Download Prescription Drug Misuse Metrics

Prescription Drug Misuse
Metrics
Drs Helen Moriarty and Roshan Perera.
University of Otago Wellington.
Importance of
prescription drug misuse
• National and international concern.
• Escalating use of prescription opioids for chronic
non-malignant pain, world-wide.
• Public health burden - cost of Rx, accidental or
non-accidental overdose, injuries under the
influence, addiction, illicit use, diversion.
• Personal health burden – iatrogenic
dependence, opiate-induced hyperalgesia,
opiate bowel syndrome, osteoporosis,
hypogonadism.
Importance of
prescription drug misuse
• Combined Australasian College strategy
document (2009)*
• Law Commission review of Misuse of Drugs Act
(2011)^
• Amenable to quality and safety activities wr to prescribing and dispensing; patient instruction
and education; and patient monitoring.
• *Improvement of prescribing a significant patient
safety issue.
*
The Royal Australasian College of Physicians. Prescription Opioid Policy: Improving management of chronic nonmalignant pain and prevention of problems associated with prescription opioid use,. Sydney 2009.
^
http://www.lawcom.govt.nz/sites/default/files/publications/2011/05/part_1_report__controlling_and_regulating_drugs.pdf
Defining the research question
• Are there any indicators to measure
prescription drug misuse?
• How good are the indicators? Can we grade
or rank them?
• Do the indicators apply to NZ settings?
• Can they be used to monitor quality of clinical
practice? benchmark NZ practices?
Finding the evidence
• Consensus and best practice guidelines
Kahan, M., A. Mailis-Gagnon, et al. (2011).
"Canadian guideline for safe and effective use of opioids for
chronic noncancer pain - Clinical summary for family physicians.
• “Artificial intelligence” tools eg
 Mailloux AT, Cummings SW, Mugdh M. A Decision Support Tool for
Identifying Abuse of Controlled Substances by ForwardHealth
Medicaid Members. Journal of Hospital marketing and Public
Relations 2010. 20:1, 34-55.
 Trafton et al. Evaluation of the Acceptability and Usability of a DSS
to encourage safe and effective use of Opioid Therapy for chronic,
non cancer pain by primary care providers. Pain Medicine
2010;epub 3/1/10.
 Trafton JA, Lewis ET, Midboe AM, et al. Status Report. Metrics from
the 2010 Clinical Practice Guideline for Chronic Opioid Therapy:
Veterans Administration, USA, 2011
Role of Sieve Indicator
Appraisal Tool (SIAT)
•
•
•
•
Tool for consistent repeatable appraisal
Identifies all important aspects of indicators
Provided parameters for classifying indicators
Classification System also constructed to aid
appropriate selection (and successful
implementation of health system indicators).
Results:
Few existing indicators re opiate
prescribing for chronic non-malignant
pain were sufficiently developed for SIAT
assessment
Developing new indicators
for NZ: Process
• 15 Veterans’ Administration metrics on opioid
prescribing were relevant to the project
• Evidence-based assessment of each was
undertaken using The SIAT.
Results:
Some indicators were not sufficiently well
defined to provide valid results.
Consequently, additional indicators were
developed by the authors.
Developing new indicators
for NZ: content
• Indicators were developed in ‘suites’ to
enable a comprehensive review of the
aspect of care in question.
Results: 7 new indicator suites
specifically for the New Zealand
context.
29 new quality measures of appropriate
opiate prescribing in chronic nonmalignant pain in NZ
Examples
Seven suites of indicators
Indicator Suite 1
Topic Area: Clinical assessment and documentation
Aspect of care: Evidence of baseline assessment
Indicator Suite 2
Topic Area: Planned opioid initiation
Aspect of care: Clinical assessment and documentation when beginning
prescribed opioid treatment
Indicator Suite 3
Topic Area: Clinical management of patients receiving their first prescription of
opioids for chronic non-malignant pain
Aspect of care: Short term review
Indicator Suite 4
Topic Area: Stepped care for chronic non-malignant pain management
Aspect of care: Stepped care in prescribing for chronic non-malignant pain.
NZ indicator suites continued
Indicator Suite 5
Topic Area: Appropriate monitoring of opioid prescribing
Aspect of care: Clinical assessment and documentation of on-going prescribed opioid
treatment
Indicator Suite 6
Topic Area: Misuse of prescription controlled drugs
Aspect of care: Avoiding controlled drug misuse
Indicator Suite 7
Topic Area: Management of complications of opiate treatment in chronic non-malignant
pain
Aspect of care: Proactive monitoring for complications of prescribing for chronic pain
Aspect of care:
Avoiding controlled drug misuse
• Need for:
– Monitoring of compliance with opioids; possible diversion; id
potential abuse;
– Optimal mgt of high risk patients incl recording; f/u; and dx of
worsening condition
– Appropriate use and interpretation of urine tests (incl availability
of quantifiable assays)
• Indicator suite:
– 1) A&D risk assessment in the past 3 months
– 2) Documented baseline urine monitoring on 1st presentation
– 3) Additional urine test within 3 months of 1st presentation
Avoiding controlled drug misuse
• Denominator:
– Patients on opioids for CNMP with A&D Hx
• Parameters for analysis and interpretation:
– Urine test needs to be specified and appropriate for the particular
opioid taken
• Potential issues:
– Funding of some medicines; clinical circumstances (e.g. dose
escalation); caveats (e.g. confounding of tests)
• Implementation:
– Data sources – access required (GP notes for paper triplicate copy or
mention of prescribing, EPM for other opiates, and electronic records
for adjunctive prescriptions); consistent coding for data collection and
collation.
Aspect of care:
Stepped care in Rx for CNMP
• Need for:
– Prescribing using the analgesic ladder to avoid unnecessary use
of opiates;
– Stepped approach to avoid unnecessary prescribing of high
potency opiates;
– Optimal pharmacological treatment to manage chronic pain and
escape pain.
• Indicator suite:
–
–
–
–
1) Documented review of pain severity measurement
2) Documented review of opiate need
3) Initial management with lower strength opiate options
4) Documented advice on use of PRN doses
Stepped care in Rx for CNMP
• Denominator:
– Patients on opioids for CNMP for 2 months or longer
• Parameters for analysis and interpretation:
– Consider that prescriptions need to be hand written on triplicate CD forms. Ma
require manual search, multiple sites an issue.
• Potential issues:
– Patient resistance to review and moderating advice
• Implementation:
– Data sources – access required (GP notes for paper triplicate copy or mention
of prescribing, EPM for other opiates, and electronic records for adjunctive
prescriptions); consistent coding for data collection and collation.
– Investigation of clinical notes may be time intensive
– Prescription data in electronic records at practices may be incomplete
The implementation phase
• Funding renegotiated due to timeline
expectations
• Implementation phase to begin in 2013
• Primary Care PHO have volunteered
• Any secondary care service volunteers???
• Action research with before-and-after data
collection design (where possible)
Where to next?
Other indicators in the topic of psychoactive
medication abuse:
•Benzodiazepines
•Antidepressants
•Antipsychotics
•Stimulants
Other indicators in other prescription drug
safety topics
Acknowledgements
• Health Quality and Safety Commission
• Jodie Trafton and Veterans Affairs
administration
• UOW Medical Librarians and Research
Office
• You – a most appreciative audience!