Prescription Drug Misuse Metrics

1. Prescription Drug Misuse Metrics Drs Helen Moriarty and Roshan Perera. University of Otago Wellington.

2. 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.

3. 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 non-malignant 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

4. 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?

5. 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

6. 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

7. 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.

8. 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 non-malignant pain in NZ

9. Examples

10. 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.

11. 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

12. 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

13. 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.

14. 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

15. 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. May 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

16. 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)

17. Where to next? Other indicators in the topic of psychoactive medication abuse: • Benzodiazepines • Antidepressants • Antipsychotics • Stimulants Other indicators in other prescription drug safety topics

18. Acknowledgements • Health Quality and Safety Commission • Jodie Trafton and Veterans Affairs administration • UOW Medical Librarians and Research Office • You – a most appreciative audience!