An idea to reduce the epidemic of opioid prescribing

Most physicians will agree that opioids continue to be overprescribed. Of course they have a useful therapeutic role in specific clinical situations, but they continue to be overprescribed in chronic non-cancer pain cases, while other modalities are underused.

Very few of us are innocent in this. But interestingly, we have no idea how our opioid-prescribing stacks up against other practitioners. Do we prescribe more than average? Less than average? Are our own prescribing rates increasing or decreasing?

Here’s what I propose. In Ontario, the Ministry of Health has set up a Narcotics Monitoring System (NMS), which “collects dispensing information for all prescriptions for monitored drugs dispensed for all Ontarians, regardless of whether the prescription is paid for under a publicly funded drug program, through private insurance or by cash”. This link provides some details into what data this program provides, and the benefits of such a program.

But while the NMS focuses mostly on the monitoring of dispensing, I would propose a plan that would use the data to affect prescribing patterns. Every 3 months, every primary care practitioner would be provided a personal report detailing their average oral morphine equivalents (OME) dispensed per patient rostered (total, and by generic drug). This would be similar in format to the Screening Activity Reports that we already receive for physician-specific cancer screening statistics.  The primary care practitioner would be provided with provincial and regional averages as well for comparison, in addition to how their rates have changed from previous reports. I understand from the above-linked report that a Narcotics Monitoring Working Group was set up a few years ago, and I wonder whether this would be a strategy they could look to adopt.

One important caveats to this idea: the physician-specific information can under no circumstances be made public, as this is an educational endeavour, not a shaming exercise. It can also not be used by the government for any payment-based incentives, as inappropriate attempts to wean or deny appropriate treatment may logically ensue.

I also understand that some physicians, because of their work with chronic pain populations, may end up at the upper end of the spectrum, but again this is a self-assessment tool, and certainly those physicians should evaluate their own prescribing patterns given their own practice context.

This would be meant to be a tool for physicians to identify privately how their prescribing compares to others, and for prescribers who are actively trying to prescribe fewer opioids (through fewer starts, more opioid tapers, etc.) to have an objective measure of the success of their efforts. Will it change the behaviour of the worst offenders? Maybe not, but prescribers having more information and insight into our own behaviour can only help our current epidemic. A program such as this would also need to be accompanied by comprehensive physician resources, such as Echo Ontario, which can give physicians the knowledge and skills to treat patients with pain appropriately and comprehensively, without immediately turning to opioids.

I look forward to your feedback in the comments, as well as details from other provinces as to whether a similar strategy may be feasible in your area.

 

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