Synopsis
The CMA surveyed e-Panel members to learn more about their experience with prescribing opioids. The results provide a picture of the challenges involved in opioid prescription, as well as potential solutions. A summary of the results of the e-Panel survey is presented below.
Survey – May 2014
The survey was sent to 2,813 e-Panel members; 659 responded, for a response rate of 23%.
Results
Survey results indicate that opioid prescription is common, with 83% of respondents prescribing them for pain management. Palliative care cases were excluded for this question. Some challenges related to opioid prescription were the addiction of patients, threatening incidents, and difficulty in monitoring opioids. There were many suggestions for the reduction of problematic use.
Opioid Prescription
While most respondents prescribe opioids for pain management, there is high variation in the frequency of these prescriptions. Specifically, 9% replied that they prescribe less than once per month, 20% prescribe 1-3 times per month; 21% prescribe 4-6 times per month; 11% prescribe 7-9 times per month; and 40% prescribe 10 or more times per month. Many respondents are asked for opioid prescriptions by their patients, and half are asked 10 or more times per year.
Opioid Dependence and Incidents
The majority of respondents (92%) have dealt with opioid addiction of patients, although only 18% often deal with this issue. Unfortunately, 70% have dealt with minor incidents related to people seeking opioids or other controlled substances; 25% have had major incidents; and 11% have experienced severe incidents.
Opioid Monitoring and Guidelines
Most respondents (68%) say that their province or territory has a prescription monitoring program, with fairly equal division between manual and electronic programs. There is high satisfaction with these programs, as only 8% of respondents who use one rated it as poor. Both awareness and use of the Canadian Guidelines for use of opioids for chronic non-cancer pain is high at 73%, with 78% finding them very useful or somewhat useful. Furthermore, 78% of respondents are familiar with the policies and practice standards of their College of Physicians regarding opioid prescribing.
Factors Influencing Opioid Prescription
Respondents were asked how significant the following actions would be in contributing to optimal opioid prescribing. Here are the results, ranked in order of significance:
- Real-time access to a prescription monitoring program (94% rated as very significant or somewhat significant)
- Continuing Medical Education (89% rated as very significant or somewhat significant)
- More specialized pain treatment facilities in my area (e.g., physician pain-treatment specialists, physiotherapy, psychological counselling) (84% rated as very significant or somewhat significant)
- A limit on the number of opioid pills that can be prescribed at any one time (65% rated as very significant or somewhat significant)
- More methadone maintenance and other addiction treatment facilities (62% rated as very significant or somewhat significant)
- A government requirement that only tamper-proof opioid formulations be approved (60% rated as very significant or somewhat significant)
- Giving the Minister of Health authority to issue notices about a physician’s over-prescribing (44% rated as very significant or somewhat significant)
- Regular drug take-back days (35% rated as very significant or somewhat significant)
There is a lack of agreement on whether physician overprescribing is to blame for the prescription drug abuse problem. However, most respondents (80%) stated that wait times for specialized pain treatment are a big problem in their area, with 43% saying that wait times for methadone maintenance or other addiction treatments are a problem.
Impact of e-Panel Results
The results of this e-Panel survey helped to inform CMA’s policy on Harms Associated with Opioids and Other Psychoactive Prescription Drugs, which can be found here: Opioid Policy (PDF). This policy recommends that Canada implement a comprehensive national strategy to address the harms associated with psychoactive drugs in Canada, whether illegal or prescription-based, complementing existing strategies to address the harms associated with the two legal drugs - alcohol and tobacco. The strategy should include improvement of drug safety; enhancement of optimal prescribing through evidence-based guidance; education and support for prescribers; enhancement of optimal prescribing through physician regulation and prescription monitoring programs; increase in access to treatment for pain; increase in access to treatment for addiction; increase in information through epidemiological surveillance; prevention of deaths due to overdose; and provision of information for patients and the public.
Respondents Told Us (selected comments)
“I think we do the best we can. No question that people use more than they should but truly the support of programs like pharmacare NS for more costly but less addictive pain controlling medications like cymbalta, ralivia, tramacet, etc would be helpful. Sometimes we as physicians have very limited options. I don't think physicians willingly throw these meds at people in hopes that they will go selling it or abusing it. I don't think drawing public attention to physicians who prescribe large numbers is useful either. Some people have chronic pain and opioids are all that helps.”
“We need to be more responsible in our prescribing, hands-down. Built-in EMR applications would be highly useful + electronic monitoring system.”
“The lack of integrated pain clinics makes it very difficult to treat pain with nonpharmacological measures. If a pain patient has to wander to numerous sites and disparate providers it becomes difficult for them to use all the tools as a combined regimen.”
“There should be strict guidelines and monitoring for narcotic prescription. I am all for monitoring physicians' prescription practices and giving warning when there is excessive use.”
“Access to QUALITY, compassionate, multidisciplinary pain management centres and methadone treatment is key. Ours are 100-400 km away, and do not provide quality care.”
“I manage a few complex patients who would not fit my usual prescribing habits and would be concerned that MOH monitoring would compromise the access and care of these patients. Perhaps a second opinion in such instances could be utilized…”
“There are a number of options on the market for Tamper-proof medications such as Targin, Oxy NEO and Bu_Trans patches. Also less addictive pain -relievers such as Tramadol, tapentadol and Topical analgesics are available to those with private plans. Yet none of these are covered by the ODBP, only the strong addictive opioids…”
“I belong to the medical mentoring for addictions and pain (MMAP) through the Ontario College of family physicians and this has been a wonderful resource for educating and supporting physicians in challenging cases.”
“[I] would love to see [an] Electronic program that would reduce paper work. [The] concept of monitoring is great and on occasion has identified patients who were accessing opioids from other sources that I was not aware of.”
“I feel that inadequate access to mental health services is a substantial contributing problem in many patients I see with pain. Anxiety, depression, inactivity and poor coping skills play a huge part in their pain experience.”
“The opioid addiction I have dealt with has been in patients accessing opioids on the street. Careful prescribing has prevented abuse of my prescriptions.”
“I appreciate ongoing education and maintenance for treating chronic pain and addiction.”