High-Dose Opioid Prescribing and Opioid-Related Hospitalization: A Population-Based Study

Abstract

AimsTo examine the impact of national clinical practice guidelines and provincial drug policy interventions on prevalence of high-dose opioid prescribing and rates of hospitalization for opioid toxicity.DesignInterventional time-series analysis.SettingOntario, Canada, from 2003 to 2014.ParticipantsOntario Drug Benefit (ODB) beneficiaries aged 15 to 64 years from 2003 to 2014.InterventionsPublication of Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain (May 2010) and implementation of Ontario’s Narcotics Safety and Awareness Act (NSAA; November 2011).MeasurementsThree outcomes were explored: the rate of opioid use among ODB beneficiaries, the prevalence of opioid prescriptions exceeding 200 mg and 400 mg morphine equivalents per day, and rates of opioid-related emergency department visits and hospital admissions.FindingsOver the 12 year study period, the rate of opioid use declined 15.2%, from 2764 to 2342 users per 10,000 ODB eligible persons. The rate of opioid use was significantly impacted by the Canadian clinical practice guidelines (p-value = .03) which led to a decline in use, but no impact was observed by the enactment of the NSAA (p-value = .43). Among opioid users, the prevalence of high-dose prescribing doubled (from 4.2% to 8.7%) over the study period. By 2014, 40.9% of recipients of long-acting opioids exceeded daily doses of 200 mg morphine or equivalent, including 55.8% of long-acting oxycodone users and 76.3% of transdermal fentanyl users. Moreover, in the last period, 18.7% of long-acting opioid users exceeded daily doses of 400 mg morphine or equivalent. Rates of opioid-related emergency department visits and hospital admissions increased 55.0% over the study period from 9.0 to 14.0 per 10,000 ODB beneficiaries from 2003 to 2013. This rate was not significantly impacted by the Canadian clinical practice guidelines (p-value = .68) or enactment of the NSAA (p-value = .59).ConclusionsAlthough the Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain led to a decline in opioid prescribing rates among ODB beneficiaries these guidelines and subsequent Ontario legislation did not result in a significant change in rates of opioid-related hospitalizations. Given the prevalence of high dose opioid prescribing in this population, this suggests that improved strategies and programs for the safe prescribing of long-acting opioids are needed.

Transition to high‐dose or strong opioids: a population‐based study of people initiating opioids in Australia

“…Our results have clinical practice and policy implications because high doses have been associated with substantial morbidity and mortality, including, falls, fractures, hospitalization, motor vehicle accidents, opioid‐related overdose and death . A recent Australian study reported that 1.9 million people initiate opioids each year .…”

“…Although we used a published list of anti‐cancer medications and included hormonal anti‐cancer therapies to determine likelihood of treatment for cancer, it is possible that some people with cancer may not have had anti‐cancer medications dispensed on the PBS (or at all) and therefore may have been misclassified as having no cancer treatment history. We used a method for defining opioid dose that was consistent with previous studies . It is possible that the actual dose for individual patients was different to the calculated average daily dose.…”

“…The average daily dose in the United States declined from 58 mg oral morphine equivalents (OMEs)/day in 2010 to 48 mg OMEs/day in 2015, but the dispensed OMEs per person remained six times higher in the highest‐prescribing than in the lowest‐prescribing counties . Prescribing of high‐dose opioids (> 200 mg OMEs/day) doubled from 4.2% in 2003 to 8.7% in 2014 in Ontario, Canada . The incidence of opioid use slightly declined from 2013 to 2017 in Australia, but initiation of strong opioids increased during this period .…”

“…High‐dose opioid use is associated with falls, fractures, hospitalization, motor vehicle injury, opioid‐related overdose and death . Definitions of high‐dose opioids use vary (range = 50–200 mg OMEs/day) . An average dose of ≥ 50 mg OMEs/day has been associated with double the risk of overdose compared to 20 mg OMEs/day .…”

Latest trends in opioid-related deaths: exploring differences among men and women

“…found that men were 44% more likely to escalate to high dose prescription opioids compared to women, which may put them at higher risk of opioid overdose. 6,7 As high dose opioid prescribing has increased in Ontario over the past two decades 8 , this may have impacted men more than women.…”