Transcript Neuropathic pain in the community: more under

University of Dundee
School of Medicine
Opioids use in primary care.
Identifying indicators of good prescribing
and problem use in primary care
Nicola Torrance
Research Fellow
Chronic Pain Research Group
http://medicine.dundee.ac.uk/chronic-pain
Adverse effects
• 80% of patients taking opioids will
experience at least one adverse
effect e.g. constipation, nausea,
itching, dizziness.
• Side effects should be managed
promptly with laxatives, anti-emetics
etc. as appropriate.
Prescribing
• Where possible regular dosing with
modified release preparations:
immediate release opioids may be
associated with tolerance and
problem drug use
• Commonly reported adverse events
with long-term use of opioids include
gastrointestinal effects (constipation,
nausea, dyspepsia), headache, fatigue,
lethargy, somnolence…
• Adverse effects led to discontinuation
in 11% of patients on weak opioids and
35-39% on strong opioids
• Avoid co-prescription of sedative and
hypnotic medication where possible
and be aware of concomitant alcohol
use
• Reassessment - Avoid the use of shortacting strong opioids. Routine use
during exacerbations may increase
tolerance and may lead to dose
escalation
Opioids in Scotland 2003-2012
Total Prescriptions
•
938,674 individual patients received any
opioid drugs in 2012
•
Overall this represents 18% of the
Scottish population
(http://www.scotland.gov.uk)
6,000,000
5,000,000
4,000,000
WEAK
STRONG
3,000,000
2,000,000
1,000,000
0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Total Number of DDDs
120,000,000
•
>1M patients were prescribed a WEAK opioid
•
85K prescribed a STRONG opioid
80,000,000
•
(Patients can be prescribed more than one)
60,000,000
100,000,000
WEAK
STRONG
40,000,000
20,000,000
0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Trends in opioids prescribing for Scotland 2003-2012
1,200,000
Number of prescriptions
1,000,000
800,000
TRAMADOL
DIHYDROCODEINE
MORPHINE
600,000
METHADONE
OXYCODONE
FENTANYL
400,000
BUPRENORPHINE
200,000
0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Aims
• To describe opioid prescription rates across
Scotland
• Explore indicators of appropriate /
inappropriate prescribing, and
• Seek indicators of the level of problem use,
and factors associated with variations in
these
Opioids data
• GP prescribing
– Split into tertiles of prescribing (High/Average/Low)
• Opioids grouped into classifications of Strong or Weak
• National level mainly aggregate data from ISD, NHS
Scotland
• Patient level opioids prescribing and health service
use from NHS Tayside & NHS Fife from the Health
Informatics Centre
Indicators of good quality prescribing
a)
Use of modified release (MR) preparations
i.
By potency; NHS board; H/Ave/Low GP prescribers
ii.
Gender & 5 year age bands
iii.
% of opioids as MR products
b)
Co-prescriptions to manage side effects
i.
Laxatives
ii.
Anti-emetics
Use of Opioid Modified Release products in GP practice prescribing by NHS Board
Strong Opioids, Males, High Prescribers
60
50
AYRSHIRE & ARRAN
% of MR items
40
FIFE
GRAMPIAN
GR GLASGOW & CLYDE
30
LANARKSHIRE
LOTHIAN
TAYSIDE
20
10
0
40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-90
Age (yrs)
90+
Use of Opioid Modified Release preparations in GP prescribing by NHS Board
Strong Opioids, Males, High prescribers
60
% of MR items
50
40
AYRSHIRE & ARRAN
FIFE
GRAMPIAN
30
TAYSIDE
20
10
0
40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-90
Age (yrs)
90+
High prescribers
lowest coprescribing of
laxatives
Overall less
prescribing for males
than females esp in
younger age groups
High prescribers had
lowest co-prescribing
of anti-emetics
Indicators of problem use
a)
The number receiving >365 Defined Daily Doses (DDDs)
• The DDD is the assumed average maintenance dose per day for a drug
used for its main indication in adults.
b)
The number obtaining a prescription from >3 GP practices/
year
c)
The number obtaining benzodiazepine co-prescriptions
d)
Use of hospital services
• Admission rates for overdose & poisoning in A&E
Percentage of patients prescribed >365 DDDs
16%
14%
12%
10%
8%
6%
Male
Female
4%
2%
0%
•
•
•
•
Daily doses of >180mg morphine equivalent
Patients prescribed > 365 DDDs per year of the same opioid in GP practices in 2012
Total of 78,216 patients
8.3% of all patients prescribed an opioid in 2012
Patients prescribed 1 or more opioids from 3 or more GP practices
160
140
Number of patients
120
100
80
Males
60
Females
40
20
0
Age group
• Total 1,578 patients
• This represents 0.2% of all patients prescribed an opioid in 2012
After age 25yrs,
higher rates of coprescribing of BZDs
for females than
males
High prescribers had
lowest co-prescribing
of BZDs
Co-prescribing of >365 DDDs of opioid with >100 DDDs of BZDs
30%
% of patients prescribed >100
DDDs of BZDs
25%
20%
15%
Male
10%
Female
5%
0%
Age (yrs)
•
•
•
78,216 patients prescribed > 365 DDDs per year of the same opioid in GP practices in 2012
13,202 were also prescribed >100 DDDs of Benzodiazepines
1.4% of all patients prescribed an opioid in 2012
Summary
1. Indicators of good quality prescribing
• MR Products – large variations between NHS boards
• Co-prescribing laxatives – increasing with age; more females; High
prescribers least likely to co-prescribe
• Co-prescribing anti-emetics – highest rates between 55-75yrs; more
females; High prescribers least likely to co-prescribe
• Attendance at OP clinics – SMR00 outpatient data probably not useful
due to questions about completeness
2. Indicators of problem use
• Excessive and/or persistent use – over 8% of all patients prescribed > 365
DDDs an opioid (1.5% of the general population)
• >3 practices/ year - >1.5K patients, most common in 25-50yr age bands
• BZD co-prescriptions - significant co-prescribing observed with over 40%
in females 30-35yrs; High prescribers least likely to co-prescribe
• A&E admission for OD & Poisoning – 0.9% of all patients prescribed an
opioids in T&F; more deprived; Tramadol most common prescription
Summary
1. Indicators of good quality prescribing
• MR Products – large variations between NHS boards
• Co-prescribing laxatives – increasing with age; more females; High
prescribers least likely to co-prescribe
• Co-prescribing anti-emetics – highest rates between 55-75yrs; more
females; High prescribers least likely to co-prescribe
• Attendance at OP clinics – SMR00 outpatient data probably not useful
due to questions about completeness
2. Indicators of problem use
• Excessive and/or persistent use – over 8% of all patients prescribed > 365
DDDs an opioid (1.5% of the general population)
• >3 practices/ year - >1.5K patients, most common in 25-50yr age bands
• BZD co-prescriptions - significant co-prescribing observed with over 40%
in females 30-35yrs; High prescribers least likely to co-prescribe
Acknowledgments
Funding from Chief Scientist Office (CZH/4/929)
Collaborators
•
Professor Blair Smith, National Lead Clinician for Chronic Pain, University of Dundee
•
Dr Lesley Colvin, University of Edinburgh
•
Dr Steve Gilbert, NHS Fife
•
Professor Gary Macfarlane, University of Aberdeen
•
Dr Mick Serpell, University of Glasgow
•
Dr Alex Baldacchino, University of Dundee
•
Professor Tim Hales, University of Dundee
•
Professor Peter Donnan, University of Dundee
•
Dr Jonathan Bannister, University of Dundee
•
Dr Rashid Mansoor, Statistician, University of Dundee
Information Services Division, NHS Scotland
•
Grant Wyper, Senior Researcher
•
Jackie Caldwell, Iain Bishop, Bradley Kirby
Co-prescribing Weak Opioids and Laxatives
SMR00 data for Tayside & Fife
• Outpatient attendance
– Anaesthetics, Pain Clinic
– Psychiatry
• Uncertainty over quality of data for SMR00
• Interim Findings
– Anaesthetics appointments for 2K patients
• Limited coding for Pain Clinic attendance
– Psychiatry
• >3K patients with 40K appointments in 141 locations
• Patients HB of residence - 84% Tayside, 16% Fife
• Appears community addiction services coded as Psychiatry in SMR00
in Tayside but not in Fife
• NHS Fife addiction services likely to code to SMR25 (Substance Misuse
Services)
Admission to A&E for “overdose & poisoning”
• Tayside & Fife for A&E attendance in
2012
• “Presenting Complaint” was
recorded as “overdose & poisoning”
• n=507 patients with a total of 621
attendances
• 84% attended once, 71% by
ambulance/ 999
• Mean age 41 years; 53% were
female; 47% were in the most
deprived quintile
• These 507 patients were prescribed
738 opioid drugs, 320 were
prescribed one opioid
Approved_Name
TRAMADOL
METHADONE
CODEINE PHOSPHATE
DIHYDROCODEINE
MORPHINE
BUPRENORPHINE
OXYCODONE
FENTANYL
MEPTAZINOL
DIAMORPHINE
HYDROMORPHONE
PETHIDINE
TAPENTADOL
TOTAL
Frequency Percent
222
30.08
175
23.71
164
22.22
88
11.92
33
4.47
18
2.44
18
2.44
10
1.36
3
0.41
2
0.27
2
0.27
2
0.27
1
0.14
738
Opioids
Drugs are grouped into classifications STRONG
BUPRENORPHINE, DIAMORPHINE, DIPIPANONE, FENTANYL,
HYDROMORPHONE, METHADONE, MORPHINE, OXYCODONE, PAPAVERETUM,
PENTAZOCINE, PETHIDINE, TAPENTADOL
WEAK
CODEINE PHOSPHATE, DIHYDROCODEINE, MEPTAZINOL, TRAMADOL
• Defined Daily Dose (DDD)
o based on methodology developed by the World Health
Organisation, WHO http://www.whocc.no/atc_ddd_index/
o The DDD is the assumed average maintenance dose per day
for a drug used for its main indication in adults.