A Review of the Impacts of Opiate Use in Ontario: Summary Report

Transcription

1 A Review of the Impacts of Opiate Use in Ontario: Summary Report A Provincial Summary Report of the Impacts of the Discontinuation of Oxycontin in Ontario: January to August 2013 December 2013

2 This report has been prepared by the Public Health Division of the Ministry of Health and Long-Term Care, in collaboration with Public Health Ontario Infectious Diseases Policy and Programs Section Public Health Policy and Programs Branch Public Health Division Ministry of Health and Long-Term Care

3 Table of Contents Executive Summary... 4 Introduction... 5 Methods... 6 Results... 7 Discussion and Limitations Summary References... 14

4 Executive Summary Introduction: The Public Health Policy and Programs Branch, Public Health Division and the Provincial Programs Branch, Negotiations and Accountability Management Division of the Ministry of Health and Long-Term Care (the Ministry) provide funding, policy directions and monitoring for harm reduction programming and services in Ontario. The public health units and their respective harm reduction partners implement and maintain the programs. The Local Health Integrated Networks provide funding to addiction treatment programs including withdrawal management services. In response to the discontinuation of Oxycontin (Oxycontin) in Ontario on February 27, 2012, the Ministry developed a plan to assist clients who use or abuse oxycodone drugs and may be affected by the changes. This plan included the collection, review and analysis of the available information about the impacts on affected populations, clinical outcomes and the health care system. This is the second report produced by the Ministry in collaboration with Public Health Ontario (PHO) and summarizes data from January 1 to August 31, Subsequent reports will be provided quarterly. Methods: Aggregate, non-identifiable data related to opioid use from the following sources were collected and reported to PHO and the Ministry: Ontario s public health unit harm reduction programs; ConnexOntario (provincial hotline for information on drug, gambling and mental health); Drug and Alcohol Treatment Information System (DATIS); Acute Care Enhanced Surveillance (ACES) (Emergency Department visits and hospital admissions); The Opioid Agonist Maintenance Program (OAMP); The Office of the Chief Coroner of Ontario (OCC). Results: Qualitative reports indicate that there are increases in the availability of opiates and that generic Oxycontin is circulating. The number of new admissions to treatment agencies, calls to telephone help lines and individuals registered through the methadone maintenance program have remained consistent. On average, 802 new patients received treatment for addiction through the OAMP each month. Emergency department visits and hospital admissions associated with opiate withdrawal or overdose have been consistent with a slight increase noted beginning in the summer months. Of the drugs resulting in death due to opiate toxicity, oxycodone was the most prevalent. Discussion and limitations: On the basis of this report, there have been no substantial changes in seeking access to health care services as a result of the discontinuation of Oxycontin. Despite no significant changes to population health or health system utilization as a result of the discontinuation of Oxycontin, both qualitative and quantitative data indicate that Oxycontin and generic versions of it are still circulating and are the leading cause of deaths attributed to opiate use. Access to emergency departments, addiction treatment centres, methadone maintenance programs and telephone help lines are all being utilized and will be important indicators to continue monitoring changes of opiate use in Ontario. There are, however, a number of limitations that must be considered when interpreting these results. Available data are limited in terms of geographic representation, and there is an identified need for more information, particularly from First Nations communities. Conclusions: The Ministry, in collaboration with PHO maintains a commitment to monitor the effects of the discontinuation in availability of Oxycontin in Ontario and will use findings from this and future summary reports to strengthen the monitoring and process of opiate use focusing on the negative effects on the population and health care system in Ontario. Future consideration of opiate surveillance and research should also include stratification of data at a local level. This may facilitate the development of more targeted harm reduction policies and public health interventions. The Ministry and PHO would like to thank all harm reduction partners for their collaboration and look forward to the continuation of this work. 4

5 Introduction The misuse of prescription drugs has been an issue of growing concern in Ontario. Between 1991 and 2007, the number of prescriptions in Ontario for oxycodone drugs increased by 850%, to the highest provincial rate of narcotics use in Canada 1. Between 1991 and 2004, the Office of the Chief Coroner of Ontario classified 7353 deaths linked to the involvement of alcohol, drugs or both. Among those deaths, 3406 involved opioid use and were listed as the main cause of death 1. In particular, the use and misuse of drugs such as OxyContin (Oxycontin), an extended release opioid medication prescribed to manage pain, has grown significantly in recent years. A review conducted by the Ministry of Health and Long-Term Care (the Ministry) on the prescribing and utilization of oxycodone controlled release tablets through the Ontario Drug Benefit program 2 found that the majority of use of Oxycontin is outside the current Limited Use criteria. This included: excessive prescribing, escalating misuse, increased diversion from the drugs intended use, increased addiction and increased opioid-related overdoses and deaths. The addition of long-acting oxycodone in Ontario led to a fivefold increase in deaths related to its use from 1999 to 2004, as well as an increase in the overall opioid-related mortality 1. As a result, the availability of Oxycontin in Ontario was discontinued on February 27, The Public Health Policy and Programs Branch, Public Health Division and the Provincial Programs Branch, Negotiations and Accountability Management Division of the Ministry provide funding, policy direction and monitoring for harm reduction programming and services in Ontario. The public health units and their respective harm reduction partners implement and maintain the programs. The Local Health Integrated Networks (LHIN) provides funding to addiction treatment programs including withdrawal management services. The goals of these programs are to respond to the needs of individuals who use substances in order to prevent the transmission of infectious diseases and to facilitate access to care and treatment services. As a result of the discontinuation of Oxycontin, an Expert Group on Narcotics Addictions was established by the Ministry in March The purpose of this group was to provide advice on short, medium and long-term recommendations to support clients who use or abuse oxycodone drugs and may be affected by the changes in the Oxycontin supply. One aspect of the strategy was to collect, review and analyze the impacts the discontinuation of Oxycontin had on: affected populations; clinical outcomes; and the health care system. The discontinuation in the availability of Oxycontin is part of the larger Narcotics Strategy 3, launched on August 27, 2010, that the Ministry supports in order to address issues around prescription opioids. Since March 2012, the Ministry, in collaboration with Public Health Ontario (PHO) has been collecting data from a variety of stakeholders in order to review the impacts of the discontinuation of oxycontin. A report entitled A Review of the Impacts of Opiate Use in Ontario: Interim Summary Report presented the data collected from March 1 to December In February 2013, a review of the surveillance approach was conducted to assess if the original objectives and data sources were still applicable to the evolving opiate use and priorities in Ontario. As a result, an updated surveillance approach was developed which included revised data sources with the intention of better capturing the negative health impacts related to opiate use. Subsequent summary surveillance reports reviewing this data will be provided on a quarterly basis. The purpose of this report is to describe the health impacts associated with opiate use on an individual and health care system levels from January 1 to August 31, A Review of the Impacts of Opiate Use in Ontario: Summary Report December

6 Methods Data from six sources have been collected from January 1 to August Information is collected by either PHO or the Ministry in aggregate format either on a monthly or quarterly basis. Analysis is conducted by both PHO and the ministry then collated for interpretation. Data Sources I. Ontario s Public Health Units (PHUs), including their respective harm reduction partners provide to the Ministry qualitative information regarding observed and client reported changes in user demographics and frequency in drugs of choice. In addition, education and/or training materials developed by PHUs are also reported. II. III. IV. ConnexOntario is a government funded provincial hotline which provides free and confidential health service information regarding drug, alcohol, problem gambling and mental health services. ConnexOntario reports to PHO the number of calls regarding drug use. The Drug and Alcohol Treatment Information System (DATIS) is a comprehensive, province-wide client information system that reports from Ontario addiction agencies. DATIS reports to PHO the number of new admissions to treatment agencies where clients specified prescription opioids as a problem substance. The Opioid Agonist Maintenance Program (OAMP) collects the number of Ontario Health Insurance Plan (OHIP) fee schedule codes that are billed by physicians for the management and supervision of a patient receiving treatment for addiction in an OAMP. Definitions of categories reported are listed below: a. Number of patients: the number of unique health numbers (OHIP) that had one or more OAMP fee codes during the month; b. New patients: number of unique health numbers (OHIP) that had one or more OAMP fee codes during the month, but did not have any in the previous 12 months; c. Number of physicians: number of unique physician billing numbers that submitted one or more OAMP fee codes during the month. V. The Acute Care Enhanced Surveillance (ACES/EDSS), formally known as Emergency Department Syndromic Surveillance (EDSS) is a syndromic surveillance system that reports to PHO the number of emergency department visits, as well as the number of hospital admissions related to opioid use. Cases are identified from a computerized system using a syndromic filter consisting of key words including: overdose, withdrawal, substance abuse and opiates. The filter excludes: alcohol, acetaminophen and other common non-narcotic drug overdoses. VI. The Office of the Chief Coroner of Ontario (OCC) collects data regarding fatalities in Ontario. The numbers of deaths due to acute drug toxicity involving opiates under surveillance (codeine, Fentanyl, heroin, hydromorphone, methadone, morphine or oxycodone) are collected. Deaths by age and month are provided to the Ministry. A Review of the Impacts of Opiate Use in Ontario: Summary Report December

7 Results Ontario s Public Health Units (PHUs) Qualitative observations from PHUs were collected from June to August, Changes in user s drug of choice varied with at least 50% of PHUs noting a slight or major change. For those that reported changes in user s drug of choice, decreases and increases were noted for specific opiates and are presented in Table 1. Overall, more increases were observed, especially pertaining to increases in heroin and hydromorphone. Generic Oxycontin was noted as circulating in some jurisdictions, as was fake oxycontin laced with Fentanyl. The category for Other noted increases in the availability of cocaine, crack cocaine, Wellbutrin and Epsom salts sold as crystal meth (methamphetamine). The use of levamisole in crack cocaine was also reported. Finally, Krokodile and the Party Powder also known as Benzylpiperazine were noted during this surveillance period. Table 1: The number of PHUs that reported decreases and increases by drug, June to August, Ontario 2013 Drug June (n=18) Decrease July (n=22) August (n=18) June (n=18) Increase July (n=22) Fentanyl Heroin Hydromorphone Methadone Morphine Oxycodone Other August (n=18) The majority (76% to 93%) of PHUs that responded indicated that for each month, no changes in the demographics of users were observed. For the few that did report either a slight or major change, the observations noted were regarding an increase in youth drug rates and users requesting to go on methadone. Informative training materials and sessions were developed by a number of PHUs and their harm reduction partners during this three month period. These topics and materials included: Sharps handling training; Information and warning packages; Opiate Outreach Treatment training; Harm reduction, overdose training and education; Peer outreach; Presentations to the Ontario Provincial Police and Emergency Medical Services on harm reduction programs/services provided and; Community forums. A Review of the Impacts of Opiate Use in Ontario: Summary Report December

8 Counts ConnexOntario The number of telephone calls to ConnexOntario help line regarding drug use from January to August is presented in Figure 1. Overall, the number of calls ranged between 200 and 350. From January to June, the number of calls and two month moving average was on the decline; however, in June and July an increase of calls was noted. The twomonth standard deviation (SD), which represents the upper limit of expected activity based on moving averages was not exceeded in any period indicating no unexpected sudden surges in activity. Figure 1: Number of calls to ConnexOntario regarding opiate use by month in Ontario from January to August Number of calls to ConnexOntario regarding opiate use by month in Ontario, January to August Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Total Distinct counts 2 Months Moving Average 2 Month Moving Average + 2SD A Review of the Impacts of Opiate Use in Ontario: Summary Report December

9 The Drug and Alcohol Treatment Information System (DATIS) The numbers of new admissions to treatment agencies where clients specified prescription opioids as a problem substance are presented in Figure 2. From January to August, the number and two-month moving average of assessments fluctuated from approximately 1400 to 1650 per month. The number and two-month moving average of assessments since May has remained steady, around 1500 per month; however, the two-month standard deviation was similar to monthly numbers in July and August steady and consistent activity. Figure 2: Number and moving average of monthly in-take assessments related to prescription opioids in Ontario, January to August 2013 The Opioid Agonist Maintenance Program (OAMP) The number of patients, new patients and unique physician billing codes that are billed through OHIP for the management and supervision of a patient receiving treatment for addiction in an OAMP from January to June 2013 are presented in Table 2. An average and median of 34,703 and 34,696 patients had one or more OAMP fee codes reported through OHIP during this time period. The number of unique health numbers (OHIP) who had one or more OAMP fee code registered in the month, but did not have any in the previous 12 months, ranged from 699 in March to 918 in June. Overall, an average of 802 new patients each month was registered for methadone management and supervision. The number of unique physician billing numbers that submitted one or more OAMP fee codes during the month was consistent, ranging from 246 in May to 253 in January. A Review of the Impacts of Opiate Use in Ontario: Summary Report December

10 Table 2: Number of Opioid Agonist Maintenance Program (OAMP) Patients and Physicians from January to June 2013 Month Number of OAMP Patients Number of New OAMP Patients Number of OAMP Physicians January 34, February 34, March 34, April 34, May 34, June 34, Data for all categories extracted September The Acute Care Enhanced Surveillance (ACES/EDSS) Opiate related emergency department (ED) visits in the ACES/EDSS syndromic surveillance system from January to August 2013 are presented in Figure 3. The number of weekly ED visits fluctuated between four and 16; however, the four-week moving average has remained consistent, averaging 10. Figure 3: Emergency department visits meeting syndromic criteria, by week, from January to August 2013 in Ontario The numbers of weekly hospital admissions related to opiate use captured in ACES/EDSS from January to August 2013 are presented in Figure 4. The number of weekly admissions ranged from 4 to 16. The four-week moving average of hospital admissions during this same time period was slightly more stable; however, a continuous increase beginning June is noted. A Review of the Impacts of Opiate Use in Ontario: Summary Report December

11 Figure 4: Hospital admissions meeting syndromic criteria, by week, from January to August 2013 in Ontario It should be noted that due to small numbers even small fluctuations can appear significant; however bi-weekly numbers do not exceed the two standard deviation upper limit of expected number of ED visits and hospital admissions respectively. The Office of the Chief Coroner of Ontario (OCC) The numbers of deaths reported from January to August 2013 as a result of acute drug toxicity involving opiates are presented in Table 3. Of the drugs resulting in death due to opiate toxicity, oxycodone was the most prevalent, followed by Fentanyl, methadone, hydromorphone, morphine, codeine and heroin. In some instances, more than one opiate was identified through toxicology analysis. The age ranges of deaths are similar across all opiates. Fentanyl and heroin contributed to more deaths in the younger age groups whereas codeine contributed to deaths in the older age group. Table 3: Number of deaths reported related to opiates in Ontario from January 1 to August 31, 2013 Opiate Number of deaths* Mean Age Median Age Age Range Codeine Fentanyl Heroin Hydromorphone Methadone Morphine Oxycodone *Where an opiate was indicated to result in death. Data extracted September 2013 is preliminary and subject to change. A Review of the Impacts of Opiate Use in Ontario: Summary Report December

12 Discussion and Limitations From January 1 to August 31, 2013, a variety of data sources were utilized to provide an overview of the negative health impacts to an individual and the health care system as a result of opioid use. There are many data limitations which need to be considered when interpreting the results and are included. The observations collected from PHUs and their harm reduction partners indicated that there were increases in the availability of drugs, especially pertaining to heroin and hydromorphone. In addition, generic oxycontin was noted as circulating in some jurisdictions, as was fake oxycontin laced with Fentanyl. Increases in the availability of nonopiates were also noted. Minimal changes in the demographics of users were reported but when noted; a decreasing age in users was observed. Many informative materials and training programs were developed, indicating a greater knowledge transfer of harm reduction practices and services offered. Modifications in the survey tool used to collect information by the PHUs and harm reduction programs commenced in June 2013 and therefore, only review a threemonth surveillance period. These reports are based on observation and direct client accounts and have monthly response rates that vary between 33% and 67%. Access to treatment agencies by where opiate use is specified as the problem substance and calls to telephone help lines have both remained consistent through this surveillance period. This may be as a result of the increase in availability of opiates widely circulating in Ontario. The number of new people accessing treatment and those continuing to access treatment for addiction through the methadone maintenance program have remained consistent from January to June The fee schedule codes are billed by physicians for the management and supervision of a patient receiving treatment for addiction in an OAMP and can include services such as: a consultation, assessment or visit; medication reviews; adjusting the dose of the opioid agonist therapy; prescribing additional therapy; discussions with pharmacists; and discussions with the patient, relative, representative or other caregivers. At this time we are not able to differentiate between patients who are on methadone and suboxone (buprenorphine). As we continue to monitor opiate surveillance in Ontario, the OAMP billing will be an important data source utilized to determine if there is an increase of drug users seeking assistance and what, if any, resources are facing challenges meeting user needs. The fee codes processed are done on a monthly basis and may be delayed. As a result, only data between January and June 2013 were included in this analysis. ED visits and hospital admissions have remained consistent through this surveillance period with a slight increase beginning in the summer months. The continued monitoring of emergency visits and admissions will be important to determine the negative outcomes related to opiate use. Data captured in ACES/EDSS are not representative of the province as a whole as approximately half the Emergency departments in Ontario are captured. Specifically, few hospitals in the southwest, Ottawa and Greater Toronto Area are included. The Ministry is committed to continue to support the expansion of this syndromic surveillance system to all hospitals in Ontario. Finally, the key words included to form the syndromic criteria were modified during this surveillance review to be more specific to opiate use, withdrawal and overdose. As a result, the data presented in this summary report cannot be compared to the previous opiate summary report from March 2012 to December Other health consequences of opioid use such as accidental injury and chronic disease including cardiovascular disease, liver damage and mental health disorders are not included in this summary report. Further research on these aspects may provide more detailed information on the long-term impacts of opioid use on individuals and the health care system. Reported deaths from the OCC indicate that acute drug toxicity as a result of oxycodone is the most predominant compared to all other opiates under surveillance; however, this information was preliminary at the time of analysis and subject to change. Due to small cell sizes, data could not be presented by month. Not all deaths are investigated by the OCC; therefore, this is an underestimate of the true number of fatal outcomes as a result of opiate use. A Review of the Impacts of Opiate Use in Ontario: Summary Report December

13 At this time data is presented at a provincial level and has not been further stratified by LHINs, PHUs or First Nation communities. Previous research 4 has indicated that statistically significant associations between prescribed opioids and related deaths were observed at a public health level. Future surveillance reports should take into consideration analyzing data by local level communities as understanding the differences within Ontario may influence specific policies and allow for more targeted harm reduction interventions. Summary In March 2012, the Ministry in collaboration with PHO committed to collect and review available data related to overdose, withdrawal and mortality associated with the discontinuation in availability of Oxycontin in Ontario. In February 2013, a surveillance review was conducted and modifications with regards to the data sources included were made. This is the second summary report developed since March 2012; however, due to data modifications, comparisons to the first report entitled A Review of the Impacts of Opiate Use in Ontario: Interim Summary Report should not be conducted. Based on available data from January 1 to August 31, 2013, and included in this report, no significant change in population health or access to the health care system related to prescription opioid use was noted. Qualitative reports indicate that there are increases in the availability of opiates and that generic Oxycontin is again available. Of the drugs resulting in death due to opiate toxicity, oxycodone was the most prevalent. Access to emergency departments, treatment centres, maintenance programs and telephone help lines are all being utilized and will be important indicators to monitor changes in opiate use in Ontario. Future consideration of opiate use surveillance and research should also include stratification and inclusion of data to determine harm reduction program activity, drug use and impacts to the health care system at a variety of local levels. This may facilitate the development of more targeted policies and public health interventions. The Ministry, in collaboration with PHO maintains a commitment to monitor the discontinuation in availability of Oxycontin in Ontario and will use findings from this and future summary reports to strengthen the monitoring of opiate use and the negative effects on the population and health care system in Ontario. A Review of the Impacts of Opiate Use in Ontario: Summary Report December

14 References 1. Dhalla, I., Mamdani, M., Sivilotti, M., Kopp, A., Qureshi, O., and Juurlink, D. (2009). Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. Canadian Medical Association Journal, 181 (12), pp Ontario Drug Benefit program Ontario s Narcotics Strategy Gomes, T. Juurlink, D. N. Moineddin, R. Gozdyra, P. Dhalla, I. et al. Geographical variation in opioid prescribing and opioid-related mortality in Ontario. ICES Report, Healthcare Quarterly Vol. 14, No A Review of the Impacts of Opiate Use in Ontario: Summary Report December

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