ObjectiveThe objective of this study is to characterise concurrent use of benzodiazepine receptor modulators and opioids among prescription opioid users in Alberta in 2017.DesignA population based retrospective study.SettingAlberta, Canada, in the year 2017.ParticipantsAll individuals in Alberta, Canada, with at least one dispensation record from a community pharmacy for an opioid in the year 2017.ExposureConcurrent use of a benzodiazepine receptor modulator and opioid, defined as overlap of supply for both drugs for at least 1 day.Main outcome measuresPrevalence of concurrency was estimated among subgroups of patient characteristics that were considered clinically relevant or associated with inappropriate medication use.ResultsAmong the 547 709 Albertans who were dispensed opioid prescriptions in 2017, 132 156 (24%) also received prescriptions for benzodiazepine receptor modulators. There were 96 581 (17.6%) prescription opioid users who concurrently used benzodiazepine receptor modulators with an average of 98 days (SD=114, 95% CI 97 to 99) of total cumulative concurrency and a median of 37 days (IQR 10 to 171). The average longest duration of consecutive days of concurrency was 45 (SD=60, 95% CI 44.6 to 45.4) with a median of 24 days (IQR 8 to 59). Concurrency was more prevalent in females, patients using an average daily oral morphine equivalent >90 mg, opioid dependence therapy patients, chronic opioid users, patients utilising a high number of unique providers, lower median household incomes and those older than 65 (p value<0.001 for all comparisons).ConclusionsConcurrent prescribing of opioids and benzodiazepine receptor modulators is common in Alberta despite the ongoing guidance of many clinical resources. Older patients, those taking higher doses of opioids, and for longer durations may be at particular risk of adverse outcomes and may be worthy of closer follow-up for assessment for dose tapering or discontinuations. As well, those with higher healthcare utilisation (seeking multiple providers) should also be closely monitored. Continued surveillance of concurrent use of these medications is warranted to ensure that safe drug use recommendations are being followed by health providers.

Background The opioid overdose epidemic in Canada and the United States has become a public health crisis - with exponential increases in opioid-related morbidity and mortality. Recently, there has been an increasing body of evidence focusing on the opioid-sparing effects of medical cannabis use (reduction of opioid use and reliance), and medical cannabis as a potential alternative treatment for chronic pain. The objective of this study is to assess the effect of medical cannabis authorization on opioid use (oral morphine equivalent; OME) between 2013 and 2018 in Alberta, Canada. Methods All adult patients defined as chronic opioid users who were authorized medical cannabis by their health care provider in Alberta, Canada from 2013 to 2018 were propensity score matched to non-authorized chronic opioid using controls. A total of 5373 medical cannabis patients were matched to controls, who were all chronic opioid users. The change in the weekly average OME of opioid drugs for medical cannabis patients relative to controls was measured. Interrupted time series (ITS) analyses was used to assess the trend change in OME during the 26 weeks (6 months) before and 52 weeks (1 year) after the authorization of medical cannabis among adult chronic opioid users. Results Average age was 52 years and 54% were female. Patients on low dose opioids (< 50 OME) had an increase in their weekly OME per week (absolute increase of 112.1 OME, 95% CI: 104.1 to 120.3); whereas higher dose users (OME > 100), showed a significant decrease over 6 months (− 435.5, 95% CI: − 596.8 to − 274.2) compared to controls. Conclusions This short-term study found that medical cannabis authorization showed intermediate effects on opioid use, which was dependent on initial opioid use. Greater observations of changes in OME appear to be in those patients who were on a high dosage of opioids (OME > 100); however, continued surveillance of patients utilizing both opioids and medical cannabis is warranted by clinicians to understand the long-term potential benefits and any harms of ongoing use.

ObjectivesCoprescribing of benzodiazepines/Z-drugs (BZDs) and opioids is a drug-use pattern of considerable concern due to risk of adverse events. The objective of this study is to estimate the effect of concurrent use of BZDs on the risk of hospitalisations/emergency department (ED) visits and deaths among opioid users.Design, setting and participantsWe conducted a population-based case cross-over study during 2016–2018 involving Albertans 18 years of age and over who received opioids. From this group, we identified 1 056 773 people who were hospitalised or visited the ED, and 31 998 who died.InterventionConcurrent use of opioids and BZDs.OutcomesWe estimated the risk of incident all-cause hospitalisation/ED visits and all-cause mortality associated with concurrent BZD use by applying a matched-pair analyses comparing concurrent use to opioid only use.ResultsConcurrent BZD use occurred in 17% of opioid users (179 805/1 056 773). Overall, concurrent use was associated with higher risk of hospitalisation/ED visit (OR 1.13, p<0.001) and all cause death (OR 1.90; p<0.001). The estimated risk of hospitalisation/ED visit was highest in those >65 (OR 1.5; p<0.001), using multiple health providers (OR 1.67; p<0.001) and >365 days of opioid use (OR 1.76; p<0.001). Events due to opioid toxicity were also associated with concurrent use (OR 1.8; p<0.001). Opioid dose-response effects among concurrent patients who died were also noted (OR 3.13; p<0.001).InterpretationConcurrent use of opioids and BZDs further contributes to the risk of hospitalisation/ED visits and mortality in Alberta, Canada over opioid use alone, with higher opioid doses, older age and increased number of unique health providers carrying higher risks. Regulatory bodies and health providers should reinforce safe drug-use practices and be vigilant about coprescribing.

BackgroundThe use of multisource feedback (MSF) for assessing physician performance is widespread and rapidly growing. Findings from early very small research studies using highly selected participants suggest high levels of satisfaction and support. However, after nearly two decades of experience using MSF to evaluate all physicians in Alberta, we are sceptical of this.ObjectivesTo determine physicians’ actual opinions of MSF using the entire physician population of Alberta, CanadaDesignOnline survey.SettingAlberta, Canada.ParticipantsAll physicians with a full licence to practice in Alberta in 2015.InterventionsAll participants were asked to grade how well they thought MSF was at assessing various aspects of physician performance using a 10-point Likert-type scale. There was also a text response field for written comments.OutcomesMean responses to quantitative questions. Qualitative content and thematic analysis of open-ended text responses.We analysed the data using SPSS V.23 and NVivo V.11 and built a multivariate model highlighting the predictors of high and low opinions of MSF.ResultsSurvey response rate was high for physicians with 2215 responses (25%). The mean rating for how successful MSF was at assessing a variety of dimensions, varied from a low of 5.03/10 for medical knowledge to a high of 6.38/10 for professionalism and communication. Canadian-trained MDs rated MSF significantly lower on every dimension by approximately 20% compared with non-Canadian-trained MDs.ConclusionsAlberta physicians have much lower opinions about the ability of MSF to measure any dimension of their performance than what has been suggested in the literature. Canadian-trained MDs have a particularly low opinion of MSF for reasons that remain unclear. The results of this survey offer a serious challenge to the effectiveness of a programme that is designed to promote self-reflection and performance improvement.

Opioid prescriptions have been monitored by the College of Physicians and Surgeons of Alberta (CPSA) since 1986, and benzodiazepine prescriptions since 2015. Recently the CPSA developed the “MD Snapshot-Prescribing Profile,” a feedback intervention consisting of a personalized report for physicians to see how many opioids and/or benzodiazepines they have prescribed to their patients. The aim of this study was to determine the attitudes and opinions of physicians in Alberta who received their prescribing profile from the CPSA in December 2016. Following mail-out of the prescribing profile, an online survey was emailed to recipients (n=8,213). The mixed survey asked five closed-ended questions, and an open-ended question asking for comments. Results from the closed-ended questions were compiled via Survey Monkey and responses to the open-ended question were analyzed using a qualitative content analysis method. Total survey response rate was 27% (n=2,148). More than half of physician-respondents indicated that they plan to make changes to their prescribing practice based on the prescribing profile and two-thirds of respondents found the information in the prescribing profile useful. Responses to the open-ended question were mixed. Physicians' attitudes and opinions regarding the receipt of their prescribing profile are diverse. Most recipients found benefit in their profile, and plan to use forthcoming versions as a useful instrument in their practices. Given the high rates of opioid/benzodiazepine prescriptions and related opioid epidemic, the MD Snapshot-Prescribing Profile is an innovative and important tool that can assist in improving physician prescribing practices.