LOADING

Type to search

Pharmacology Professional Issues Supporting Your Practice

What are the trends in high-dose opioid prescription in Canada?

Drug Abuse 3D Sphere Word Cloud ConceptThis summaary is based on the article published in Canadian Family Physician: Trends in high-dose opioid prescribing in Canada (September 2014)

Tara Gomes, Muhammad M. Mamdani,  J. Michael Paterson, Irfan A. Dhalla, David N. Juurlink 

 

Context

Canada and the United States have the highest levels of prescription opioid consumption in the world, and the use of these medications continues to increase dramatically across North America. (1–5)

Until recently, clinical practice guidelines and product monographs provided no recommended maximum dose, and opioids were marketed as having no upper dose threshold, despite scant evidence of safety or effectiveness at high doses, particularly in patients with chronic non-malignant pain. (5–7)

Several Canadian provinces have adopted strategies to improve opioid prescribing, including prescription monitoring programs (8–12) and restricted reimbursement of opioids on publicly funded drug plans. However, little is known about the effectiveness of these efforts, particularly their influence on high-dose opioid use. One study published in 2011 reported variation in the defined daily dose of opioids dispensed provincially, and demonstrated increasing trends of “strong” (non-codeine) opioid dispensing in Canada and interprovincial differences in dispensing of individual opioids. (13)

Purpose of the Study

To describe trends in the prescribing of high-dose opioid formulations, and to investigate the types of opioids most commonly prescribed in high-dose formulations across Canada.

Key Findings

There is marked interprovincial variation in the dispensing of high-dose opioid formulations in Canada, emphasizing the need to understand the reasons for these differences, and to consider developing a national strategy to address opioid prescribing.

Although guidelines suggest that high-dose opioid formulations might be appropriate in some instances, there is little evidence to support this practice. On the other hand, high-dose opioid prescribing is clearly associated with increased risk of fracture, trauma, overdose, and death.

The daily doses exceeding 100 mg of morphine (or equivalent) have been associated with a 9-fold increased risk of overdose, (14) and a doubling of the risk of opioid-related death compared with lower doses. (15)

The considerable variation in the prevalence of use of high-dose opioid formulations across Canada underscores the need for further research on both the determinants and the consequences of this variation, and emphasizes the urgent need for a unified national effort to promote safe opioid prescribing.

References

  1. International Narcotics Control Board. Opioid consumption motion chart. Madison, WI: Board of Regents of the University of Wisconsin System; 2012.
  2. Dhalla IA, Mamdani MM, Sivilotti ML, Kopp A, Qureshi O, Juurlink DN. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMAJ 2009; 181(12):891-6.
  3. Boudreau D, Von KM, Rutter CM, Saunders K, Ray GT, Sullivan MD, et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf 2009; 18(12):1166-75.
  4. Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med 2006; 31(6):506-11.
  5. Gomes T, Juurlink DN, Dhalla IA, Mailis-Gagnon A, Paterson JM, Mamdani MM. Trends in opioid use and dosing among socio-economically disadvantaged patients. Open Med 2011; 5(1):e13-22.
  6. Chou R, Ballantyne JC, Fanciullo GJ, Fine PG, Miaskowski C. Research gaps on use of opioids for chronic non-cancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain 2009; 10(2):147-59.
  7. Purdue Pharma. OxyContin [product monograph]. Pickering, ON: Purdue Pharma; 2009.
  8. Nova Scotia Prescription Monitoring Program [website]. Halifax, NS: Prescription Monitoring Board; 2013. Available from: www.nspmp.ca. Accessed 2014 Jul 28.
  9. The Prescription Review Program. Regina, SK: Government of Saskatchewan; 2012. Available from: http://formulary.drugplan.health.gov.sk.ca/PDFs/ThePrescriptionReviewProgram.pdf. Accessed 2014 Jul 28.
  10. PharmaNet [website]. Vancouver, BC: Government of British Columbia; 2007. Available from: www.health.gov.bc.ca/pharmacare/pharmanet/netindex.html. Accessed 2014 Jul 28.
  11. College of Physicians and Surgeons of Alberta. Triplicate Prescription Program. Edmonton, AB: College of Physicians and Surgeons of Alberta; 2012. Available from: www.cpsa.ab.ca/Services/Triplicate_Prescription_Program/TPP_Overview.aspx. Accessed 2014 Jul 28.
  12. OxyContin Task Force. OxyContin Task Force final report. St John’s, NL: Government of Newfoundland and Labrador; 2004.
  13. Fischer B, Jones W, Krahn M, Rehm J. Differences and over-time changes in levels of prescription opioid analgesic dispensing from retail pharmacies in Canada, 2005-2010. Pharmacoepidemiol Drug Saf 2011; 20(12):1269-77.
  14. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010; 152(2):85-92.
  15. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with non-malignant pain. Arch Intern Med 2011; 171(7):686-91.

 

Leave a Comment

Your email address will not be published. Required fields are marked *