scholarly journals Time trends and prescribing patterns of opioid drugs in UK primary care patients with non-cancer pain: a retrospective cohort study

2020 ◽  
Author(s):  
Meghna Jani ◽  
Belay Birlie Yimer ◽  
Therese Sheppard ◽  
Mark Lunt ◽  
William G Dixon
Keyword(s):  
Primary Care ◽  
Cancer Pain ◽  
Case Mix ◽  
High Dose ◽  
Opioid Use ◽  
Opioid Dose ◽  
Opioid Prescribing ◽  
Prescribing Behaviour ◽  
Physician Prescribing

ABSTRACTBackgroundThe U.S. opioid epidemic has led to similar concerns about prescribed opioids in the U.K. In new users, escalation to more potent and high-dose opioids may contribute to long-term use as well as opioid-related morbidity/mortality. The scale of such escalation is unclear for non-cancer pain. Additionally, physician prescribing behaviour has been described as a key driver of rising opioid prescriptions and long-term opioid use. No studies have investigated the extent to which regions, practices, prescribers, vary in opioid prescribing, whilst accounting for case-mix.MethodsUsing a retrospective cohort study we used U.K. primary-care electronic health records from Clinical Practice Research Datalink to: (i)describe prescribing trends between 2006-17 (ii)evaluate the transition of opioid dose and potency in the first 2-years from initial prescription (iii)quantify and identify risk factors for long- term opioid use (iv)quantify the variation of long-term use attributed to region, practice and prescriber, accounting for case-mix and chance variation. Adult patients with a new prescription of an opioid without cancer were included.Findings1,968,742 new-users of opioids were identified. Rates of codeine use were highest, increasing five-fold from 2006-2017, reaching up to 2,456 prescriptions/10,000 people/year. Morphine, buprenorphine and oxycodone prescribing rates continued to rise steadily throughout the study period. Of those who started on high (100-200 Morphine Milligram Equivalents [MME]/day) or very high dose opioids (>200 MME/day), 4.9% and 10.3% remained in the same or higher MME/day category throughout 2-years, respectively. Following opioid initiation, 15% became long-term opioid users. In the fully adjusted model, MME at initiation, older- age, social deprivation, fibromyalgia, rheumatological conditions, substance abuse, suicide/self-harm and gabapentinoid use were associated with the highest odds of long-term use. After adjustment for case-mix, the North-West, Yorkshire, South- West; 103 practices (25.6%) and 540 prescribers (3.5%) were associated with a significantly higher risk of long-term use.InterpretationPatients commenced on high MMEs were more likely to stay in the same state for a subsequent 2-years and were at increased risk of long-term use. In the first UK study evaluating long-term opioid prescribing with adjustment for patient-level characteristics, variation in regions and especially practices and prescribers were observed. Our findings support greater calls for action for reduction in practice and prescriber variation by promoting safe practice in opioid prescribing.FundingVersus Arthritis and National Institute for Health ResearchResearch in ContextEvidence before this studyDrug dependence and deaths due to opioids have led to an opioid-overdose crisis in several countries globally including the US and Canada, and subsequent concerns about overprescribing in the UK. Physician prescribing behaviour has implicated as a key driver of rising opioid prescriptions and long-term opioid use however this needs to be assessed in the context of region, GP practice and individual patients. We searched Pubmed and Google Scholar between January 2005 and November 2019, with the terms “opioid” AND/OR “opiate”, “chronic pain” AND/OR “non-cancer pain”, and UK AND/OR England AND/OR “Great Britain” AND/OR “NHS”. We also reviewed relevant reports from Public Health England and other national bodies. The more recent trends for opioid prescribing have included all prescriptions including those for cancer pain, and those that include primary care UK prescription data for non-cancer indications are several years out of date. No studies evaluated how opioid dose and potency changes over time in individual patients after starting an opioid for the first time to assess escalation or tapering. National variation in opioid prescribing reported thus far has not accounted for patient case-mix. No studies have assessed the effect of the prescriber on opioid prescribing adjusting for regional, practice level variation and for individual characteristics.Added value of this studyThere has been a substantial overall increase in opioid-prescribing for non-cancer pain with clear drug-specific trends between 2006-17. To our knowledge, this is the first UK study that has evaluated the sequential transition on how dose/potency vary when a patient is first prescribed an opioid in primary care. Furthermore we report for the first time the effect of individual risk factors, UK regions, GP practice and prescriber (whilst considering these elements together) on long-term opioid use.Implications of all the available evidenceOur study highlights the key subpopulations in a UK primary care setting at risk of developing long-term opioid use and the need for closer monitoring of at risk patients. Marked variation between region, practice and prescribers still exists after adjusting for case-mix warranting evidence-based harmonised opioid prescribing guidelines with clearer MME/day thresholds. On a practice level, guidance on regular review and dose reduction, as well as using prescriber and practice variations as a proxy for quality of care through audit and feedback, to highlight unwarranted variation to prescribers, could help drive safer prescribing.

scholarly journals Evaluating health and well-being outcomes following the South Gloucestershire Pain Review pilot for patients on long-term opioids for chronic non-cancer pain

2019 ◽  
Vol 69 (suppl 1) ◽  
pp. bjgp19X703445
Author(s):  
Jo Kesten ◽  
Lauren Scott ◽  
Kevin Bache ◽  
Rosie Closs ◽  
Sabi Redwood ◽  
...  
Keyword(s):  
Primary Care ◽  
Pain Management ◽  
Cancer Pain ◽  
Management Strategies ◽  
Well Being ◽  
Service Users ◽  
Opioid Use ◽  
The South ◽  
Health And Well Being

BackgroundThe South Gloucestershire Pain Review pilot is an individually-tailored service to help primary care patients on long-term (>3 months) treatment with opioid painkillers for chronic non-cancer pain understand their relationship with opioids and support alternative non-drug-based pain management strategies. The pilot was based in two GP practices in South Gloucestershire.AimTo evaluate the health and well-being outcomes and perceived impact of the pilot service to inform future service development.MethodQuantitative data were collected for all enrolled patients on demographics; opioid use, misuse and dose; and pre-post intervention changes in health, well-being, quality of life (QoL), pain intensity/relief, and interference with life measures. Twenty-five semi-structured interviews (18 service users, seven service providers) explored experiences of the pilot including perceived impacts.ResultsFifty-nine patients were invited to use the service and 34 (58%) enrolled. The median prescribed opioid dose reduced from 90 mg (interquartile range [IQR] 60–240) at baseline to 72 mg (IQR 30–160) at follow-up (P<0.001). On average, service users showed improvement on all health, well-being, and QoL outcomes except pain relief. The service was received positively. Perceived benefits related to well-being and QoL, use of pain management strategies (for example pacing), changes in medication use and changes in primary care use.ConclusionThe pilot has shown promising results. The service was viewed as acceptable and health and well-being outcomes suggest a benefit. Following further development of the service, a randomised controlled trial is needed to formally test the effects of this type of care pathway on pain management and reducing long-term opioid use.

scholarly journals Understanding long-term opioid prescribing for non-cancer pain in primary care: a qualitative study

2015 ◽  
Vol 16 (1) ◽  
Author(s):  
Carolyn McCrorie ◽  
S. José Closs ◽  
Allan House ◽  
Duncan Petty ◽  
Lucy Ziegler ◽  
...  
Keyword(s):  
Primary Care ◽  
Qualitative Study ◽  
Cancer Pain ◽  
Opioid Prescribing

scholarly journals Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project.

2020 ◽  
Author(s):  
Aleksandra E Zgierska ◽  
James M Robinson ◽  
Robert P Lennon ◽  
Paul D Smith ◽  
Kate Nisbet ◽  
...  
Keyword(s):  
Primary Care ◽  
Quality Improvement ◽  
Cancer Pain ◽  
System Level ◽  
Stepped Wedge ◽  
Convenience Sample ◽  
Clinic Staff ◽  
Opioid Prescribing ◽  
Urine Drug

Abstract Background: Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations. Methods: Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4-6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p<0.05, 95% confidence intervals and/or Cohen’s d. Results: Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1,255 patients in the QI and 1,632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p=0.019) and prescribed ≥90mg/day MED (23.0% vs 15.5%, p=0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p=0.02), but not other outcomes (p³0.05). Conclusions: Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented.Trial Registration – Not applicable

An observational study assessing high dose opioid prescribing and associated adrenal insufficiency

2018 ◽  
Vol 68 (suppl 1) ◽  
pp. bjgp18X696641 ◽  
Author(s):  
Sophie Hayhoe ◽  
Simon Rudland ◽  
Damian Morris
Keyword(s):  
Adrenal Insufficiency ◽  
Case Reports ◽  
Serum Cortisol ◽  
Adrenal Suppression ◽  
Endocrine Function ◽  
High Dose ◽  
Opioid Use ◽  
Practice List ◽  
Opioid Dose

BackgroundLong-term opioid use is known to affect endocrine function, with case reports indicating an association with adrenal insufficiency.AimThis study aims to investigate long-term, high-dose opioid use (≥80mg morphine or equivalent per day) at a Suffolk (UK) General Practice and its effect on adrenal function.MethodFrom a practice list of 18,300, retrospective data was collected for patients prescribed high-dose opioids for non-cancer pain for at least three months on current repeat prescription. Patient demographics and prescribing information were collected using SystmOne. Cortisol levels in the high-dose opioid patients, and short synacthen testing if indicated, were performed.ResultsThe 35 identified patients (0.2% of practice list) were predominantly female (77%) ≥70 years old (37%), and taking opioids prescribed for osteoarthritis or back pain (77%). 6% were prescribed >280mg morphine or equivalent per day, with one patient prescribed 705 mg. Routine evaluation for development of adrenal suppression and subsequent management was poor. 31% (11 of 35) had developed symptoms potentially indicative of adrenal insufficiency. One of these patients was among the 21% (7 of 35) with suppressed serum cortisol. Adrenal insufficiency secondary to opioids was confirmed in one patient using short synacthen testing. There was no statistical difference in either opioid dose or months of use for those with or without early morning cortisol suppression.ConclusionThe investigation highlights both the considerable use of high-dose opioids for non-malignant pain and their apparent association with adrenal suppression, demonstrating the need for formal guidelines to aid recognition and diagnosis.

scholarly journals O18 National variation and factors associated with long-term opioid use for non-cancer pain in the first year of use

Rheumatology ◽  
2020 ◽  
Vol 59 (Supplement_2) ◽  
Author(s):  
Meghna Jani ◽  
Belay Birlie-Yimer ◽  
Therese Sheppard ◽  
Mark Lunt ◽  
William G Dixon
Keyword(s):  
High Risk ◽  
Case Mix ◽  
First Year ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Factors Associated ◽  
Opioid Prescribing ◽  
Population Average ◽  
Opioid Users

Abstract Background Physician prescribing behaviour has been described as a key driver of rising opioid prescriptions and long-term opioid use. However, the effect of prescribers requires interpretation within context. No studies have investigated the extent to which regions, practices, prescribers, vary in opioid prescribing by considering this hierarchy together, whilst accounting for case-mix. Objectives: (i)quantify and identify risk factors for the transition from new-users to long-term opioid users (ii) quantify variation of long-term use attributed to region, practice, prescriber, accounting for patient mix and chance variation. Methods We conducted a retrospective observational study between 2006-2017 using Clinical Practice Research Datalink. New users of opioids, ≥18 years, without cancer were identified. Long-term opioid use was defined as ≥ 3 opioid prescriptions within a 90-day period from index date, or ≥ 1 opioid prescription lasting at least 90-days in the first year. A multi-level random-effects logistic regression model was used to examine the association of patient characteristics with the odds of becoming a long-term opioid-user. To examine variation in opioid use among prescribers, GP-practices and region after adjusting for case-mix, we used a nested random-effect structure. A ‘high-risk’ region, prescriber or practice was defined as those where the entire adjusted 95% CI lay above population average. Results 1,968,742 new opioid users were included; 14.6% transitioned to long-term use. In the fully-adjusted model, factors associated with higher-odds of long-term use included high morphine-milligram equivalents (MME)/day at first prescription, older-age, deprivation, fibromyalgia, rheumatological conditions and prior surgery (Table 1). After adjustment for case-mix, the North-West, Yorkshire and South-West were found to be high-risk regions for long-term use. 103 practices (25.6%) and 540 prescribers (3.5%) were associated with a significantly higher risk of long-term use. The odds of becoming a long-term user for patients belonging to these prescribers reached up to &gt; 3.5 times than the population average. Conclusion Prescribing factors, age, deprivation and conditions including fibromyalgia and rheumatological conditions were associated with higher odds of long-term opioid use. In the first UK study evaluating long-term opioid prescribing with patient-level characteristics adjustment, variation in regions, especially practices and prescribers were observed. Our findings support greater calls for action to reduce practice/prescriber variation by promoting safe practice in opioid-prescribing. Disclosures M. Jani: None. B. Birlie-Yimer: None. T. Sheppard: None. M. Lunt: None. W.G. Dixon: None.

scholarly journals Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Aleksandra E. Zgierska ◽  
James M. Robinson ◽  
Robert P. Lennon ◽  
Paul D. Smith ◽  
Kate Nisbet ◽  
...  
Keyword(s):  
Primary Care ◽  
Quality Improvement ◽  
Cancer Pain ◽  
System Level ◽  
Stepped Wedge ◽  
Convenience Sample ◽  
Clinic Staff ◽  
Opioid Prescribing ◽  
Urine Drug

Abstract Background Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations. Methods Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4–6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse risk screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90 mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p < 0.05, 95% confidence intervals and/or Cohen’s d. Results Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1255 patients in the QI and 1632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p = 0.019) and prescribed ≥90 mg/day MED (23.0% vs 15.5%, p = 0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90 mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p = 0.02), but not other outcomes (p ≥ 0.05). Conclusions Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented. Trial registration Not applicable.

scholarly journals Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project.

2020 ◽  
Author(s):  
Aleksandra E Zgierska ◽  
James M Robinson ◽  
Robert P Lennon ◽  
Paul D Smith ◽  
Kate Nisbet ◽  
...  
Keyword(s):  
Primary Care ◽  
Quality Improvement ◽  
Cancer Pain ◽  
System Level ◽  
Stepped Wedge ◽  
Convenience Sample ◽  
Clinic Staff ◽  
Opioid Prescribing ◽  
Urine Drug

Abstract Background: Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations. Methods: Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4-6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The intervention subjects were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p<0.05, 95% confidence intervals and/or Cohen’s d. Results: Two-hundred-fifteen intervention subjects, a subset of clinical staff, received at least one intervention component; 1,255 patients in the intervention and 1,632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more intervention than comparison clinic patients were screened for depression (8.1% vs 1.1%, p=0.019) and prescribed ≥90mg/day MED (23.0% vs 15.5%, p=0.038). The stepped-wedge analysis did not show statistically significant change in outcomes in the intervention clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the intervention clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90mg/day MED in the intervention compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p=0.02), but not other outcomes (p³0.05). Conclusions: Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, under more rigorous implementation conditions.

scholarly journals Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project.

2020 ◽  
Author(s):  
Aleksandra E Zgierska ◽  
James M Robinson ◽  
Robert P Lennon ◽  
Paul D Smith ◽  
Kate Nisbet ◽  
...  
Keyword(s):  
Primary Care ◽  
Quality Improvement ◽  
Cancer Pain ◽  
System Level ◽  
Stepped Wedge ◽  
Convenience Sample ◽  
Clinic Staff ◽  
Opioid Prescribing ◽  
Urine Drug

Abstract Background: Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations.Methods: Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4-6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p<0.05, 95% confidence intervals and/or Cohen’s d.Results: Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1,255 patients in the QI and 1,632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p=0.019) and prescribed ≥90mg/day MED (23.0% vs 15.5%, p=0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p=0.02), but not other outcomes (p³0.05).Conclusions: Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented.Trial Registration – Not applicable

scholarly journals Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project.

2020 ◽  
Author(s):  
Aleksandra E Zgierska ◽  
James M Robinson ◽  
Robert P Lennon ◽  
Paul D Smith ◽  
Kate Nisbet ◽  
...  
Keyword(s):  
Primary Care ◽  
Quality Improvement ◽  
Cancer Pain ◽  
System Level ◽  
Stepped Wedge ◽  
Convenience Sample ◽  
Clinic Staff ◽  
Opioid Prescribing ◽  
Urine Drug

Abstract Background: Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations. Methods: Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4-6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p<0.05, 95% confidence intervals and/or Cohen’s d. Results: Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1,255 patients in the QI and 1,632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p=0.019) and prescribed ≥90mg/day MED (23.0% vs 15.5%, p=0.038). The stepped-wedge analysis did not show statistically significant change in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p=0.02), but not other outcomes (p³0.05). Conclusions: Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented.Trial Registration – Not applicable

scholarly journals Patterns of regional variation of opioid prescribing in primary care in England: a retrospective observational study

2018 ◽  
Vol 68 (668) ◽  
pp. e225-e233 ◽  
Author(s):  
Luke Mordecai ◽  
Carl Reynolds ◽  
Liam J Donaldson ◽  
Amanda C de C Williams
Keyword(s):  
Primary Care ◽  
Observational Study ◽  
Cancer Pain ◽  
Regional Variation ◽  
Social Deprivation ◽  
Retrospective Observational Study ◽  
Opioid Prescribing ◽  
The North ◽  
Government Data

BackgroundOpioids are a widely prescribed class of drug with potentially harmful short-term and long-term side effects. There are concerns about the amounts of these drugs being prescribed in England given that they are increasingly considered ineffective in the context of long-term non-cancer pain, which is one of the major reasons for their prescription.AimTo assess the amount and type of opioids prescribed in primary care in England, and patterns of regional variation in prescribing.Design and settingRetrospective observational study using publicly available government data from various sources pertaining to opioids prescribed in primary practice in England and Indices of Social Deprivation.MethodOfficial government data were analysed for opioid prescriptions from August 2010 to February 2014. The total amount of opioid prescribed was calculated and standardised to allow for geographical comparisons.ResultsThe total amount of opioid prescribed, in equivalent milligrams of morphine, increased (r = 0.48) over the study period. More opioids were prescribed in the north than in the south of England (r = 0.66, P<0.0001), and more opioids were prescribed in areas of greater social deprivation (r = 0.56, P<0.0001).ConclusionLong-term opioid prescribing is increasing despite poor efficacy for non-cancer pain, potential harm, and incompatibility with best practice. Questions of equality of care arise from higher prescription rates in the north of England and in areas of greater social deprivation. A national registry of patients with high opioid use would improve patient safety for this high-risk demographic, as well as provide more focused epidemiological data regarding patterns of prescribing.

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