There is growing global recognition of the harm caused by the inappropriate prescribing of opioids, particularly strong
opioids such as oxycodone. More than 165 000 people died from overdoses of opioid medicines in the United States from
1999 to 2014.1 Furthermore, an estimated 1.9 million people abused or were dependent on opioid medicine in
the United States during 2013.1 Deaths due to prescription opioids are increasingly being reported in Australia;2 in
New Zealand wide variations in the rate of opioid prescribing across DHBs has prompted the Health Quality and Safety Commission
(HQSC)to voice concerns.3
Efforts are underway to reduce the harm
There have been numerous campaigns to improve opioid prescribing internationally, however, these initiatives have often
had limited success due to:4
- Lack of co-ordination
- Inability to implement best practice recommendations
- Failure to engage with local communities
- Lack of awareness among patients of the danger of opioids
- Influence from the pharmaceutical industry
Opioid prescribing campaigns that have succeeded have involved system-wide approaches with a number of common features
(Table 1). A collaborative partnership aiming to reduce the harm from opioids in hospitals was formed between HQSC and
DHBs in 2014. To reduce the harm from inappropriate prescribing in New Zealand, further system-wide approaches to optimising
opioid use are required.
Further information from the HQSC on the safe use of opioids is available from:
Table 1: System-wide strategies to reduce opioid overuse in the United States, adapted from Martin
et al (2016)4
- Electronic decision support
- Limits on dosing quantity and duration
- Collaboration with pharmacy and medical specialities
- Prescriber monitoring with feedback reports
- Developing care plans in collaboration with patients
- Monitoring of patients
- Training and education for health professionals
- Improving referrals to secondary care
- Identifying patients who were over-using opioids
- Education for health professionals
- Quantity limits for prescribing, e.g. no more than 90 pills every 30 days
- Standardising care for patients with long-term pain
- Recommending non-pharmacological treatment
- Opening a long-term pain clinic
||An 85% reduction in prescriptions of oxycodone (slow release)
||Halved the number of non-cancer patients taking daily opioid doses > 120 mg morphine-equivalent
||A more than 50% reduction in the number of patients receiving long-term opioid treatment in one year
The CCDHB launched a project in 2012 which aimed to reduce the prescribing of oxycodone as the first choice strong opioid
in primary and secondary care. The project focused on patients with long-term non-cancer pain.
The project targets were reductions in the number of oxycodone prescriptions of:
- 10% across the DHB
- 10% in primary care
- 50% in secondary care
The project was developed around three key prescribing messages:
- Pain management should be guided by the World Health Organisation (WHO) pain ladder which places oxycodone at step
three: a strong opioid
- Patients taking oxycodone or other opioids long-term should be reviewed to determine if treatment with opioids is
- Highlighting the potential for addiction associated with the use of opioids
The team behind the campaign decided that a two-pronged approach was required to influence prescribing behaviour using
the three key messages outlined above. Hospital prescribers were the main focus of the campaign due to their influence
on prescribing behaviour in primary care when patients are discharged. Prescribers in primary care were also targeted
as they initiate new prescriptions of oxycodone and also continue treatment initiated in secondary care.
Distribution of messages
To maximise the influence of the prescribing campaign clinical champions were engaged from primary and secondary care.
The approach in primary care
The “top 20” oxycodone primary care prescribers were identified in each PHO within the CCDHB via the Pharmaceutical
Collection data warehouse. Support for practices with relatively high rates of oxycodone prescribing was provided by pharmacist
facilitators which included:
- An oxycodone practice audit accredited by the Royal New Zealand College of General Practitioners
- Campaign posters
- Practice education forums
- Peer review groups
A multidisciplinary pain management education session was held that was attended by 96 clinicians including general
practitioners, nurses and pharmacists.
The approach in secondary care
The hospital utilisation of oxycodone for 2011/12 was analysed. Education sessions were delivered by a specialty pain
team and staff from the hospital pharmacy to nurses, house surgeons and registrars in the three wards with the highest
A series of campaign posters was developed which were changed on a weekly basis. A booklet summarising opioid prescribing
messages from the bpacnz pain management guidelines with a reminder to contact the pain team for advice and a one-page
information sheet was distributed across all wards. The oxycodone prescribing campaign was featured on the hospital intranet
The effect of the campaign on oxycodone prescribing
The oxycodone campaign resulted in a 24% reduction in the number of oxycodone scripts written across the DHB and a 20%
reduction in the number of oxycodone items dispensed.5 The targets of a 10% reduction in the number of oxycodone
prescriptions in primary care and 50% reduction in the number of oxycodone hospital prescriptions were achieved.5 Before
the oxycodone prescribing campaign, the CCDHB were reportedly the third lowest DHB for oxycodone usage; following the
campaign they were ranked the lowest DHB for oxycodone use.5 The amount of harm reduction the campaign achieved
is hard to quantify, however, the financial savings in reduced medicine use amounted to at least $50 000.5
Prescribing changes in primary care
There was a 22% decrease in the annual prescribing of oxycodone across 18 general practices in the CCDHB following the
Prescribing changes in secondary care
There were substantial decreases in the rate of oxycodone prescribing in the hospital following the campaign with the
goal of a 50% reduction being met by most wards (Table 2).5
Personalised reports for oxycodone prescribing in primary are available from:
Further information on opioid prescribing across individual DHBs is available from:
Table 2: Percentage reduction of in-hospital use of oxycodone from June 2011 – July 2012, compared with March 2012 – February 20135
|General medicine, oncology, renal
Best practice points for the use of opioids for non-cancer pain:
- Maximise appropriate non-opioid treatments first
- Morphine is the first-line strong opioid for non-cancer pain unless the patient is intolerant
- Use shared decision-making and ensure the patient is educated about the risks and benefits of opioid treatment
- Avoid prescribing more than three days’ supply unless circumstances clearly warrant additional opioid treatment
- Prescribe opioids with caution in elderly patients: take into account renal function and consider prescribing lower
- Make sure the patient is aware that opioids can affect their work duties and driving
Dr Peter Moodie led the CCDHB opioid prescribing campaign. He works as a general practitioner at the Karori Medical
Centre and was Medical Director of PHARMAC until 2013. Dr Moodie provides insight into how the prescribing
campaign was undertaken and what was learnt from it.
1. What were the challenges faced during the prescribing campaign?
The greatest challenges for the project were data; accurate data and relevant data. In New Zealand we are blessed
with an amazing data repository called the “Pharmhouse” [Pharmaceutical Collection data warehouse].
Every script dispensed in community pharmacies goes into that database and virtually everything on
the prescription is searchable, albeit with the patient’s name encrypted.
The downsides are that secondary care data is not included unless their prescription is dispensed outside the hospital
and you have to know what you are doing when interrogating the data.
Once you have the data, putting it into a meaningful format is again critical. It is possible to work out who initiated
a prescription when there is chain of scripts for the same person as although the NHIs are encrypted, it is always with
the same encryption. This means that if a script was initiated when a patient was discharged it can be followed to see
who then continued the prescription.
2. How was the programme received by prescribers in primary care, in particular the use of individualised prescriber
How was all of this received? Well if you are like me, you know what you prescribe and don’t need anyone else to tell
you; like I knew that I never used oxycodone…well I thought I didn’t. When confronted with the data I had lots of excuses:
“The other doctor was away and I had to write the script”, or “They came out of hospital on it and I just had to repeat
it” or “I knew I shouldn’t have but I can’t quite remember the reason why I did it”. And remember I was the clinical champion
for the project!
In other words, we can all get defensive but for groups that do not get audited often it can be even more challenging.
For example when pointing out that anaesthetists were often big prescribers, they often blamed it on the orthopaedic surgeon
who thought it was a good drug. Why? We all rationalise.
3. Was it possible to identify which specific aspects of the campaign were effective?
The seminars were well attended and the prescribing data was useful but we found that it had to be presented in a manner
which encouraged feedback. Simply handing it out didn’t do much.
4. Do you think a similar approach could be successful in other DHBs?
The programme should go nation-wide, however, it is important that pressure groups are not allowed to dilute the messages.
5. What were the learning points that prescribers could take from the campaign?
What were the greatest learnings? Firstly, every time we reach for a controlled drug pad and start to write oxycodone
or fentanyl, we should ask ourselves why we aren’t writing a script for morphine. There are lots of reasons and one of
them is possibly, “it’s not actually morphine – it’s just strong codeine” – yeah right. The other and more insidious is
“the pain clinic uses it and I don’t want to be old fashioned”. Finally feedback from peers is critical. Secondary care
needs honest feedback from their peers and likewise primary care.