EMRs are tool for safe opioid prescribing

865 people died from opioid overdoses in Ontario in 2015

865 people died from opioid overdoses in Ontario in 2015

Family physicians participating in a province-wide push to alleviate the opioid epidemic should be making use of their electronic medical records (EMRs) to gauge their prescribing habits and identify patients who can be better served by other pain-relieving strategies, according to Dr. Darren Larsen, chief medical information officer, OntarioMD, a subsidiary of the Ontario Medical Association.

“We know that if you’ve had your EMR for longer than a year, you probably have a lot of information in there about the prescriptions your patients are on,” said Larsen.

“We want to be able to identify the patients in a practice who may be at risk because of the length of time they’ve been on an opioid, a very high dose that they’re on, or the combination of an opioid with medication like benzodiazepines which may double or triple the risk of respiratory arrest.”

According to the recently released Canadian consensus guidelines on opioid prescribing, patients taking more than 50mg of morphine equivalent per day are at an intermediate risk, while those taking more than 90mg/day are considered to be at high risk of either accidental overdose or severe side effects.

“The first goal is to identify the individual patients who may need some extra attention,” said Larsen. “The second goal is to look at it from a population perspective across an entire group practice, and ask, ‘What are we doing collectively? Are there good reasons for it? If not, how do we correct it?’

The idea is to think about the problem, then tap into the available resources (to modify our prescribing habits).”

A plethora of resources are available through Health Quality Ontario’s (HQO) Partnered Efforts in Safe Opioid Prescribing project, which brings together OntarioMD, the Ontario College of Family Physicians, the Association of Family Health Teams of Ontario, the Centre for Effective Practice, the University of Toronto’s Department of Family and Community Medicine, the Centre for Addiction and Mental Health (CAMH) and the College of Physicians and Surgeons of Ontario.

One-on-one mentorship programs delivered by pain management specialists, as well as online and in-person courses are available from several partner organizations – all of which are identified on the website of the Ontario College of Family Physicians.

HQO’s Partnered Efforts in Safe Opioid Prescribing project addresses three classes of physicians, according to Larsen.

The first group consists of the 86 doctors who were flagged by the Ministry of Health and Long-Term Care’s narcotics monitoring system in November for their “unusual” opioid prescribing habits.

The names of the doctors in question were submitted to the College of Physicians and Surgeons of Ontario to decide if the prescriptions were appropriate.

At the time, Minister of Health Dr. Eric Hoskins revealed some of the dosages prescribed “were equivalent to roughly 150 Tylenol 3s being consumed in a single day.”

Some of these doctors may be serving inner city or Indigenous communities, noted Larsen.

The second group of physicians to be targeted consists of doctors who aren’t serving high-risk communities and may be unconsciously prescribing more opioids than they should.

“Then there’s the rest of us who could always benefit from more education and may need help periodically with challenging patients,” said Larsen.

“The goal in the long term is to decrease the number of new narcotic prescriptions written for acute pain management and to guide doctors to safely and effectively taper patients on high doses of narcotics so we can very gradually get them out of the risk category for overdose or significant side effects.”

Other modes of pain management including mindfulness, non-opioid pain relievers, exercise, counselling and sleep training are some of the alternative interventions from which patients can benefit.

“These are people who have real difficulties,” said Larsen. “They’re not malingerers generally. These are people who have pain. We feel for them. We advocate for them. We want them to find relief, but we need to start thinking of safer ways to do it so we don’t put them at risk.”

According to Ontario’s interactive opioid tracker, 865 people died from opioid overdoses in Ontario in 2016, up from 556 in 2011.

In 2015/16, one in seven Ontarians (close to two million people) filled an opioid prescription for a total of just over nine million prescriptions.

Powerful new electronic tools are currently in development to help doctors curtail opioid abuse and better understand their prescribing habits.

According to Larsen, doctors in Northern Ontario will soon be able to access the province’s Narcotics Monitoring System through the Connecting Ontario Northern and Eastern portal.

“If I’m going to prescribe for a patient, I will have a place to look to see if my patient has been prescribed opioids before, how much they got and when they got it, so I’ll know if they’re double doctoring.”

Larsen also sees improvements in EMRs on the horizon that will simplify and standardize data mining.

One family practice in Waterloo-Wellington, for example, has a tool that will perform a complete opioid assessment that includes a narcotics contract and questions that need to be asked to help with real time decision-making.

Not every doctor will take the time to mine their EMR to identify opioid users who should be candidates for alternative strategies, “but there’s a real incentive to do so these days because the opioid crisis is in our faces every day,” said Larsen. “We have to create the processes that make it as easy as possible for them to look and act. It’s up to them to actually do the work, but with some support we hope they’re more likely to do it.”

Opioid stats for Northern Ontario, 2016

North East LHIN
ED visits: 226
(40.2 per 100,000 population)
Hospitalizations: 134
(23.8 per 100,000)
Morbidity/Mortality: 46
(8.2 per 100,000)

North West LHIN
ED visits: 110
(46.6 per 100,000 population)
Hospitalizations: 53
(22.5 per 100,000)
Morbidity/Mortality: 19
(8.1 per 100,000)

Ontario
ED visits: 4,427
(31.7 per 100,000 population)
Hospitalizations: 1,906
(13.7 per 100,000)
Morbidity/Mortality: 865
(6.2 per 100,000)

Source: Public Health Ontario, Interactive Opioid Tracker

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