Fentanyl initiation rate following the requirement for specialist approval

Importance Healthcare organizations are exploring tools to address unwarranted fentanyl use which often leads to increased risk of addiction and overdose. Objective To assess the impact of a requirement for a specialist's approval on fentanyl initiation for non-oncological pain. Design, Settings and Participants Retrospective 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 Measures We 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. Results The 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 12th month 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 Relevance Our 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.