Fentanyl Initiation Rate Following the Requirement for Specialist Approval

Background: Healthcare organizations attempt 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: A retrospective cohort study based on observational data. Participants: All 4.4 million non-oncological members of Clalit Health Services were included, from July 20, 2021, to July 19, 2023. Main Measures: The rate of fentanyl initiation was assessed before and after the implementation of the requirement for specialist’s approval, which was introduced on July 2022, and expanded 6 months later for continued use. A sub-group analysis by age group was performed, and patient characteristics and indications were assessed. We also compared total opioid dispensation in the 6th and 12th months after the implementation with the predicted rate based on pre-implementation rates. Key Results: Fentanyl initiation rate in the year before the requirement was 711 per million capita, which decreased following the requirement by − 81% (95% CI: − 77%; − 85%). The decrease attenuated with age. The prevalence of diagnosis with substance abuse disorders at the time of fentanyl initiation decreased from 6 to 3%. In the 6th and 12th months after the requirement was implemented, the morphine milligram equivalent (MME) from dispensation of total opioids was lower than predicted based on pre-implementation rates by 7% and 26%, respectively. Conclusions: 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. The requirement for specialist approval upon fentanyl initiation and continuous fentanyl may present an effective tool for limiting the use of fentanyl and total opioids in healthcare systems.