How I reduced my opioid prescribing rate

Edwin Kruys

4/02/2020 10:39:01 AM

Dr Edwin Kruys decided to scale back prescriptions of opioids two years ago. Here’s how he did it.

Falling numbers
Change is slow – but important, according to Dr Edwin Kruys.

One of my resolutions for 2018 was continuing to reduce my opioid prescription rate for patients with chronic non-cancer pain, in line with RACGP guidelines.
So, two years on, did I put my money where my mouth is?
It isn’t always easy to obtain the required data from our systems, even with the available extraction tools (tips are welcome, of course), but a while back NPS MedicineWise broke the news to me via the mail.
The data suggested that the number of opioids I prescribed per 100 Medicare consultations was seven. The next year it dropped to six, and the following year – last financial year – it was down to five.

My opioid prescription rate over the past years. (Source: NPS)

How did this happen?
I would like to think that taking the time for conversations about the role of pharmacological and non-pharmacological options has begun to pay off.
Out of the recommended activities to reduce opioid prescribing, I have made a particular effort to apply the following actions:

  • Avoid opioids in headache, dysmenorrhoea, dental pains and minor musculoskeletal strains/sprains
  • Engage a physiotherapist early for more severe acute musculoskeletal injuries
  • If opioids are necessary for severe acute pain, limit prescription to several days’ supply only
  • On discharge from hospital, discuss early tapering of opioids as part of the recovery process
  • Maximise non-opioid therapies and multidisciplinary care in chronic pain
  • Avoid opioids for chronic non-cancer pain in patients with an active or past substance use disorder or unstable psychiatric disorder
  • Reassess opioid-responsiveness regularly and often
  • Undertake intermittent reductions of opioid dosage
Since making that resolution two years ago, I have spent time practising a multi-pronged approach to pain management with patients, in which opioids more often play a short-term or last-resort role.
Obviously, there have also been less successful attempts. At times, a patient has not been ready to accept a different approach. Change can be a slow process.
One of the main challenges I have found is the ever-present time constraint in general practice (a reason I am very much in favour of better-remunerated long consultations).
While encouraging, the NPS statistics also raise questions.
For example, have some patients with complex dependency or pain issues been avoiding me? Are they now simply getting their scripts elsewhere?
Overall, though, I can see that data analysis and data-driven quality improvement in general practice is useful.
The NPS opioid prescription information has reinforced my management and approach to pain.
I aim to continue this approach in 2020 – because, as always, there is room for further evaluation and improvement.
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Dr Arshad Hussain Merchant   5/02/2020 7:43:15 AM

A great effort - well done and keep going
On a second thought, our prescribing is watched via various authorities but I have not seen any pharmacy opioid dispensing data. even when codeine was changed, a huge stock of codeine medicine were sold without any pharmacy data published on the OTC

Dr Hercules Morkel Duvel   5/02/2020 8:03:43 AM

Dear Edwin
Thanks for your article, and good work.
The points you raise are valid.
Statistic are like a bikini what they reveal is interesting but what they cover up is vital.
The rx per 100 medicare consultations would actually be adversely affected by giving patients less medications and for shorter intervals more often.
The best way to avoid opioids is to NOT go down that path for non cancer pain.
I agree with you, the 3 minute answer is opioids and you stay on time, however that is not the correct answer. I have found by talking to patients and using the " Brain Man" videos, I have been successful to avoid opioids.
Another frustration is the chronic pain clinics that are supposed to be multidisciplinary often start patients on opioids. It is very difficult to get patients the multidisciplinary consultations in a timely fashion.
We are likely not alone!

Dr Evan Ackermann   6/02/2020 11:31:04 AM

Well done Edwyn - but is "opioids prescribed per 100 Medicare consultations" a valid or reliable indicator of anything?
The RACGP was quite vocal about getting reliable indicators for appropriate prescribing, yet many bodies refused to even entertain our advice. Yes there are shortcoming in the databases collected, but there are opportunities to refine it too - which is not entertained.