There has been very little evaluation of the effectiveness of strategies to assist GPs to manage chronic pain patients on prescription opioids, even high-risk patients. Current treatment guidelines recommend GPs establish a time-limited trial period of prescription opioids, although there have been no demonstration or evaluation trials of this approach. It is likely GPs find the routine implementation of such trial periods extremely challenging in practice, given their time and resource constraints. A recent NDARC RCT aimed at improving prescribing for alcohol dependence - another chronic, relapsing condition - showed that mailed, tailored feedback to GPs about their prescribing practice is a simple, low-cost strategy that significantly improves patient outcomes and appeared to reduce expensive inpatient hospitalisations for alcohol dependence. This project involves a pilot trial of these two approaches to inform a large scale RCT.
Dr Simon Holliday
Albert St Medical Centre
Dr Fiona Shand
Black Dog Institute, UNSW
Dr David Gorman
Spine Service, St George Hospital
Dr Denis Petrie
University of Melbourne
Chronic pain is a common complaint, and use of prescription opioids for pain has increased an estimated 300% between 1992-2007 in Australia. Although opioids have a well-established place in the treatment of cancer-related pain, reviews have cast doubt on their long-term effectiveness for managing chronic non-malignant pain. They also cause unintended harm: 15,000 US residents die annually from an unintended overdose of prescription opioids and 5% of the US population misuse prescription opioids.
Although treatment guidelines recommend GPs/patients establish a trial period of prescription opioids, there have been no demonstration or evaluation trials. Alternatively, mailed, tailored feedback to GPs was shown in an NDARC RCT to improve GP prescribing for alcohol dependence (another chronic, relapsing disorder), resulting in an annual average cost-saving to the health care system of $21,680/hospital. This study will identify the likely feasibility, acceptability to GPs and patients, costs and effectiveness of these two approaches.
To conduct a pilot trial of the cost-effectiveness of two interventions to improve GPs prescribing of pharmaceutical opioids:
- Education session describing a GP/patient trial period of prescription opioids; and
- Mailed, tailored feedback to GPs.
The hypothesis is that the effectiveness of the interventions will be comparable, but mailed, tailored feedback will be more cost-effective because of its lower implementation costs.
- Mailed, tailored feedback will be in the form of a brief letter. It will provide concise feedback to GPs on prescribing data and evidence, including:
- the benefits and risks of pharmaceutical opioids
- evidence about current rates of over-prescribing of pharmaceutical opioids, modelled to their community
- evidence-based alternatives to prescribing, including techniques for managing high-risk patients
- clear recommendation to reduce their prescribing of pharmaceutical opioids
- GP Education session. GPs will be provided with a protocol (based on current guidelines) for implementing an opioid trial period with chronic pain patients. Prior to prescribing (and during opioid treatment), GPs/patients will review the likely effectiveness of the opioids against the 5A’s criteria: analgesia, affect, activity, aberrant behaviours, and adverse effects. If the decision to prescribe is reached, a written agreement will be negotiated between GPs and patients, and patient progress will be monitored.
Data collection is complete: Towns A and C have received mailed interventions, and Town B has received an education session. Analysis of post-intervention data on feasibility and acceptability is currently underway. Medicare PBS and MBS data has been requested.
Peer-reviewed publications are currently being prepared.
Conference presentations arising from this study:
Shakeshaft, A., Larance, B., Degenhardt, L., Shand, F., Mattick, R.P., Holiday, S., Petrie, D., Gorman, D. (2013) Community-level interventions to improve the treatment of chronic pain and prescription of pharmaceutical opioids in general practice. Poster presentation to APSAD Conference, Brisbane, 24-27 November 2013.
Larance, B., Holliday, S., Degenhardt, L., Shand, F., Mattick, R.P., Petrie D., Shakeshaft, A. (2014) Apilot study of community-level interventions to improve the treatment of chronic pain and prescription of pharmaceutical opioids in general practice. Poster presentation at the National Drug and Alcohol Research Centre (NDARC) Symposium, September 2014, University of New South Wales, Sydney.
GPs will benefit from improved knowledge and confidence in their current prescribing for, and management of, patients using pharmaceutical opioids. Policy makers will benefit from obtaining information about the likely benefits, costs and acceptability of two different approaches to improving GPs management of chronic pain patients. This information would provide them with evidence to inform their decisions about the types of programs they could provide in NSW as the anticipated epidemic of pharmaceutical opioids emerges in Australia over the foreseeable future.