Fentanyl initiation rate following the requirement for specialist approval
Authors: Miron Oren , Wolff-Sagy Yael , Levin Mark , Lubich Esti , Lewinski Jordan , Shpunt Maya , Ahmad Wiessam Abu , Borochov Ilya , Netzer Doron , Lavie Gil 
Published: March 2024

AbstractImportanceHealthcare organizations are exploring tools to address unwarranted fentanyl use which often leads to increased risk of addiction and overdose.ObjectiveTo assess the impact of a requirement for a specialist’s approval on fentanyl initiation for non-oncological pain.Design, Settings and ParticipantsRetrospective cohort examination of fentanyl initiations and opioid dispensations for 4.4 million members of Clalit Health Services following a requirement for specialist’s approval for fentanyl initiation on July 2022, which was expanded 6 months later for continued use.Main Outcomes and MeasuresWe analyzed the change in initiations of fentanyl in the year before and after the implementation and 95% confidence interval, with a sub-group analysis by age group. We also compared total opioid dispensation, fentanyl, and non-fentanyl in the 6th and 12th month after the implementation with the predicted rate based on pre-implementation rates.ResultsThe fentanyl initiation rate in the year before the requirement was 711/1,000,000 capita, which decreased following the requirement by -81% (95% confidence interval:-77%; -85%). The decrease attenuated with age: at ages 0-17 years -100% (16%; -216%), at ages 18-39 years -88% (−78%; -97%), at ages 40-64 years -89% (−83%; -95%) and at ages 65 years and above -73% (−68%; -79%). In the 6th month after the requirement was implemented the morphine milligram equivalent from dispensation of total opioids and fentanyl was lower than predicted by 7% and 12% respectively, while non-fentanyl opioids dispensation was 3% higher than predicted. In the 12thmonth after the initiation requirement, the dispensation of total opioids and fentanyl was lower than predicted by 26% and 39% respectively, while in non-fentanyl opioids it was 4% higher than predicted.Conclusions and RelevanceOur results indicate that requiring specialist approval for fentanyl initiation for non-oncological chronic pain was associated with a decrease in fentanyl prescription initiations, especially among non-elderly patients. A decrease also occurred gradually in total opioid dispensations, further decreasing following the extension of the requirement to continuous fentanyl. These findings suggest that requiring specialist approval for non-oncological fentanyl initiations is likely an effective strategy to be considered by other healthcare providers.QuestionWas the requirement for specialist approval when initiating fentanyl for non-oncological pain followed by a decrease in fentanyl initiations and overall dispensing of opioids?AnswerIn this cohort study of 4.4 million members of Clalit Health Services without cancer, 81% decrease in fentanyl initiations was observed in the year following the implementation of the requirement for specialist approval. After 6 months from implementation, dispensed morphine milligram equivalent from opioids decreased by 7%.MeaningThese findings suggest that requiring specialist approval for fentanyl initiation in non-oncological pain can help reduce fentanyl initiations and overall opioids dispensed and is likely an effective strategy to be considered by other healthcare providers.