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Bansal N, Campbell SM, Lin CY, Ashcroft DM, Chen LC. Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care-a modified e-Delphi study. BMC Med 2024; 22:5. [PMID: 38167142 PMCID: PMC10763174 DOI: 10.1186/s12916-023-03213-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Long-term opioid use is associated with dependency, addiction, and serious adverse events. Although a framework to reduce inappropriate opioid prescribing exists, there is no consensus on prescribing indicators for preventable opioid-related problems in patients with chronic pain in primary care in the UK. This study aimed to identify opioid prescription scenarios for developing indicators for prescribing opioids to patients with chronic pain in primary care. METHODS Scenarios of opioid prescribing indicators were identified from a literature review, guidelines, and government reports. Twenty-one indicators were identified and presented in various opioid scenarios concerning opioid-related harm and adverse effects, drug-drug interactions, and drug-disease interactions in certain disease conditions. After receiving ethics approval, two rounds of electronic Delphi panel technique surveys were conducted with 24 expert panellists from the UK (clinicians, pharmacists, and independent prescribers) from August 2020 to February 2021. Each indicator was rated on a 1-9 scale from inappropriate to appropriate. The score's median, 30th and 70th percentiles, and disagreement index were calculated. RESULTS The panel unanimously agreed that 15 out of the 21 opioid prescribing scenarios were inappropriate, primarily due to their potential for causing harm to patients. This consensus was reflected in the low appropriateness scores (median ranging from 1 to 3). There were no scenarios with a high consensus that prescribing was appropriate. The indicators were considered inappropriate due to drug-disease interactions (n = 8), drug-drug interactions (n = 2), adverse effects (n = 3), and prescribed dose and duration (n = 2). Examples included prescribing opioids during pregnancy, concurrently with benzodiazepines, long-term without a laxative prescription and prescribing > 120-mg morphine milligram equivalent per day or long-term duration over 3 months after surgery. CONCLUSIONS The high agreement on opioid prescribing indicators indicates that these potentially hazardous consequences are relevant and concerning to healthcare practitioners. Future research is needed to evaluate the feasibility and implementation of these indicators within primary care settings. This research will provide valuable insights and evidence to support opioid prescribing and deprescribing strategies. Moreover, the findings will be crucial in informing primary care practitioners and shaping quality outcome frameworks and other initiatives to enhance the safety and quality of care in primary care settings.
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Affiliation(s)
- Neetu Bansal
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK.
| | - Stephen M Campbell
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria, 0208, South Africa
- Centre for Epidemiology and Public Health, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Chiu-Yi Lin
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Darren M Ashcroft
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, M13 9PL, UK
| | - Li-Chia Chen
- Drug Usage and Pharmacy Practice Group, Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, Centre for Pharmacoepidemiology and Drug Safety, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
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Moffat AK, Apajee J, Le Blanc VT, Westaway K, Andrade AQ, Ramsay EN, Blacker N, Pratt NL, Roughead EE. Reducing opioid use for chronic non-cancer pain in primary care using an evidence-based, theory-informed, multistrategic, multistakeholder approach: a single-arm time series with segmented regression. BMJ Qual Saf 2023; 32:623-631. [PMID: 37105724 PMCID: PMC10646855 DOI: 10.1136/bmjqs-2022-015716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/12/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Many countries have high opioid use among people with chronic non-cancer pain. Knowledge about effective interventions that could be implemented at scale is limited. We designed a national intervention that included audit and feedback, deprescribing guidance, information on catastrophising assessment, pain neuroscience education and a cognitive tool for use by patients with their healthcare providers. METHOD We used a single-arm time series with segmented regression to assess rates of people using opioids before (January 2015 to September 2017), at the time of (October 2017) and after the intervention (November 2017 to August 2019). We used a cohort with historical comparison group and log binomial regression to examine the rate of psychologist claims in opioid users not using psychologist services prior to the intervention. RESULTS 13 968 patients using opioids, 8568 general practitioners, 8370 pharmacies and accredited pharmacists and 689 psychologists were targeted. The estimated difference in opioid use was -0.51 persons per 1000 persons per month (95% CI -0.69, -0.34; p<0.001) as a result of the intervention, equating to 25 387 (95% CI 24 676, 26 131) patient-months of opioid use avoided during the 22-month follow-up. The targeted group had a significantly higher rate of incident patient psychologist claims compared with the historical comparison group (rate ratio: 1.37, 95% CI 1.16, 1.63; p<0.001), equating to an additional 690 (95% CI 289, 1167) patient-months of psychologist treatment during the 22-month follow-up. CONCLUSIONS Our intervention addressed the cognitive, affective and sensory factors that contribute to pain and consequent opioid use, demonstrating it could be implemented at scale and was associated with a reduction in opioid use and increasing utilisation of psychologist services.
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Affiliation(s)
- Anna K Moffat
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Jemisha Apajee
- Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vanessa T Le Blanc
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Kerrie Westaway
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Andre Q Andrade
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Emmae N Ramsay
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Natalie Blacker
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Nicole L Pratt
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Elizabeth Ellen Roughead
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
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Alderson S, Ivers NM, Foy R. The opioid prescribing problem: an opportunity to embed rigorous evaluation within initiatives to improve population healthcare. BMJ Qual Saf 2023; 32:617-619. [PMID: 37369577 DOI: 10.1136/bmjqs-2023-016239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 06/29/2023]
Affiliation(s)
- Sarah Alderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Noah Michael Ivers
- Family and Community Medicine, Women's College Hospital-University of Toronto, Toronto, Ontario, Canada
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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McCracken RK, Narayan S, Maclure M, Cooper I, Cui Z, Cullen W, Dormuth C, Hamilton MA, Nolan S, Singer J, Socías ME, Wong S, Klimas J. Evaluation of audit and feedback to family physicians on prescribing of opioid analgesics to opioid-naïve patients: A pragmatic randomized delay trial. Contemp Clin Trials 2023; 134:107354. [PMID: 37802223 DOI: 10.1016/j.cct.2023.107354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/29/2023] [Accepted: 10/01/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Exposure to opioid analgesics have historically raised concern for a risk of developing opioid use disorder. Prescriber audit-and-feedback interventions may reduce opioid prescribing, but some studies have shown detrimental effects for current users. We examined the effectiveness of an audit and feedback intervention, named Portrait, to reduce initiation of opioid analgesics among opioid-naïve patients experiencing pain. METHODS REDONNA was a single-blinded, two-arm (Early vs Delayed mailing) randomized trial of a portrait for eligible family physicians (FPs) in British Columbia (BC), Canada. The primary outcome was the change in the number of initiations of opioid analgesic prescriptions written by FPs for acute/chronic pain management. We compared outcomes for a 6-month window before vs. after each mailed intervention, using differences in percent differences (DPD) with 95% confidence intervals (CI) and odds ratios (OR) from logistic regressions adjusted for clustering of patients by FP. RESULTS In the Early (n = 2260) and Delayed (n = 2156) groups, opioid initiations per month were the same in the Before (2.10 Early; 2.06 Delayed) and After (1.94 Early; 1.95 Delayed) windows. The DPD was -2.1% (CI: -4.4% to 0.3%), and ORs were: 0.98 (CI: 0.96 to 1.01) for any opioid, 0.97 (CI: 0.94 to 1.01) for codeine (62% of initiations), and 1.0 (CI: 0.97 to 1.07) for tramadol (25% of initiations). There were no differences in mean quantity of tablets, mean milligrams of morphine equivalents (MME), or mean number of days. CONCLUSION Portrait had no impact on FPs' rates of prescribing opioid analgesics to opioid-naïve patients experiencing pain. TRIAL REGISTRATION The study was registered prospectively on 30 March 2020 at the ISRCTN Register (https://www.isrctn.com/ISRCTN34246811).
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Affiliation(s)
- Rita K McCracken
- Department of Family Practice, University of British Columbia, 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada; Centre for Health Evaluation & Outcome Sciences, University of British Columbia, 570-1081 Burrard Street St. Paul's Hospital, Vancouver, BC V6Z IY6, Canada.
| | - Shawna Narayan
- Department of Family Practice, University of British Columbia, 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada
| | - Malcolm Maclure
- Therapeutics Initiative, Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
| | - Ian Cooper
- Cummings School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - Zishan Cui
- British Columbia Center on Substance Use, 400-1045 Howe St, Vancouver, BC V6Z 2A9, Canada
| | - Walter Cullen
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| | - Colin Dormuth
- Therapeutics Initiative, Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
| | - Michee-Ana Hamilton
- Department of Family Practice, University of British Columbia, 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada
| | - Seonaid Nolan
- British Columbia Center on Substance Use, 400-1045 Howe St, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, British Columbia V5Z 1 M9, Canada
| | - Joel Singer
- Centre for Health Evaluation & Outcome Sciences, University of British Columbia, 570-1081 Burrard Street St. Paul's Hospital, Vancouver, BC V6Z IY6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - M Eugenia Socías
- British Columbia Center on Substance Use, 400-1045 Howe St, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, British Columbia V5Z 1 M9, Canada
| | - Sabrina Wong
- Centre for Health Services and Policy Research, University of British Columbia, 201-2206 East Mall, Vancouver, BC V6T 1Z3, Canada; School of Nursing, University of British Columbia, 211 Wesbrook Mall T201, Vancouver, BC V6T 2B5, Canada
| | - Jan Klimas
- Department of Family Practice, University of British Columbia, 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada
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Jager A, Wong G, Papoutsi C, Roberts N. The usage of data in NHS primary care commissioning: a realist review. BMC Med 2023; 21:236. [PMID: 37400837 DOI: 10.1186/s12916-023-02949-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/19/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Primary care has been described as the 'bedrock' of the National Health Service (NHS) accounting for approximately 90% of patient contacts but is facing significant challenges. Against a backdrop of a rapidly ageing population with increasingly complex health challenges, policy-makers have encouraged primary care commissioners to increase the usage of data when making commissioning decisions. Purported benefits include cost savings and improved population health. However, research on evidence-based commissioning has concluded that commissioners work in complex environments and that closer attention should be paid to the interplay of contextual factors and evidence use. The aim of this review was to understand how and why primary care commissioners use data to inform their decision making, what outcomes this leads to, and understand what factors or contexts promote and inhibit their usage of data. METHODS We developed initial programme theory by identifying barriers and facilitators to using data to inform primary care commissioning based on the findings of an exploratory literature search and discussions with programme implementers. We then located a range of diverse studies by searching seven databases as well as grey literature. Using a realist approach, which has an explanatory rather than a judgemental focus, we identified recurrent patterns of outcomes and their associated contexts and mechanisms related to data usage in primary care commissioning to form context-mechanism-outcome (CMO) configurations. We then developed a revised and refined programme theory. RESULTS Ninety-two studies met the inclusion criteria, informing the development of 30 CMOs. Primary care commissioners work in complex and demanding environments, and the usage of data are promoted and inhibited by a wide range of contexts including specific commissioning activities, commissioners' perceptions and skillsets, their relationships with external providers of data (analysis), and the characteristics of data themselves. Data are used by commissioners not only as a source of evidence but also as a tool for stimulating commissioning improvements and as a warrant for convincing others about decisions commissioners wish to make. Despite being well-intentioned users of data, commissioners face considerable challenges when trying to use them, and have developed a range of strategies to deal with 'imperfect' data. CONCLUSIONS There are still considerable barriers to using data in certain contexts. Understanding and addressing these will be key in light of the government's ongoing commitments to using data to inform policy-making, as well as increasing integrated commissioning.
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Affiliation(s)
- Alexandra Jager
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, Medical Sciences, University of Oxford, Oxford, UK
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Espnes KA, Nøst TH, Handal M, Skurtveit SO, Langaas HC. Can academic detailing reduce opioid prescriptions in chronic non-cancer pain? BMC PRIMARY CARE 2023; 24:84. [PMID: 36973685 PMCID: PMC10042395 DOI: 10.1186/s12875-023-02040-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 03/16/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND One measure to support optimal opioid prescription is academic detailing (AD) with one-to-one visits by trained professionals (academic detailers) to general practitioners (GPs). OBJECTIVE To investigate the usefulness of AD visits on GPs' opioid prescribing patterns in Norway, and academic detailers' experiences with AD visits to GPs on opioid prescription. METHODS Design: A quantitative registry study on opioid prescriptions and a qualitative focus group interview study with academic detailers. PARTICIPANTS For the registry study, municipalities where more than 75% of the GPs had received an AD visit were considered intervention municipalities, whereas in the non-intervention municipalities no GPs had received AD-visits. In the focus groups, academic detailers who had conducted three or more AD-visits were invited to participate. INTERVENTION A campaign on opioid prescription with AD visits using a brochure with key messages based on the national guideline for treatment of chronic non-cancer pain and updated evidence on the potential benefits and risks of prescribing opioids. The AD visits in the campaign were planned for 20-25 min in a one-to-one setting in the GP's office. MAIN MEASURES The Norwegian Prescription Database (NorPD) was utilized for registry data. Data on amount of drugs dispensed are recoded as Defined Daily Doses (DDDs). RESULTS Compared to non-intervention, the intervention resulted in a decrease in the number of prevalent and incident users of opioids and incident users of reimbursed opioids for chronic non-cancer pain in municipalities in Central Norway. The results from the focus group interviews were categorized into the themes: "To get in position", "Adjusting messages", "What did the GPs struggle with, in relation to opioid prescription?" and "Did we reach the right recipients with the visits?". CONCLUSIONS In Central Norway, the intervention resulted in a desired effect on number of opioid users. According to the academic detailers, the GPs' length of working experience and familiarity with the topic gave different presumptions for making use of the information presented in the AD-visits.
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Affiliation(s)
- Ketil Arne Espnes
- KUPP - The Norwegian Academic Detailing Program. Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim University Hospital, P.O.Box 3250 Torgarden, 7006, Trondheim, Norway.
- Section for Drug Safety, Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Torunn Hatlen Nøst
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Technology and Science, Trondheim, Norway
- Norwegian Advisory Unit On Complex Symptom Disorders, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Marte Handal
- Norwegian Institute of Public Health, Oslo, Norway
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Svetlana O Skurtveit
- Norwegian Institute of Public Health, Oslo, Norway
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Harald C Langaas
- KUPP - The Norwegian Academic Detailing Program. Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim University Hospital, P.O.Box 3250 Torgarden, 7006, Trondheim, Norway
- Regional Medicines Information and Pharmacovigilance Centre (RELIS), Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Fu Y, Allen B, Batterham AM, Price C, Jones N, Martin D, Hex N, Maule E, Finch T, Newton JL, Ryan CG. Digitally deployed, GP remote consultation video intervention that aims to reduce opioid prescribing in primary care: protocol for a mixed-methods evaluation. BMJ Open 2023; 13:e066158. [PMID: 36746541 PMCID: PMC9906169 DOI: 10.1136/bmjopen-2022-066158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Opioid prescribing rates are disproportionately high in the North of England. In addition to patients' complex health needs, clinician prescribing behaviour is also a key driver. Although strategies have been initiated to reduce opioid prescribing nationally, the COVID-19 pandemic has interrupted service provision and created challenges for the system and health professionals to tackle this complex issue. A pilot intervention using smartphone video messaging has been developed to remotely explain the rationale for opioid reduction and facilitate self-initiation of support. The aim of this study is to evaluate the potential benefits, risks and economic consequences of 'at scale' implementation. METHODS AND ANALYSIS This will be a mixed-methods study comprising a quasi-experimental non-randomised before-and-after study and qualitative interviews. The intervention arm will comprise 50 General Practitioner (GP) Practices using System 1 (a clinical computer system hosting the intervention) who will deliver the video to their patients via text message. The control arm will comprise 50 practices using EMIS (a different computer system) who will continue usual care. Monthly practice level prescribing and consultation data will be observed for 6 months postintervention. A general linear model will be used to estimate the association between the exposure and the main outcome (opioid prescribing; average daily quantity (ADQ)/1000 specific therapeutic group age-sex related prescribing unit). Semi-structured interviews will be undertaken remotely with purposively selected participants including patients who received the video, and health professionals involved in sending out the videos and providing additional support. Interviews will be audio recorded, transcribed and analysed thematically. ETHICS AND DISSEMINATION Ethics approval has been granted by the NHS Health Research Authority Research Ethics Committee (22/PR/0296). Findings will be disseminated to the participating sites, participants, and commissioners, and in peer-reviewed journals and academic conferences. TRIAL REGISTRATION NUMBER NCT05276089.
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Affiliation(s)
- Yu Fu
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Applied Research Collaboration North East and North Cumbria, NIHR, Gosforth, UK
| | | | - Alan M Batterham
- Centre for Rehabilitation, Teesside University, Middlesbrough, UK
| | - Christopher Price
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Applied Research Collaboration North East and North Cumbria, NIHR, Gosforth, UK
- Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Niki Jones
- Centre for Rehabilitation, Teesside University, Middlesbrough, UK
| | - Denis Martin
- Applied Research Collaboration North East and North Cumbria, NIHR, Gosforth, UK
- Health and Social Care Institute, Teesside University, Middlesbrough, UK
| | - Nick Hex
- York Health Economics Consortium Ltd, University of York, York, UK
| | - Ewan Maule
- North East and North Cumbria Integrated Care Board, North East and North Cumbria Integrated Care System, Sunderland, UK
| | - Tracy Finch
- Applied Research Collaboration North East and North Cumbria, NIHR, Gosforth, UK
- Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | - Julia L Newton
- Academic Health Science Network for the North East and North Cumbria, Newcastle upon Tyne, UK
| | - Cormac G Ryan
- Centre for Rehabilitation, Teesside University, Middlesbrough, UK
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Begley EK, Poole HM, Sumnall HR, Frank BF, Montgomery C. Opioid prescribing and social deprivation: A retrospective analysis of prescribing for CNCP in Liverpool CCG. PLoS One 2023; 18:e0280958. [PMID: 36888607 PMCID: PMC9994720 DOI: 10.1371/journal.pone.0280958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 01/12/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Treating Chronic Non-Cancer Pain (CNCP) with long-term, high dose and more potent opioids puts patients at increased risk of harm, whilst providing limited pain relief. Socially deprived areas mapped from Index of Multiple Deprivation (IMD) scores show higher rates of high dose, strong opioid prescribing compared to more affluent areas. OBJECTIVE To explore if opioid prescribing is higher in more deprived areas of Liverpool (UK) and assess the incidence of high dose prescribing to improve clinical pathways for opioid weaning. DESIGN AND SETTING This retrospective observational study used primary care practice and patient level opioid prescribing data for N = 30,474 CNCP patients across Liverpool Clinical Commissioning Group (LCCG) between August 2016 and August 2018. METHOD A Defined Daily Dose (DDD) was calculated for each patient prescribed opioids. DDD was converted into a Morphine Equivalent Dose (MED) and patients stratified according to high (≥120mg) MED cut off. The association between prescribing and deprivation was analysed by linking GP practice codes and IMD scores across LCCG. RESULTS 3.5% of patients were prescribed an average dose above 120mg MED/day. Patients prescribed long-term, high dose, strong opioids were more likely to be female, aged 60+, prescribed three opioids and reside in the North of Liverpool where there is a higher density of areas in the IMD most deprived deciles. CONCLUSION A small but significant proportion of CNCP patients across Liverpool are currently prescribed opioids above the recommended dose threshold of 120mg MED. Identification of fentanyl as a contributor to high dose prescribing resulted in changes to prescribing practice, and reports from NHS pain clinics that fewer patients require tapering from fentanyl. In conclusion, higher rates of high dose opioid prescribing continue to be evident in more socially deprived areas further increasing health inequalities.
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Affiliation(s)
- Emma K. Begley
- School of Psychology, Liverpool John Moores University, Liverpool, Merseyside, United Kingdom
| | - Helen M. Poole
- School of Psychology, Liverpool John Moores University, Liverpool, Merseyside, United Kingdom
| | - Harry R. Sumnall
- Public Health Institute, Liverpool John Moores University, Liverpool, Merseyside, United Kingdom
| | - Bernhard F. Frank
- Walton Centre NHS Foundation Trust, Liverpool, Merseyside, United Kingdom
- Pain Research Institute, University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - Catharine Montgomery
- School of Psychology, Liverpool John Moores University, Liverpool, Merseyside, United Kingdom
- * E-mail:
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Kroon D, van Dulmen SA, Westert GP, Jeurissen PPT, Kool RB. Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study. BMJ Open 2022; 12:e062902. [PMID: 36343997 PMCID: PMC9644331 DOI: 10.1136/bmjopen-2022-062902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework. DESIGN AND METHODS This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies. RESULTS The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters. CONCLUSIONS The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.
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Affiliation(s)
| | | | | | | | - Rudolf B Kool
- IQ Healthcare, Radboudumc, Nijmegen, The Netherlands
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10
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Rock KL, Reynolds LM, Rees P, Copeland CS. Highlighting the hidden dangers of a 'weak' opioid: Deaths following use of dihydrocodeine in England (2001-2020). Drug Alcohol Depend 2022; 233:109376. [PMID: 35248998 DOI: 10.1016/j.drugalcdep.2022.109376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/12/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dihydrocodeine (DHC) is considered a 'weak' opioid, but there is evidence of its increasing misuse in overdose deaths. This research aims to analyse trends in DHC-related deaths in England relevant to source and dose of DHC, and decedent demographics. METHODS Cases from England reported to the National Programme on Substance Abuse Deaths (NPSAD) where DHC was identified at post-mortem and/or implicated in death between 2001 and 2020 were extracted for analysis. RESULTS 2071 DHC-related deaths were identified. The greatest number of deaths involved illicitly obtained DHC and a significant increase in these deaths was recorded over time (r = 0.5, p = 0.03). However, there was a concurrent decline in the implication rate of DHC in causing death (r = -0.6, p < 0.01). Fatalities were primarily due to accidental overdose (64.8%) and misuse was highly prevalent in combination with additional central nervous system depressants (95.3%), namely illicit heroin/morphine and diazepam. In contrast, when DHC was obtained over-the-counter (OTC) suicide mortality accounted for almost half of the deaths (42.5%). Differences in polysubstance use were also identified, with less heroin/morphine and benzodiazepine co-detection, but increased OTC codeine co-detection. CONCLUSIONS DHC misuse in England is increasing. The pharmacological consideration of DHC as a 'weak' opioid may be misinterpreted by users, leading to accidental overdosing. There is an urgent need to understand increasing polypharmacy in overdose deaths. Additionally, suicides involving DHC is a potential cause for concern and a review of OTC opioid-paracetamol preparations is necessary to determine whether the benefits of these medications continue to outweigh the risks of intentional overdose.
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Affiliation(s)
- Kirsten L Rock
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Medicine, King's College London, Franklin-Wilkins Building, Stamford Street, London SE1 9NH, UK.
| | - Laura M Reynolds
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Medicine, King's College London, Franklin-Wilkins Building, Stamford Street, London SE1 9NH, UK
| | - Paul Rees
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Medicine, King's College London, Franklin-Wilkins Building, Stamford Street, London SE1 9NH, UK
| | - Caroline S Copeland
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Medicine, King's College London, Franklin-Wilkins Building, Stamford Street, London SE1 9NH, UK; National Programme on Substance Abuse Deaths, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK
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