By Melanie Jollymore
What do a family doctor, a hospital-based pharmacist, a handful of Dalhousie health researchers, and a Nova Scotian who has experience with opioids for chronic pain, have in common?
They all want patients with chronic, severe non-cancer pain to receive the best possible treatment for their pain. But first they need to learn more about who is receiving opioids for their pain, and how they are doing with this treatment. To get to the bottom of this, they need to examine the patterns of how opioids are prescribed in family practice in Nova Scotia.
“Family physicians play a large role in the management of chronic pain, and this includes prescribing opioid therapy,” notes Dr. Mathew Grandy, a family physician and faculty member teaching in Dalhousie Family Medicine’s clinic in Spryfield, N.S. “What remains difficult is access to patient demographics and prescribing patterns at the family-practice level, which is so important when considering quality improvement initiatives and primary care research.”
As a family doctor working in a university-based clinic, Dr. Grandy was inspired to embark on a research project to learn more.
“We need to expand and refine our systems for monitoring patients’ opioid use at the level of the electronic medical record, or EMR,” Dr. Grandy says. “This is especially important in team-based environments, to facilitate communication among providers and minimize medication errors.”
Research guidance from BRIC NS
For guidance in getting a research project off the ground, Dr. Grandy went to BRIC NS (Building Research for Integrated Primary Healthcare in Nova Scotia), a primary health care research network based in Dalhousie’s Department of Family Medicine.
“BRIC NS director, Beverley Lawson, was instrumental in helping us build a team, develop the application and approach the most promising sources of funding,” says Dr. Grandy of the welcome assistance. “It’s safe to say this project wouldn’t be happening without BRIC NS.”
To form just the right research team, Dr. Grandy and Ms. Lawson approached Heather Neville—a drug-utilization pharmacist at Nova Scotia Health Authority (NSHA)—to be Dr. Grandy’s co-investigator. They also involved senior researchers, Dr. Fred Burge (Department of Family Medicine) and Dr. Ingrid Sketris (College of Pharmacy), Dalhousie pharmacy student Isaac Bai (funded by BRIC NS), and a patient advisor.
BRIC NS helped the team design a two-year study of opioid-prescribing patterns in family practices across Nova Scotia and secure funding from the NSHA Research Fund to conduct the study, now one year underway.
Defining the patient and problem
“We are using anonymous data extracted from the electronic medical record to develop a ‘case definition’ that identifies the key features of patients on chronic high-dose opioid therapy,” says Dr. Grandy of the progress to date. “This information will go into our data-analysis algorithms, so we can identify the right records and ask sophisticated questions about patient demographics, the nature of their pain problems, and how they are being treated for their pain.”
“Opioid” is a class of powerful pain-relieving yet highly addictive drugs that includes morphine, codeine, oxycodone and hydromorphone. Opioids play a vitally important role in managing a wide range of acute pain conditions, including pain from trauma, surgery and cancer. What is less clear is their efficacy in managing chronic non-cancer pain conditions, where prolonged use raises the risk of addiction and other side effects that may outweigh the pain-relief benefits.
“Patients on opioids want to be treated appropriately,” notes Ms. Neville, whose job as a drug-utilization pharmacist is to make sure drugs are used properly, to avoid adverse events and prevent unnecessary costs to the health care system. “It’s our responsibility as health care providers to monitor how these medications are prescribed and minimize patients’ risk of developing an opioid-use disorder, while still treating their pain.”
The researchers involved a patient on their study team, from the earliest planning stages. “She has contributed a lot,” Ms. Neville notes. “As a person who’s familiar with prescription opioid use, and knows a lot of other people with chronic pain, she brings our attention to many difficult aspects of the problem. We would be blind to those aspects without her involvement.”
Informing family prescribing practice
The researchers are working through MaRNET (Maritime Family Practice Research Network), a network of more than 90 family practices involved in research in the Maritimes, to capture data from patients’ electronic medical records.
“We are really digging into the EMR to learn what information we can access and how we can track it by family practice,” Dr. Grandy says. “We will then feed this information back to the physicians in the network, so they can reflect on their opioid-prescribing patterns, see how they compare with their peers and with national clinical practice guidelines, and make adjustments as needed.”
As Dr. Grandy notes, the information they receive may prompt family doctors to ask a variety of questions, such as, “How are my patients on long-term opioid therapy doing? Can we adjust the dosage down, or wean them off? What are some alternatives to help them manage their pain?”
Casting a wider net
It can be difficult to see patterns from inside a practice and, as Ms. Neville points out, family physicians typically don’t have the time or the data-analysis expertise to track their own prescribing patterns. And, she says, it’s more powerful for doctors to be able to see how their pattern fits into the bigger picture.
“It’s important we are doing this work as a collective,” Ms. Neville emphasizes. “The participating physicians are contributing to a larger understanding of opioid-prescribing patterns in primary care in Nova Scotia. And because we are also part of regional and national networks, we aim to expand the work so physicians all across Canada will be able to see what’s happening in their own practice, their province, and their country.”
The connection to BRIC NS makes it easier for the researchers to connect with likeminded investigators in other provinces. “We are part of a ‘network of networks’ of primary care researchers all across Canada,” explains BRIC NS director, Beverley Lawson, a leading primary care researcher based in Dalhousie’s Department of Family Medicine. “When we partner with other provinces, we are eligible for federal funding designed to improve the flow of information among provinces, so we can work together to create solutions to challenges we all share, in every part of the country.”