Crazy opioid prescription discrepancies

Have you ever heard the newspaper term “burying the lede”? That’s industry jargon for what happens when a garrulous, sloppy writer like me takes forever to get around to the key piece of information in the copy he is writing — information that should, according to our traditions and best practices, appear at the very top of the story. ( News folk misspell “lede” and other English words like “follo” as a hint that some scribbled or telegraphed remark is an editorial annotation, not to appear in print.)

I’m kinda burying the lede right now, I suppose. I only mention this concept to you today because it is of quite general usefulness. It is applicable to plenty of other varieties of communication. Scholarship and public policy communications, for instance, are often guilty of burying the lede.

On Wednesday, the Canadian Institute for Health Information released a remarkable report on trends in outpatient opioid prescribing in Canada. CIHI involves scholars of the highest calibre in its research, and it knows that opioids are a matter of urgent public concern. With Canada having huge problems with oxycodone addictions and fentanyl adulteration of street opioids, the overall quantity of prescription painkillers has emerged as a special issue.

The Institute’s press materials highlighted the modest good news in the report. Overall, the volume of opioids being pushed out into the Canadian environment is declining slowly. The number of prescriptions is increasing faster than the population, which one might reasonably expect as that population ages, but doctors seem to be handing out opioids to each patient in smaller, presumably less dangerous quantities.

The total count of fentanyl prescriptions declined seven per cent between 2012 and 2016, which is almost certainly good news. Fentanyl ( contrary to its developing popular reputation as some sort of demon molecule) is a boon to mankind: in particular, it is safer than other opioids when it is used in a hospital setting (and professionally manufactured). But there probably should not be much outpatient use of fentanyl at all, except among the terminally ill.

You have to scroll down a ways to find what, for me, is the most remarkable thing in the CIHI report — the buried lede. CIHI’s data analysis shows some bizarre, almost inexplicable differences between the provinces in the mix of outpatient opioid prescriptions. The total volume of opioid prescriptions — measured roughly as a morphine- equivalent “defined daily dose” (DDD), with stronger opioids weighed more heavily — is estimated to be more than double per capita in Alberta and Newfoundland than it is in abstemious Quebec.

Alberta doctors, as the Edmonton Journal was quick to notice on receiving the re- port, prescribed more than 8,000 DDDs per thousand people per year in 2016. In Ontario, the figure is about 7,000. In B. C., it’s in the neighbourhood of 5,500; in Quebec, the figure is around 3,700. The authors of the report observe that Quebec, probably not coincidentally, also has the lowest level of drug-related hospital admissions in the country. ( The data that form the basis for these calculations is provided in aggregated form to CIHI by a multinational health-information company. Yuk. But CIHI also has fine- grained data from some provincial public drug plans, and they used that as a check on the store bought info.)

All of the provinces issue about the same number of prescriptions per capita, more or less, so the volume differences must arise from the mix of drugs being handed out. And this proves to be so. The report has DDD volumes broken down by specific drug and by province, and these figures confirm that the overall mix varies wildly. Ontario’s DDD- per- thousandpeople rate for fentanyl is estimated at nearly 800 for the year 2016. Alberta’s fentanyl-prescribing volume is less than 400.

But Alberta is much freer than Ontario with codeine and tramadol. Both Ontario and Alberta are oxycodone “offenders,” with per- capita prescribing volumes four times as great as Saskatchewan’s. And every other province is much more liberal with almost every top-selling opioid than Quebec is.

There’s an old evangelical saying related to the historical Jesus: “evidence that demands a verdict.” That saying comes to mind as I study the different collective prescribing habits of Canadian doctors, as revealed or implied by CIHI’s report. In evidence-based medicine, strong regional differences in the usage of particular drugs or therapies is usually taken as an ipso facto sign that somebody is doing something “wrong,” or at least suboptimum.

You can’t always be sure whether the problem is with the overprescribing region or the under-prescribing one — but you do know, given fairly similar populations, that the numbers shouldn’t be crazily out of line. Quebec’s population probably cannot be so different demographically from Alberta’s to account for a twofold difference in the demand for outpatient opioids. Alberta is the younger province, so, if anything, one would expect opioid volumes there to be lower.

The other thing about regional usage differences is that they are low-hanging public- health fruit: where appropriate evidence- based prescribing guidelines exist, it is fairly inexpensive to lean on one region’s doctors (and pharmacists) to stick to the damn things.

In this instance, better data — ideally data CIHI doesn’t have to pay a private company exorbitant sums for — would help us understand the phenomena. Are there dramatic within- province differences between cities or zones? Could the numbers be influenced by small clusters of physicians — what is the between- doctor variation in prescribing volumes? What the hell is going on exactly, and how do we take the next step toward finding out?