Abstract
AimsTo examine the impact of national clinical practice guidelines and provincial drug policy interventions on prevalence of high-dose opioid prescribing and rates of hospitalization for opioid toxicity.DesignInterventional time-series analysis.SettingOntario, Canada, from 2003 to 2014.ParticipantsOntario Drug Benefit (ODB) beneficiaries aged 15 to 64 years from 2003 to 2014.InterventionsPublication of Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain (May 2010) and implementation of Ontario’s Narcotics Safety and Awareness Act (NSAA; November 2011).MeasurementsThree outcomes were explored: the rate of opioid use among ODB beneficiaries, the prevalence of opioid prescriptions exceeding 200 mg and 400 mg morphine equivalents per day, and rates of opioid-related emergency department visits and hospital admissions.FindingsOver the 12 year study period, the rate of opioid use declined 15.2%, from 2764 to 2342 users per 10,000 ODB eligible persons. The rate of opioid use was significantly impacted by the Canadian clinical practice guidelines (p-value = .03) which led to a decline in use, but no impact was observed by the enactment of the NSAA (p-value = .43). Among opioid users, the prevalence of high-dose prescribing doubled (from 4.2% to 8.7%) over the study period. By 2014, 40.9% of recipients of long-acting opioids exceeded daily doses of 200 mg morphine or equivalent, including 55.8% of long-acting oxycodone users and 76.3% of transdermal fentanyl users. Moreover, in the last period, 18.7% of long-acting opioid users exceeded daily doses of 400 mg morphine or equivalent. Rates of opioid-related emergency department visits and hospital admissions increased 55.0% over the study period from 9.0 to 14.0 per 10,000 ODB beneficiaries from 2003 to 2013. This rate was not significantly impacted by the Canadian clinical practice guidelines (p-value = .68) or enactment of the NSAA (p-value = .59).ConclusionsAlthough the Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain led to a decline in opioid prescribing rates among ODB beneficiaries these guidelines and subsequent Ontario legislation did not result in a significant change in rates of opioid-related hospitalizations. Given the prevalence of high dose opioid prescribing in this population, this suggests that improved strategies and programs for the safe prescribing of long-acting opioids are needed.
Highlights
Long-term opioid treatment for non-cancer pain has become common, little evidence supports the practice[1,2]
Given the prevalence of high dose opioid prescribing in this population, this suggests that improved strategies and programs for the safe prescribing of longacting opioids are needed
The introduction of the Canadian clinical practice guidelines in May 2010 significantly impacted the rate of opioid use (p-value = .03) leading to a decline, from 2713 users per 10,000 Ontario Drug Benefit (ODB) eligible persons in the first half of 2010 to 2342 users per 10,000 ODB eligible persons in the second half of 2014
Summary
Long-term opioid treatment for non-cancer pain has become common, little evidence supports the practice[1,2]. Over the last two decades, significant increases in opioid prescribing rates and average prescription volumes have been documented in both the United States [3] and Canada [4] These trends are concerning because high-dose opioid therapy is associated with considerable morbidity and mortality, including drug toxicity, overdose death, falls, fractures, and motor vehicle injury [5,6,7,8]. In Canada, interventions aimed at reducing opioid use have included the publication of national clinical practice guidelines regarding use of opioids in chronic non-cancer pain in May 2010[15] and the Ontario’s Narcotics Safety and Awareness Act (NSAA) in November 2011 [16]. The publication of national clinical practice guidelines provided evidence-based recommendations on opioid indications, selection, precautions and monitoring to Canadian physicians with the focus of reducing opioid-related harms such as addiction and overdose [15]
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