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Clinical inertia

Researcher part of 'dream team' investigating opioid prescribing

Research

By Kelly Foss

Dr. Joshua Rash may have only been at Memorial for a few months, but he is already putting the university on the map.

A clinical health psychologist in the Department of Psychology, Faculty of Science, Dr. Rash is also a member of a dream team of Canadian researchers and partners investigating health-care provider knowledge, attitudes, beliefs and practices surrounding the prescription of opioids for the management of chronic non-cancer pain.

Dr. Joshua Rash
Photo: Rich Blenkinsopp

The group recently received a highly competitive grant from the Canadian Institutes of Health Research, the federal agency responsible for funding health and medical research in Canada.

The money was set aside by the Government of Canada specifically for work on issues related to the country’s growing opioid crisis.

“We want to understand the . . . failure of health-care providers to follow clinical practice guidelines when prescribing opioids.” — Dr. Joshua Rash

Dr. Rash says he believes the reason they received the funding is because of the strength of the team.

“We’re also focusing on a different angle,” he said. “While others are looking at how to support patients who are addicted to opioids, we want to understand the extent of clinical inertia, or failure of health-care providers to follow clinical practice guidelines when prescribing opioids for long-term use.”

Dr. Rash says health-care providers may have many reasons why they aren’t following current guidelines and practices for prescribing opioids, but sometimes those reasons aren’t well-justified.

“Opioid prescribing is a double-edged sword. If you prescribe too much, you run the risk of non-medical use, addiction and mortality. But if you prescribe too little, the patient could have pain that is sub-optimally managed, and they may seek alternative sources for pain relief, including the use of illicit drugs.”

National guidelines

While doctors in Canada prescribe more opioids per capita than any other country, Dr. Rash says there’s good evidence to suggest that long-term opioid use doesn’t have a large benefit on pain or function, and higher doses don’t equate to greater benefit.

He also says that many national guidelines for the management of chronic pain recommend that non-opioid therapies, such as cognitive behavioural therapy, are preferred for the management of chronic pain because they have fewer risks and offer comparable long-term benefits for pain and function.

“A lack of awareness regarding the long-term effectiveness of opioid medication, disagreement with current guidelines and cognitive biases are some of the reasons why providers may find it difficult to adhere to clinical practice guidelines for the prescription of opioid medications,” he said.

Clinical inertia

Dr. Rash will lead the charge to understand the scope and extent of clinical inertia in the prescription of opioid medication for chronic pain – specifically, what are the provider-level factors and influences making it challenging to adhere to opioid-prescribing guidelines for chronic non-cancer pain.

“The ultimate goal of this work is to optimize prescribing practices . . . without restricting a health-care provider’s ability to select the most appropriate treatment.” — Dr. Joshua Rash

The team will focus on provider attitudes, behaviour, knowledge and beliefs. Based upon evidence from other areas of medicine, the researchers know that provider-level factors account for the most variability and are the primary drivers of clinical inertia.

“The ultimate goal of this work is to optimize prescribing practices in order to prevent opioid-related morbidity and mortality without restricting a health-care provider’s ability to select the most appropriate treatment for an individual patient,” said Dr. Rash.

“We’re going to accomplish this through our knowledge translation partners and by embedding principles of health-behaviour change within routine practice.”

Canadian experts

Dr. David Flusk, is the grant’s principle knowledge user.

A physician and head of anesthesiology and pain management at the Carbonear General Hospital, he is also an adjunct professor in Memorial’s Faculty of Medicine.

Dr. Flusk has co-developed The Prescribing Course – Safe Opioid Prescribing for Chronic Non-cancer Pain, which is required by all physicians in the province to help them better understand and follow opioid-prescribing guidelines.

“We’re really bringing together different clusters of Canadian experts for this project.” — Dr. Joshua Rash

The other members of the team include Dr. Tavis CampbellDr. Patricia Poulin, Dr. Kim Corace, Dr. Norman BuckleyDr. Jason Busse,; Lynn Cooper, Dr. Alfonso IorioDr. Kim Lavoie and Brittany Sauvé.

“We’re really bringing together different clusters of Canadian experts for this project,” said Dr. Rash. “The team members are well-connected with government and public policy and are very savvy when it comes to knowledge translation. I really do feel privileged to be part of this group.”


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