Introduction

Prescription opioid misuse continues to be a concern with 16,500 opioid-related deaths in Canada since 2013, approximately one-third of whom had an active opioid prescription at the time of death. Individuals engaging in prescription opioid misuse seek care in emergency departments for medication refills or new opioid prescriptions, for symptoms related to withdrawal, intoxication, or in extreme cases, psychosis or overdose. After assessment and treatment, patients are discharged. Currently, physicians’ clinical documentation does not follow the patient. 

Unlike the electronic prescription monitoring programs in the United States, PharmaNet – BC’s prescription drug dispensing database – does not automatically monitor dispensing patterns to flag opioid misuse. It is left to provider’s discretion to identify any inappropriate opioid seeking behaviour based on either their interaction with the patient, or the information available in the local health record or in PharmaNet. Without widespread documentation, regulation, or standardization of medication history-taking, provider behaviours vary widely. 

We have designed, piloted, and refined a software application called ActionADE that allows healthcare providers to document adverse drug events, like suspected prescription opioid misuse. After ActionADE’s integration with PharmaNet, it will use reported data to create standardized patient-level safety alerts in local community pharmacies when providers attempt to re-dispense the same or similar medications as ones that previously caused harm. Using ActionADE to share reports of suspected opioid misuse between a patient’s healthcare providers could increase opportunities for consistent messaging and counselling across sites, and may improve patient outcomes. However, sharing this information also has the potential to stigmatize patients, reduce access to needed prescriptions, and push patients into the illicit market. It is currently unclear which of these outcomes is more likely to occur in the scientific literature. 

Objectives

Our objectives are to evaluate the effect of standardized patient-level alerts about suspected prescription opioid misuse on community pharmacists’ opioid dispensing and patient behaviours and health outcomes.

Methods

We propose a quadruple-blinded randomized control trial among adults suspected of misusing at least one prescription opioid in the emergency department or on a hospital ward of a participating institution, whose suspected misuse is reported in ActionADE. We will exclude patients with cancer pain and palliative patients. Patients in the intervention group will have information about their suspected prescription opioid misuse communicated through PharmaNet to create pop-up alerts in community pharmacies when attempts are made to re-dispense an opioid. Patients in the control group will have information about their prescription opioid misuse recorded in ActionADE and retained locally. We will measure community pharmacist and patient outcomes administratively after a 12-month follow-up period.

Impacts on EM

If automated, standardized, cross-sector communication about suspected prescription opioid misuse proves to be beneficial, emergency department prescribers that use ActionADE to report suspected prescription opioid misuse have the potential to create value by reducing the misuse of prescribed opioids, increasing the uptake of opioid-agonist therapies, and preventing avoidable opioid-related deaths.