Morphine: oxycodone interventions in Denmark
- 1Medical Information Centre, The Capital Region of Denmark Hospital Pharmacy, Bispebjerg Hospital, Copenhagen, Denmark
- 22Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
- Correspondence to Camilla Munk Mikkelsen, Region Hovedstaden Apotek, Apotekets Information, Bispebjerg Hospital, Bispebjerg Bakke 23 opg. 51, 2. sal, 2400 København NV, Denmark
- Received 12 September 2012
- Revised 22 October 2012
- Accepted 25 October 2012
In the years of the late 2000s, the use of oxycodone in both primary care and hospital care increased significantly in Denmark while the use of morphine decreased. Although oxycodone and morphine are considered equally effective and safe, oxycodone is much more expensive than morphine. Therefore, morphine is more cost effective than oxycodone. In primary care, in particular, the price of oxycodone is about 2–3 times higher than that of morphine.
Public health insurance in Denmark pays up to 80% of the medication costs for patients in primary care and the regions pays all costs for patients in hospital care. On this basis, it is economically very important that drug use in both sectors is cost effective.
To change this apparent irrational preference for oxycodone and to reduce drug costs, particularly in primary care, several regional interventions were launched. Here we give an overview of these interventions and the results obtained.
Denmark has five regions, each with their own hospital administrations. Each region has several hospitals and one or more hospital pharmacies. Each region designed its own intervention independently. In some regions, the hospital pharmacy was the initiator and in other regions it was the Drug and Therapeutics Committee.
Details on the interventions were collected from the hospital pharmacist in each region (table 1).
The strategy for all regions was to encourage a switch from oxycodone to morphine. The aim was cost saving without compromising efficacy and safety.
A wide range of interventions were used—for example, information to clinicians in both sectors, education, and practical tools to assist clinicians and pharmacy services such as medication review and journal notes.
Morphine cannot be used for all patients. For some nephrological patients, oxycodone or other opioids are preferable due to accumulation of morphine metabolite. Furthermore, oxycodone is an alternative in patients who cannot achieve adequate pain management and in patients with unacceptable side effects of morphine. These issues are handled locally in the regions.
In all regions, a reduction in the use of oxycodone was observed. Thus in both sectors the use of oxycodone began declining in 2010. In hospitals, a 50–80% reduction was seen (figure 1), most pronounced in the region where restrictions were part of the intervention. In primary care, the use declined by 20–45% (figure 2).
In primary care, the difference between the first quarter of 2010, the most expensive quarter in Denmark, and the first quarter of 2012, was 12%. It corresponds to a decrease in costs of 1 million Euros. In the second quarter of 2012, the costs decreased further because of a price reduction in oxycodone. In hospitals, the cost did not change significantly because the difference in price and the amount used was less.
These data indicate that it is possible to change the prescribing pattern of strong opioids in both sectors by use of a multifactorial and multidisciplinary intervention. Although it is not possible to single out the most effective part of these multifactorial interventions, restrictions appear to be a very effective tool, at least in the hospital sector.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.