Opioid prescribing practice standard in British Columbia, Canada: Rationale, controversies, and directions

Lim, Jeong-Ok; McCracken, Rita; Panagiotoglou, Dimitra

doi:10.1016/j.drugpo.2021.103363

Cited by 7 publications

(5 citation statements)

References 37 publications

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“…Toxicology analyses continue to implicate fentanyl from the unregulated drug supply as the main driver of overdose deaths, with hydromorphone implicated in less than 2% of overdose deaths in BC from March 27, 2020 to May 31, 2021 [ 3 , 36 ]. The concerns of prescribers with the SAFER team, nonetheless, speak to the tensions involved in developing and implementing medicalized models of safer supply in a context of broader efforts to reduce opioid prescribing (e.g., clinical guidelines for chronic pain management and intensifying prescription monitoring programs) [ 37 – 39 ]. Addressing such tensions and concerns during early SAFER program implementation was important to ensure prescribers were available and willing to prescribe.…”

Section: Resultsmentioning

confidence: 99%

Prescribed safer supply during dual public health emergencies: a qualitative study examining service providers perspectives on early implementation

McCall,

Hobbs,

Ranger

et al. 2024

Subst Abuse Treat Prev Policy

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Background Within North America and worldwide, drug related overdoses have increased dramatically over the past decade. COVID-19 escalated the need for a safer supply to replace unregulated substances and to reduce toxicity and overdoses. Service providers play an integral role in the delivery of safer supply but there is little empirical evidence that conceptualizes effective safer supply from their perspectives. This study explored early implementation and impacts of a safer supply program, capturing the perspectives of an interdisciplinary team of service providers on tensions and issues encountered in the development of the SAFER program. Methods Using a community-based participatory approach, we conducted individual interviews with program providers (n = 9). The research team was composed of researchers from a local drug user organization, a local harm reduction organization, and academic researchers. The Consolidated Framework for Implementation Research (CFIR) informed the interview guide. Data was analyzed using thematic analysis. Results There are six themes describing early implementation: (1) risk mitigation prescribing as context for early implementation; (2) developing SAFER specific clinical protocols; (3) accessibility challenges and program innovations; (4) interdisciplinary team and wraparound care; (5) program tensions between addiction medicine and harm reduction; (6) the successes of safer supply and future visions. Conclusion Early implementation issues and tensions included prescriber concerns about safer supply prescribing in a highly politicized environment, accessibility challenges for service users such as stigma, encampment displacement, OAT requirements, program capacity and costs, and tensions between addiction medicine and harm reduction. Navigating these tensions included development of clinical protocols, innovations to reduce accessibility challenges such as outreach, wraparound care, program coverage of medication costs and prescribing safer supply with/without OAT. These findings contribute important insights for the development of prescribed safer supply programs.

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Section: Resultsmentioning

confidence: 99%

Prescribed safer supply during dual public health emergencies: a qualitative study examining service providers perspectives on early implementation

McCall,

Hobbs,

Ranger

et al. 2024

Subst Abuse Treat Prev Policy

View full text Add to dashboard Cite

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“…The regulatory institution for physicians in the province expressed concerns regarding the limited empirical evidence base; the possibility of diversion, limited training, and expertise in providing prescribed safer supply within their scope of practice; and preference for team-based practices, which may deter adoption of new guidelines among prescribers in preference of well-established treatments [ 54 – 56 ]. As the evidence base for PSS emerges, future implementation strategies to improve PSS uptake will require engagement with both regulatory institutions and prescribers, acknowledging and addressing the concerns of both parties [ 57 ].…”

Section: Discussionmentioning

confidence: 99%

Influence of physician networks on the implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia

Kurz,

Guerra-Alejos,

Min

et al. 2024

Implementation Sci

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Background Characterizing the diffusion of adopted changes in policy and clinical practice can inform enhanced implementation strategies to ensure prompt uptake in public health emergencies and other rapidly evolving disease areas. A novel guidance document was introduced at the onset of the COVID-19 pandemic in British Columbia (BC), Canada, which supported clinicians to prescribe opioids, stimulants, and benzodiazepines. We aimed to determine the extent to which uptake and discontinuation of an initial attempt at a prescribed safer supply (PSS) program were influenced through networks of prescribers. Methods We executed a retrospective population-based study using linked health administrative data that captured all clinicians who prescribed to at least one client with a substance use disorder from March 27, 2020, to August 31, 2021. Our main exposure was the prescribing patterns of an individuals’ peers, defined as the proportion of a prescribers’ professional network (based on shared clients), which had previously prescribed PSS, updated monthly. The primary outcome measured whether a clinician had prescribed their initial PSS prescription during a given calendar month. The secondary outcome was the discontinuation of PSS prescribing, defined as an absence for PSS prescriptions for at least 3 months. We estimated logistic regression models using generalized estimated equations on monthly repeated measurements to determine and characterize the extent to which peer networks influenced the initiation and discontinuation of PSS prescribing, controlling for network, clinician, and caseload characteristics. Innovators were defined as individuals initiating PSS prior to May 2020, and early adopters were individuals initiating PSS after. Results Among 14,137 prescribers treating clients with substance use disorder, there were 228 innovators of prescribed safer supply and 1062 early adopters through the end of study follow-up, but 653 (50.6%) were no longer prescribing by August 2021. Prescribers with over 20% of peers whom had adopted PSS had a nearly fourfold higher adjusted odds of PSS prescribing themselves (aOR: 3.79, 95% CI: (3.15, 4.56)), compared to those with no connected safer supply prescribers. Conclusions The uptake of PSS in BC was highly dependent on the behavior of prescribers’ peer networks. Future implementation strategies to support PSS or other policies would benefit from leveraging networks of prescribers.

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“…Concerns that OUD practice standards and guidelines promote an ineffective and standardized approach to patient care have been raised in BC [25], which may create a sense of apprehension among prescribers to follow new clinical practice recommendations. Prescriber uptake of new treatment recommendations may be influenced by stigma, legal constraints, training, logistical factors such as remuneration or time commitment and concerns for diversion [26], where addressing clients’ needs may require a more cautious approach.…”

Section: Discussionmentioning

confidence: 99%

Prescribing practices in opioid agonist treatment and changes in compliance to clinical dosing guidelines in British Columbia, Canada

Guerra‐Alejos,

Yan,

Kurz

et al. 2024

Addiction

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Background and aimIn British Columbia, Canada, clinical guidelines for the treatment of opioid use disorders (OUD) were updated in 2017, during a period in which the potency and composition of the illicit drug supply changed rapidly. We aimed to describe changes in opioid agonist treatment (OAT) prescribing practices at the population level in a setting in which fentanyl and its analogs have become the primary illicit opioid of use.Design, setting and participantsThis was a population‐based retrospective cohort study using three linked health administrative databases in British Columbia (BC), Canada. All individuals with at least one OAT dispensation in BC between 1 January 2014 and 31 August 2021 took part.MeasurementsTo assess changes in OAT prescribing practices over time, we calculated initiation doses, dose titration intervals, maintenance doses and take‐home dosing intervals stratified by medication [methadone, buprenorphine–naloxone and slow‐release oral morphine (SROM)] according to recommended guidelines.FindingsA total of 265 410 OAT episodes (57.5% on methadone, 34.5% on buprenorphine–naloxone and 8.0% on SROM) were initiated during the study period. Compared with the guideline recommendation, observed initiation doses were higher among all medications from 2014 (2017 for SROM) to 2021 (buprenorphine–naloxone: 14–29%; methadone: 53–66%; SROM: 26–55%). Titration intervals were shorter for all medications, consistent with guidelines for buprenorphine–naloxone (26–49%), but shorter than recommended for methadone or SROM (28–51% and 12–41%, respectively). Higher maintenance dosing was observed for methadone (68–78%) and SROM (3–21%). Take‐home allowances extending beyond the recommended guideline length increased across medications (buprenorphine–naloxone: 18–35%; methadone: 50–64%; SROM: 34–39%). Changes in prescribing patterns were similar for first‐time OAT initiators.ConclusionIn British Columbia, Canada, from 2014 to 2021, prescribers of opioid agonist treatment (OAT) appeared to initiate both new and experienced OAT clients at higher doses than guideline recommendations, titrate them more rapidly and maintain clients at higher doses. Take‐home dose allowances also gradually increased.

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Opioid prescribing practice standard in British Columbia, Canada: Rationale, controversies, and directions

Cited by 7 publications

References 37 publications

Prescribed safer supply during dual public health emergencies: a qualitative study examining service providers perspectives on early implementation

Prescribed safer supply during dual public health emergencies: a qualitative study examining service providers perspectives on early implementation

Influence of physician networks on the implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia

Prescribing practices in opioid agonist treatment and changes in compliance to clinical dosing guidelines in British Columbia, Canada

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