Three-fold opioid variation a cue to look at prescribing

Three-fold opioid variation a cue to look at prescribing, says Commission

Evidence that the number of people being given one of the most dangerous classes of medicine varies up to three-fold around New Zealand is a cue for hospitals and primary health care providers to take a close look at their prescribing, says the Health Quality & Safety Commission.

Opioids include fentanyl, methadone, morphine, oxycodone and pethidine at the stronger end and tramadol, codeine and dihydrocodeine at the weaker, and are highly effective in managing pain.

But they are also the class of medicine most commonly implicated in patient harm – which might include nausea, constipation, delirium, hypotension, addiction or even potentially life-threatening over-sedation and respiratory depression.

March, the final month of the Commission’s Open for better care national patient safety campaign’s six-month focus on reducing harm from high-risk medicines, looks at the safe use of opioids.

The wide differences in usage are shown in the recently published opioid domain of the Commission’s Atlas of Healthcare Variation – a series of easy-to-use maps, graphs, tables and commentaries that chart the provision and use of specific health services and outcomes.

The domain records subsidised opioids dispensed from community pharmacies in 2013, but not those used in hospitals. However, the prescription may have come from a hospital, as nearly half of those dispensed a strong opioid had been a public hospital inpatient or outpatient in the week prior.

‘The question is do we need to use strong opioids as much as we do and are there alternatives?’ says Dr Alan Davis, chair of the expert advisory group that developed the opioid domain.

‘Yes, there are alternatives, and district health boards need to investigate why their usage is different to other district health boards’ and if they should be exploring those alternatives.

‘It may be a patient who’s had an operation doesn’t actually need strong opioids once they leave hospital but they’ve been given them anyway. It may be appropriate they change at that stage to weaker-strength painkillers. Maybe they could get by without painkillers at all. There might be lifestyle strategies to help them manage discomfort.

‘Of course, it may also be the prescription is completely appropriate as it is. The atlas itself doesn’t tell us this, but by showing such wide variation it does tell us these are important questions for clinicians to be asking themselves.’

Among the atlas’s key findings are:

• An average of 17/1000 people received a strong opioid, with a greater than three-fold variation between district health board (DHB) geographical areas

• An average of 64/1000 people received a weak opioid, with a two-fold variation between DHB areas

• Women were dispensed significantly more both weak and strong opioids than men

• Opioid use increased significantly with age: 1 in 10 people aged 80 and over received a strong opioid and 1 in 7 a weak opioid

• People identifying as European or Other ethnicity had two to four times the use of strong opioids as those of Maori, Pacific or Asian ethnicity

• People identifying as European or Other received significantly more weak opioids, and Asian peoples significantly fewer

• An average of 11/1000 people received morphine, 10,000 more than in 2011, with a two-fold variation between DHB areas

• An average of 6.4/1000 people received oxycodone, 5000 fewer than in 2011, with a three-fold variation between DHB areas.

Dr Davis says it is unlikely all – or even most – of the variations are due to the DHB areas having different populations with different needs.

‘So there is a great deal to consider in the atlas for DHBs, along with primary health organisations, general practices and others prescribing opioids in their communities.’

The opioid domain of the Atlas of Healthcare Variation can be viewed atwww.hqsc.govt.nz/atlas/opioids.

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