP). Because population pharmacokinetic parameter values are needed to estimate drug dosing regimen designs for individual patients using COP, and those values are not readily available to prescribers because they exist scattered in the vast pharmacology literature, we estimated the population pharmacokinetic parameter values for 12 commonly prescribed opioids from various sources using the bootstrap resampling technique. Our results show that opioid dosing regimen design, evaluation, and modification is feasible using COP. We conclude that COP is a new technique for the quantitative assessment of opioid dosing regimen design evaluation and adjustment, which may help prescribers to manage acute and chronic pain at the point-of-care. Potential benefits include opioid dose optimization and minimization of adverse opioid drug events, leading to potential improvement in patient treatment outcomes and safety.     

Physician attitudes toward opioid prescribing for patients with persistent noncancer pain

OBJECTIVES: Physicians frequently express dissatisfaction about caring for patients with chronic pain and frequently report that inadequate training and concern about addiction are impediments to prescribing opioids. Elderly patients with chronic pain may be at increased risk of experiencing uncontrolled pain and this patient population is increasingly being cared for by geriatricians rather than internists. We sought to determine if there is a differential impact on internists and geriatricians of the factors that adversely affect attitudes toward opioid prescribing. METHODS: Anonymous survey of geriatric and internal medicine physicians at a large urban academic medical center about their beliefs and behaviors regarding opioid prescribing. RESULTS: One hundred thirty-two of 187 physicians completed the survey for an overall response rate of 71%. Controlling for level of training, internists were more likely to be concerned about illegal diversion (adjusted odds ratio=10.0, P=0.004), were more concerned about causing addiction (38% vs. 0%, P<0.001), and were more likely to be concerned about their inability to prescribe the correct opioid dose (adjusted odds ratio=11.1, P=0.020). DISCUSSION: Factors shown to have an adverse affect on opioid prescribing disproportionately impact on the attitudes of internists compared with geriatricians. Further research is needed to determine if there is also a differential impact on how internists care for their elderly patients with chronic pain.     

Uganda: delivering analgesia in rural Africa: opioid availability and nurse prescribing

Hospice Africa Uganda introduced palliative medicine to Uganda in 1993 with enough funds to support a team of three clinicians for three months. Training in the medical and nursing schools was introduced in 1994. Since then, Uganda has achieved the three essential components of an effective public health strategy. It has also been the first country to have palliative care described as an essential clinical service and included in both the government's Strategic Health Plan and its HIV/AIDS National Strategic Framework (in 2000 and 2004), and to change the law to allow nurses and clinical officers who complete special training in palliative medicine at Hospice Uganda to prescribe morphine. Palliative care is spreading throughout the districts of Uganda, ensuring that morphine will be available to everyone who needs it. This is being done in collaboration with the Ministry of Health (MOH) and other organizations that collaborate in two umbrella organizations: the Palliative Care Association of Uganda and the Uganda Palliative Care Country Team. The former works "on the ground" in each district, establishing standards, collaborating, and carrying out continuing medical education in palliative care for all. The latter, chaired by the MOH, operates with the government to implement an integrated, coordinated, affordable, and culturally acceptable palliative care service throughout the country.     

The DIRE score: predicting outcomes of opioid prescribing for chronic pain.

The objective of this retrospective study was to test the validity and reliability of a scoring tool (the DIRE Score), for use by clinicians, that predicts which chronic noncancer pain patients will have effective analgesia and be compliant with long-term opioid maintenance treatment. DIRE scores were assigned to 61 cases from the pain center's databases. These cases were abstracted into vignettes that were reviewed and scored by 6 physicians. Repeat scoring was carried out on a subset of 30 vignettes after 2 weeks. The main outcome measures were: global impression of compliance and efficacy as indicated in the medical record and by interview with the patient's treating clinician; and final disposition, ie, whether or not opioids were continued or discontinued at the time of last clinical documentation. Internal consistency of the factors making up the DIRE Score was high (Cronbach's alpha = .80). Sensitivity and specificity of the DIRE Score for predicting patient compliance were 94% and 87%, respectively. For efficacy, sensitivity and specificity were 81% and 76%. For disposition, the sensitivity and specificity were 86% and 73%. Intraclass correlation was 0.94 for interrater reliability and 0.95 for intrarater reliability. PERSPECTIVE: Public controversy about the use of long-term opioids for chronic pain fuels physician ambivalence about the prescribing process. In this initial retrospective study, validity and reliability of the DIRE Score are demonstrated. The score correlated well with measures of patient compliance and efficacy of long-term opioid therapy.