An individual opioid prescribing Portrait was sent to BC physicians meeting certain criteria (see below), inviting them to consider sparing opioid prescription to primary care patients who are “opioid naïve” presenting to their prescriber in primary care clinics with pain from new or ongoing non-cancer causes, such as: new or chronic MSK issue (e.g., ankle sprain), mechanical low back pain, osteoarthritic knee pain, rotator cuff pain, dental pain, etc. The Portrait contains a graphical illustration of the number of opioid naïve patients initiated on prescription opioids in the past 3 years, a breakdown of opioid prescriptions to opioid naïve patients in 2020 and a graph showing the typical new opioid prescription strength for opioid naïve patients in 2020 in morphine equivalents daily (MED) dosage22 for the individual prescriber compared with the median BC primary care prescriber. To view this sample Portrait in PDF format click on the DOWNLOAD button. This sample Portrait contains fictional individual physician data. If you are a BC family physician and wish to sign up for (or opt out of) receiving Portrait click on the REGISTER button.
Rethink prescribing opioids to opioid naïve patients because:
- there is little evidence they are any more effective than alternatives, 1-3
- there is evidence of harms associated with opioid prescribing, 4-12
- there is no risk prediction tool that can reliably identify high- or low-risk patients for opioid use disorder13
We suggest that prescribers:
- assess pain in terms of effect on daily function, sleep, and quality of life,
if appropriate, recommend non-pharmacological treatments (heat/ice, physiotherapy),14,15
educate about benefit expectations and limitations of pain treatments,16,17
if non-pharmacological therapy is inadequate or not an option, start with nonopioid pharmacological treatments (e.g. acetaminophen, NSAIDs),16,17
if a prescription for opioids is still indicated2,18 (e.g. very severe acute pain), prescribe at the lowest dose for the shortest duration (e.g. <1 week),19-21 and
follow-up post-opioid prescription to reassess daily function, sleep, and quality of life.
Portrait Data Definitions
Who received this portrait?
BC physicians meeting all of the following criteria received an individual opioid prescribing Portrait:
- were defined as a General Practitioner with a licence status of Private Practice according to the BC Medical Services Plan (MSP), and
- had a valid mailing address in BC according to the College of Physicians and Surgeons of British Columbia’s public physician information, and
- had ≥100 prescriptions filled at a community pharmacy in 2019 according to PharmaNet claims data, and
- prescribed an oral opioid to at least one opioid naïve patient in 2017-2019 according to PharmaNet claims data.
Physicians may have received a Portrait with missing data elements (i.e. no personal data are shown) because they met the above requirements but prescribed between 0 and 6 opioid prescriptions for that section of the Portrait. Our data access agreement requires masking of data elements that contain <6 patients.
Eligible physicians (approximately 5,200) were randomized into early and delayed mailing groups; physicians who meet the above criteria but did not receive a Portrait in November/December 2020 are likely randomized to the delayed group.
How are patients assigned to a portrait?
Patients are included in a physician’s portrait if they meet all of the following criteria:
- were continuously registered with the MSP in 2019, 2018, or 2017, and the respective preceding six months (washout period), and
- filled a prescription for an opioid at a community pharmacy with that physician’s prescribing number in PharmaNet, and
- were opioid-naïve (i.e. no opioids dispensed in the previous six months per PharmaNet), and
- were age ≥ 19 years at time of opioid dispensation, and
- were not on MSP plan P (palliative) or plan B (long-term care), and
- did not have a cancer diagnosis or record of chemotherapy recorded in MSP fee-for-service claims, the hospital discharge abstract database, or the National Ambulatory Care Reporting System database during the study period or the preceding six months. Skin cancers (BCC, SCC) were included.
- Cancer diagnosis codes: (ICD = International Classification of Diseases) ICD-10 C00.xx-C43.xx, C45.xx-C97.xx or ICD-9 140.xx-172.xx, 174.xx-209.xx
- Radiation and chemotherapy codes: (CCI = Canadian Classification of Health Interventions) CCI 1.xx.26.xx, 1.xx.26.xx; ICD-9-CM 99.25, V58.1, V66.2, V67.2; ICD-10 Z51.11; or MSP fee item 33581-33583
Prescription data for patients who are federally insured (e.g. Veterans, RCMP, Armed Forces and beneficiaries of Non-Insured Health Benefits) or formerly federally insured (First Nations Health Benefits – Plan W) was not included.
How are prescriptions included in a portrait?
Opioid prescriptions are taken from PharmaNet claims data and include all prescriptions filled at a community pharmacy in BC with that physician’s prescribing number. Reversed prescription claims, out-of-province prescriptions, or medication dispensed in hospital are not included.
All oral formulations of prescription opioids available in BC were included, including codeine, tramadol, hydromorphone, oxycodone, morphine, meperidine, tapentadol, pentazocine, and fentanyl. Opioid combination products (e.g. codeine-acetaminophen-caffeine) were included. Codeine formulations to control cough were not included. Methadone, buprenorphine, and Kadian© were not included as these were assumed to be for opioid antagonist therapy (OAT).
We included only opioid prescription to opioid-naïve patients, defined as patients without an opioid dispensed in the previous six months (washout period).
How are morphine equivalent daily (MED) dosages calculated?
We calculated opioid dose equivalents from the standard reference (doi.org/10.1002/pds.3945) used for recent opioid utilization studies and the 2017 Canadian opioid guideline. We recognize that drug interactions, kidney and liver disease, and a patient’s genotype for opioid-metabolizing enzymes can affect opioid metabolism. Both tramadol and codeine are prodrugs that are converted to active metabolites before exerting their main actions on opioid receptors. Inter-individual differences in intestinal and hepatic CYP450 genes cause some people to metabolize tramadol or codeine poorly or extensively. This may impact analgesic or adverse effects significantly in individual patients (doi.org/10.4065/84.7.613).
Converting tramadol to ‘equivalent’ doses of opioid agonists is difficult because its non-opioid pharmacological actions likely affect its effect on pain (doi.org/10.2165/00003088-200443130-00004).
The impact of this Portrait on prescribing of opioids will be evaluated at an aggregated level over the coming year. Ethics approval for this evaluation has been obtained from the University of British Columbia Clinical Ethics Review Board (H20-00656 – Reducing unsafe prescribing of prescription opioid medications to opioid naïve patients). This evaluation will be led by Dr. Rita McCracken, University of British Columbia, Faculty of Medicine, Department of Family Practice. This study was registered prospectively on 30 March 2020 at the ISRCTN Register https://www.isrctn.com/ISRCTN34246811. The protocol was published in Contemporary Clinical Trials, May 2021, Page: 106462. doi: https://doi.org/10.1016/j.cct.2021.106462
Approximately 5,200 BC family physicians were randomly divided into two groups which received the opioid naïve Portrait at different times. We call these the early and delayed groups. To determine the possible impact of the Portrait on physician prescribing, the evaluation will compare pooled prescribing data from physicians in the early group to pooled prescribing data from physicians in the delayed group.
All prescribing data analyzed for this evaluation will not contain names, only encrypted patient and physician numbers. Results will be in the form of pooled data only. No physician or patient will ever be identified in any reports or publications.
If you have any questions or would like further information with respect to this evaluation, you may contact the Portrait team at (604) 822-4887 or email Portrait@ti.ubc.ca
Opioid Portrait References
- Chang AK, Bijur PE, Esses D, et al. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017 Nov 7;318(17):1661–7. doi:10.1001/jama.2017.16190
- Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: a systematic review and meta-analysis. JAMA. 2018 Dec 18;320(23):2448–60. doi:10.1001/jama.2018.18472
- Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018 Mar 6;319(9):872–82. doi:10.1001/jama.2018.0899
- Daoust R, Paquet J, Cournoyer A, et al. Side effects from opioids used for acute pain after emergency department discharge. Am J Emerg Med. 2020 Apr 1;38(4):695-701. Epub 2019 Jun 3. doi:10.1016/j.ajem.2019.06.001
- Fischer B, Jones W, Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005-2009. Pharmacoepidemiol Drug Saf. 2013 Apr 1;22(14):438–42. doi:10.1002/pds.3404
- Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015 Feb 17;162(4):276–86. doi:10.7326/M14-2559
- Nielsen S, Van Hout MC. Over-the-counter codeine—from therapeutic use to dependence, and the grey areas in between. Curr Top Behav Neurosci. 2016;34:59–75. doi:10.1007/7854_2015_422
- Das M, Jain R, Dhawan A, et al. Assessment of abuse liability of tramadol among experienced drug users: double-blind crossover randomized controlled trial. J Opioid Manag. 2016 Nov;12(6):421–30. doi:10.5055/jom.2016.0361
- Adams EH, Breiner S, Cicero TJ, et al. A comparison of the abuse liability of tramadol, NSAIDs, and hydrocodone in patients with chronic pain. J Pain Symptom Manage. 2006 May;31(5):465–76. doi:10.1016/j.jpainsymman.2005.10.006
- Smolina K, Crabtree A, Chong M, et al. Patterns and history of prescription drug use among opioid-related drug overdose cases in British Columbia, Canada, 2015-2016. Drug Alcohol Depend. 2018 Jan 1;194:151-8. doi:10.1016/j.drugalcdep.2018.09.019
- Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016 Jan 14;374:154–63. doi:10.1056/NEJMra1508490
- Ray WA, Chung CP, Murray KT, et al. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016 Jun 14;315(22):2415–23. doi:10.1001/jama.2016.7789
- Klimas J, Gorfinkel L, Fairbairn N, et al. Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: a systematic review. JAMA Netw Open. 2019 May 3;2(5):e193365. doi:10.1001/jamanetworkopen.2019.3365
- Chenot JF, Becker A, Leonhardt C, et al. Use of complementary alternative medicine for low back pain consulting in general practice: a cohort study. BMC Complement Altern Med. 2007 Dec 18;7(1):42. doi:10.1186/1472-6882-7-42
- Tick H, Nielsen A, Pelletier KR, et al. Evidence-based nonpharmacologic strategies for comprehensive pain care: the consortium pain task force white paper. Explore (NY). 2018 May 1;14(3):177–211. doi:10.1016/j.explore.2018.02.001
- Choosing Wisely Canada. Opioids – When you need them and when you don’t [Internet]. Toronto (ON): Choosing Wisely Canada [cited 2020 Nov 24]. Available from: https://choosingwiselycanada.org/patient-pamphlet-opioids/
- Institute for Safe Medication Practices Canada. Opioids for short-term pain [Internet]. Toronto (ON): Institute for Safe Medication Practices Canada [cited 2020 Nov 24]. Available from: https://www.ismp-canada.org/download/OpioidStewardship/Opioids-ShortTermPain-EN.pdf
- Wood E, Simel DL, Klimas J. Pain management with opioids in 2019-2020. JAMA. 2019 Oct 10;322(19):1912-13. doi:10.1001/jama.2019.15802
- Howard R, Fry B, Gunaseelan V, et al. Association of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. 2019;154(1):e184234. doi:10.1001/jamasurg.2018.4234
- Hill MV, McMahon ML, Stucke RS, et al. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2017 Apr 1;265(4):709–14. doi:10.1097/SLA.0000000000001993
- Hill MV, Stucke RS, McMahon ML, et al. An educational intervention decreases opioid prescribing after general surgical operations. Ann Surg. 2018 Mar 1;267(3):468–72. doi:10.1097/SLA.0000000000002198
- Nielsen S, Degenhardt L, Hoban B, et al. A synthesis of oral morphine equivalents (OME) for opioid utilisation studies. Pharmacoepidemiol Drug Saf. 2016 Jun 1;25(6):733–7. doi:10.1002/pds.3945
Opioids – When you need them and when you don’t. Choosing Wisely Canada. https://choosingwiselycanada.org/patient-pamphlet-opioids/
Opioids for short-term pain. Institute for Safe Medication Practices Canada. https://www.ismp-canada.org/download/OpioidStewardship/Opioids-ShortTermPain-EN.pdf