Changing patterns of opioid initiation for pain management in Ontario, Canada: A population-based cross-sectional study
The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following the...
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| Published in | PloS one Vol. 17; no. 12; p. e0278508 |
|---|---|
| Main Authors | , , , , , , |
| Format | Journal Article |
| Language | English |
| Published |
United States
Public Library of Science
08.12.2022
Public Library of Science (PLoS) |
| Subjects | |
| Online Access | Get full text |
| ISSN | 1932-6203 1932-6203 |
| DOI | 10.1371/journal.pone.0278508 |
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| Abstract | The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release.
We conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015-March 2016; fiscal year [FY] 2015) and in the most recent year available (January-December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication.
In FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%).
Despite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing. |
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| AbstractList | Introduction
The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release.
Methods
We conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015—March 2016; fiscal year [FY] 2015) and in the most recent year available (January—December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication.
Results
In FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%).
Conclusion
Despite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing. The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release. We conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015-March 2016; fiscal year [FY] 2015) and in the most recent year available (January-December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication. In FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%). Despite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing. The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release.INTRODUCTIONThe recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release.We conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015-March 2016; fiscal year [FY] 2015) and in the most recent year available (January-December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication.METHODSWe conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015-March 2016; fiscal year [FY] 2015) and in the most recent year available (January-December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication.In FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%).RESULTSIn FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%).Despite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing.CONCLUSIONDespite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing. Introduction The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release. Methods We conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015—March 2016; fiscal year [FY] 2015) and in the most recent year available (January—December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication. Results In FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%). Conclusion Despite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing. IntroductionThe recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release.MethodsWe conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015-March 2016; fiscal year [FY] 2015) and in the most recent year available (January-December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication.ResultsIn FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%).ConclusionDespite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing. The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release. We conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015-March 2016; fiscal year [FY] 2015) and in the most recent year available (January-December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication. In FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%). Despite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing. |
| Audience | Academic |
| Author | Mamdani, Muhammad M. Juurlink, David N. Tadrous, Mina Men, Siyu Campbell, Tonya J. Paterson, J. Michael Gomes, Tara |
| AuthorAffiliation | 4 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada 5 Women’s College Hospital, Toronto, Ontario, Canada 1 Unity Health Toronto, Toronto, Ontario, Canada 3 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada 6 Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada Stanford University School of Medicine, UNITED STATES 2 ICES, Toronto, Ontario, Canada |
| AuthorAffiliation_xml | – name: Stanford University School of Medicine, UNITED STATES – name: 4 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada – name: 1 Unity Health Toronto, Toronto, Ontario, Canada – name: 5 Women’s College Hospital, Toronto, Ontario, Canada – name: 3 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada – name: 6 Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada – name: 2 ICES, Toronto, Ontario, Canada |
| Author_xml | – sequence: 1 givenname: Tara orcidid: 0000-0002-1468-1965 surname: Gomes fullname: Gomes, Tara – sequence: 2 givenname: Siyu surname: Men fullname: Men, Siyu – sequence: 3 givenname: Tonya J. orcidid: 0000-0001-8459-208X surname: Campbell fullname: Campbell, Tonya J. – sequence: 4 givenname: Mina orcidid: 0000-0003-1911-6129 surname: Tadrous fullname: Tadrous, Mina – sequence: 5 givenname: Muhammad M. surname: Mamdani fullname: Mamdani, Muhammad M. – sequence: 6 givenname: J. Michael orcidid: 0000-0001-5995-1714 surname: Paterson fullname: Paterson, J. Michael – sequence: 7 givenname: David N. surname: Juurlink fullname: Juurlink, David N. |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/36480526$$D View this record in MEDLINE/PubMed |
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| CitedBy_id | crossref_primary_10_1186_s13037_024_00408_w crossref_primary_10_1097_j_pain_0000000000003402 crossref_primary_10_1186_s12954_024_01149_w crossref_primary_10_1186_s40634_023_00585_0 |
| Cites_doi | 10.1001/jamanetworkopen.2019.10734 10.1002/pds.5180 10.1111/head.12499 10.1097/j.pain.0000000000001242 10.1016/j.bja.2018.11.019 10.15585/mmwr.mm6610a1 10.1001/jama.2016.1464 10.1016/j.japh.2018.09.005 10.1136/bmj.330.7497.960 10.1001/jama.2011.370 10.1186/s40545-020-00271-x 10.1503/cmaj.170363 10.1056/NEJMsa1807069 10.7326/M14-2559 10.1097/PHH.0000000000001149 10.12927/hcq.2019.26025 10.1016/S0140-6736(19)30428-3 10.1001/archinternmed.2011.117 10.1016/j.jpain.2017.06.010 |
| ContentType | Journal Article |
| Copyright | Copyright: © 2022 Gomes et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. COPYRIGHT 2022 Public Library of Science 2022 Gomes et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. 2022 Gomes et al 2022 Gomes et al |
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| DOI | 10.1371/journal.pone.0278508 |
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| Notes | ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 14 content type line 23 Competing Interests: Dr. Muhammad Mamdani has received honoraria from Boehringer Ingelheim, Pfizer, Mristol-Myers Squibb, and Bayer. Dr. David Juurlink has received payment for lectures and medicolegal opinions regarding the safety and effectiveness of analgesics, including opioids. He is a member of Physicians for Responsible Opioid Prescribing, a volunteer organization that seeks to reduce opioid-related harm through more cautious prescribing practices. Dr. Gomes has received grant funding from the Ontario Ministry of Health. No other authors have any conflicts of interest to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials. |
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| References_xml | – ident: pone.0278508.ref017 – volume: 2 start-page: e1910734 issue: 9 year: 2019 ident: pone.0278508.ref027 article-title: Opioid Prescribing After Surgery in the United States, Canada, and Sweden publication-title: JAMA Netw Open doi: 10.1001/jamanetworkopen.2019.10734 – volume: 30 start-page: 379 issue: 3 year: 2021 ident: pone.0278508.ref024 article-title: Initial opioid prescription patterns and the risk of ongoing use and adverse outcomes publication-title: Pharmacoepidemiol Drug Saf doi: 10.1002/pds.5180 – volume: 55 start-page: 3 issue: 1 year: 2015 ident: pone.0278508.ref025 article-title: The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies publication-title: Headache doi: 10.1111/head.12499 – volume: 159 start-page: 1562 issue: 8 year: 2018 ident: pone.0278508.ref013 article-title: Clinical indications associated with opioid initiation for pain management in Ontario, Canada: a population-based cohort study publication-title: Pain doi: 10.1097/j.pain.0000000000001242 – volume: 122 start-page: e198 issue: 6 year: 2019 ident: pone.0278508.ref029 article-title: The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse publication-title: Br J Anaesth doi: 10.1016/j.bja.2018.11.019 – volume: 66 start-page: 265 issue: 10 year: 2017 ident: pone.0278508.ref015 article-title: Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use—United States, 2006–2015 publication-title: MMWR Morb Mortal Wkly Rep doi: 10.15585/mmwr.mm6610a1 – volume: 315 start-page: 1624 issue: 15 year: 2016 ident: pone.0278508.ref006 article-title: CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016 publication-title: JAMA doi: 10.1001/jama.2016.1464 – volume: 59 start-page: 17 issue: 1 year: 2019 ident: pone.0278508.ref018 article-title: Associations between initial opioid exposure and the likelihood for long-term use publication-title: J Am Pharm Assoc (2003) doi: 10.1016/j.japh.2018.09.005 – volume: 330 start-page: 960 issue: 7497 year: 2005 ident: pone.0278508.ref020 article-title: Reader’s guide to critical appraisal of cohort studies: 2. 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| SubjectTerms | Ambulatory care Analgesics, Opioid - therapeutic use Cancer Care and treatment Chronic pain Cross-Sectional Studies Dosage and administration Drug dosages Drug overdose Emergency medical care Health insurance Humans Indication Medicine and Health Sciences Morphine Narcotics Ontario - epidemiology Opioids Pain Pain Management Palliative care People and places Personal health Population Population studies Population-based studies Practice Patterns, Physicians Prescriptions Quality standards Substance use disorder |
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| Title | Changing patterns of opioid initiation for pain management in Ontario, Canada: A population-based cross-sectional study |
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