What do a family doctor, a hospital-based pharmacist, a handful of AV俱乐部 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 optimal 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.
鈥淔amily physicians play a large role in the management of chronic pain, and this includes prescribing opioid therapy,鈥� notes Dr. Mathew Grandy, a family physician and faculty member teaching in AV俱乐部 Family Medicine鈥檚 clinic in Spryfield, N.S. 鈥淲hat 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.鈥�
As a family doctor working in a university-based clinic, Dr. Grandy was inspired to embark on a research project to learn more.
鈥淲e need to expand and refine our systems for monitoring patients鈥� opioid use at the level of the electronic medical record, or EMR,鈥� Dr. Grandy says. 鈥淭his is especially important in team-based environments, to facilitate communication among providers and minimize medication errors.鈥�
(Right to left): Dal family physician, Dr. Mathew Grandy, and NSHA drug-utilization pharmacist, Ms. Heather Neville, worked closely with Ms. Beverley Lawson (BRIC NS) and Dr. Ingrid Sketris (College of Pharmacy) to design and launch a two-year study of opioid-prescribing patterns in Nova Scotia.
Research guidance from BRIC NS
For guidance in getting a research project off the ground, Dr. Grandy went to , a primary health care research network based in AV俱乐部鈥檚 Department of Family Medicine.
鈥淏RIC NS director, Beverley Lawson, was instrumental in helping us build a team, develop the application and approach the most promising sources of funding,鈥� says Dr. Grandy of the welcome assistance. 鈥淚t鈥檚 safe to say this project wouldn鈥檛 be happening without BRIC NS.鈥�
To form just the right research team, Dr. Grandy and Ms. Lawson approached Heather Neville 鈥� a drug-utilization pharmacist at Nova Scotia Health Authority (NSHA) 鈥� to be Dr. Grandy鈥檚 co-investigator. They also involved senior researchers, Dr. Fred Burge (Department of Family Medicine) and Dr. Ingrid Sketris (College of Pharmacy), data analyst Sara Sabri, AV俱乐部 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
鈥淲e are using anonymous data extracted from the electronic medical record to develop a 鈥榗ase definition鈥� that identifies the key features of patients on chronic high-dose opioid therapy,鈥� says Dr. Grandy of the progress to date. 鈥淭his 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.鈥�
鈥淥pioid鈥� 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.
鈥淧atients with chronic pain want to be treated appropriately,鈥� notes 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. 鈥淚t鈥檚 our responsibility as health care providers to monitor how pain medications are prescribed and minimize patients鈥� risk of developing an opioid-use disorder, while still treating their pain.鈥�
Data analyst Sara Sabri and AV俱乐部 pharmacy student Isaac Bai play vital roles in the NSHA-funded study of opioid-prescribing patterns.
The researchers involved a patient on their study team, from the earliest planning stages. 鈥淪he has contributed a lot,鈥� Neville notes. 鈥淎s a person who鈥檚 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.鈥�
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鈥� electronic medical records.
鈥淲e are really digging into the EMR to learn what information we can access and how we can track it by family practice,鈥� Dr. Grandy says. 鈥淲e 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.鈥�
As Dr. Grandy notes, the information they receive may prompt family doctors to ask a variety of questions, such as, 鈥淗ow 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?鈥�
Casting a wider net
It can be difficult to see patterns from inside a practice and, as Neville points out, family physicians typically don鈥檛 have the time or the data-analysis expertise to track their own prescribing patterns. And, she says, it鈥檚 more powerful for doctors to be able to see how their pattern fits into the bigger picture.
鈥淚t鈥檚 important we are doing this work as a collective,鈥� Neville emphasizes. 鈥淭he 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鈥檚 happening in their own practice, their province, and their country.鈥�
The connection to BRIC NS makes it easier for the researchers to connect with likeminded investigators in other provinces. 鈥淲e are part of a 鈥榥etwork of networks鈥� of primary care researchers all across Canada,鈥� explains BRIC NS Director Beverley Lawson, a leading primary care researcher based in AV俱乐部鈥檚 Department of Family Medicine. 鈥淲hen 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.鈥�