Posted 19th Aug 2016 in Health Quality Evaluation

The Health Quality & Safety Commission says figures showing a continuing increase in the prescription of powerful opioids are a prompt for hospitals and primary health care providers to take a close look at their prescribing.

Opioids such as fentanyl, methadone, morphine, oxycodone, pethidine, are classed as ‘strong’ while tramadol, codeine and dihydrocodeine opioids have lesser effect and are classed as ‘weak’.

Dr Alan Davis, chair of the Commission’s opioid expert advisory group says while opioids are highly effective in managing certain types of pain, they can also cause patient harm.

“This might include nausea, constipation, delirium, hypotension, addiction or even potentially life-threatening over-sedation and respiratory depression.

“‘Strong’ opioids are very effective at managing pain – but evidence shows the longer they are used, the less effective they are.

“Strong opioids should therefore only be used for a short term, but in New Zealand it seems some people are remaining on strong opioids for longer.”

The figures are from the Commission’s Atlas of Healthcare Variation. This opioid Atlas shows significant differences in opioid use between DHBs.

“The data are a prompt for DHBs to see where they sit and find out more about why differences exist.

“The question is, do we need to use strong opioids as much as we do and are there alternatives? Yes, there are, and district health boards may need to investigate why their usage is different to other district health boards’ and if they should be exploring those alternatives,” he says.

The data shows a significant decrease in dispensing of oxycodone by DHBs, with 7800 fewer New Zealanders receiving the opioid in 2015 than in 2011.

“This is a pleasing finding as it indicates efforts to reduce DHB prescribing of oxycodone are having an impact,” says Dr Davis.”

The Atlas records opioids dispensed with a subsidy from community pharmacies in 2015, but not those used in hospitals, although the prescription may have come from a hospital. Of every 10 people dispensed a strong opioid, 4.7 had been a public hospital inpatient or outpatient in the week prior.

Among the Atlas’s key findings:

  • An average of 16.4/1000 people received a strong opioid, with a two-fold variation between DHBs
  • An average of 66/1000 people received a weak opioid, with a two-fold variation between DHBs
  • Women were dispensed significantly more both weak and strong opioids than men
  • Opioid use increased significantly with age: 1 in 9 people aged 80 and over received a strong opioid and 1 in 7 a weak opioid
  • People identifying as European or Other ethnicity had two to five times the use of strong opioids as those of Maori, Pacific or Asian ethnicity
  • People identifying as European or Other received significantly more weak opioids, and Asian peoples significantly fewer
  • An average of 11/1000 people received morphine, 17,600 more than in 2011, with a two-fold variation between DHBs
  • An average of 5.4/1000 people received oxycodone, 7800 fewer than in 2011, with a three-fold variation between DHBs.

Dr Davis says it is unlikely all – or even most – of the variations in usage are due to the DHBs’ different populations and their different needs.

“One theory is that opioids may be used more where there is poor access to specialist pain services, less access to non-pharmacological options for pain management and less access to palliative care services.”

The opioid domain of the Atlas of Healthcare Variation can be viewed at www.hqsc.govt.nz/atlas/opioids.

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