Canadians from all walks of life have been profoundly impacted by the effects of problematic opioid use, and the crisis continues to claim lives at an alarming rate. By making investments in targeted, priority-driven research, the Canadian Institutes of Health Research (CIHR) can mobilize researchers to confront threats such as the opioid crisis, increasing awareness of the issue and our capacity to respond.
The Canadian Drugs and Substances Strategy, the Institute of Neurosciences, Mental Health and Addiction (INMHA), and the Institute of Health Services and Policy Research (IHSPR), funded 22 knowledge syntheses (an investment of over $1.8-million) with the goal of generating a large amount of knowledge in a short duration of time that would help tackle the opioid epidemic. Our team was fortunate to receive one grant: “Healthcare provider knowledge, attitudes, beliefs and practices around prescribing opioids to manage chronic-non-cancer pain.”
Funding Source: CIHR
Opioids analgesics can improve pain and function for many patients, but the decision to prescribe is complicated, and not without risk. Clinical practice guidelines help healthcare providers and their patients decide when potential benefits outweigh possible risks. Dr. Josh Rash collaborated with researchers, patients, and policy-makers from across Canada to examine 96 studies reporting on the knowledge, attitudes and beliefs of nearly 18,500 healthcare providers to see how these factors affect opioid prescribing practices. They observed that regulated professionals follow treatment guidelines with their patients in approximately 50% of interactions. Reasons for deviating from recommendations range from concerns surrounding potential misuse and other side effects, diversion of medication, regulatory scrutiny, and practitioner concerns in implementing complex recommendations. Interventions that target provider beliefs, and provide education and practical tools show improved adherence to clinical practice guidelines.
A link to detailed information page can be found here.
Results: Prescriber Adherence to Opioid Guidelines
Thirty-eight studies quantified prescriber adherence to opioid prescribing guidelines for chronic
noncancer pain and were eligible, comprising 17 cross-sectional studies (n 11,835 providers) and 22 chart reviews (n 22,512 patients). Survey data indicated that adherence was 49% (95% CI [40, 59]) for treatment agreements, 33% (95% CI [19%, 47%]) for urine drug testing, 48% (95% CI [26%, 71%]) for consultation with drug monitoring program, 57% (95% CI [35%, 79%]) for assessing risk of aberrant medication-taking behavior, and 61% (95% CI [35%, 87%]) for mental health screening. Chart review data indicated that the proportion of patients with documentation was 40% (95% CI [29, 51]) for treatment agreements, 41% (95% CI [32%, 50%]) for urine drug testing, 40% (95% CI [2%, 78%]) for consultation with drug monitoring program, 41% (95% CI [20%, 64%]) for assessing risk of aberrant medication-taking behavior, and 22% (95% CI [9%, 33%]) for mental health screening. Year of publication, practice guideline referenced, and risk of bias explained significant heterogeneity. No study evaluated whether
nonadherence to recommendations reflected well-justified deviations to care. Conclusions: Adherence to guideline recommendations for opioids for chronic pain is low. It is unclear whether nonadherence reflects thoughtful deviations in care.
Results: Interventions to Influence Opioid Prescribing Practices
Twenty studies (8 controlled and 12 prospective cohort) involving 1,491 providers and 72 clinics evaluated interventions to improve adherence to guideline recommendations for prescribing opioids for chronic non-cancer pain. Interventions included education, audit and feedback,
interprofessional support, shared decision making, and multifaceted strategies. Multifaceted interventions improved the use of urine drug testing (n=2, or =2.31, 95% CI=1.53, 3.49, z=3.98, p<0.01; high-certainty evidence), treatment agreements (n=2, or =1.96, 95% CI=1.47, 2.61, z=4.56, p<0.01; moderate-certainty evidence), and mental health screening (n=2, 2.57-fold, 95% CI=1.56, 4.24, z=2.32, p=0.02; low-certainty evidence) when prescribing opioids for chronic noncancer pain. Very low−certainty evidence suggests that several interventions improved the use of treatment agreements, urine drug testing, and prescription drug monitoring programs. Conclusions: Mostly very low−certainty evidence supports a number of interventions for improving adherence to risk management strategies when prescribing opioids for chronic noncancer pain; however, the effect on patient important outcomes (e.g., overdose, addiction, death) is uncertain.