Original Title: État des pratiques: usage des opioïdes chez les personnes couvertes par le régime public d’assurance médicaments du Québec

Authors' objectives: Opioids are a class of psychoactive drugs generally used to treat the moderate to severe pain associated with acute and chronic medical conditions. Opioids are being used increasingly to treat chronic noncancer pain in certain areas of North America, despite the uncertainty regarding its long-term benefits. The increase in emergency department visits, hospitalizations and deaths due to opioid intoxication have led Canadian authorities to describe the situation as a “national public health crisis”. Concerned about the potentially inappropriate use of prescribed opioids in Québec, the Ministère de la Santé et des Services sociaux (MSSS) asked the Institut national d’excellence en santé et en services sociaux (INESSS) to provide a portrait of the use of this class of drugs in persons covered by Québec’s public prescription drug insurance plan (RPAM). This study served to describe the use of opioids obtained on prescription from 2006 to 2016 and to determine if problems associated with opioid use observed in certain areas of North America are encountered in Québec.

Authors' results and conclusions: RESULTS: The prevalence of opioid use and the cumulative incidence of new opioid users remained stable during the study years at approximately 10.5% and 7.0%, respectively. The prevalence of opioid use in 2016, compared to 2006, was stable in the 0 to 13 age group, decreased in the 14 to 54 age group, but increased in the 55 year old age group or more. The increase in the prevalence of use was greater in the age group 85 or older than in the 55 to 84 age group. In 2016, the age-adjusted prevalence of opioid use varied slightly from one health and social services region to another, being approximately 9.0% in Laval and Montréal and more than 13.0% in Abitibi-Témiscamingue and the Saguenay─Lac-Saint-Jean. Although the prevalence of opioid use remained stable from 2006 to 2016, the types of opioids prescribed to persons covered by the RPAM changed. The prevalence of the use of hydromorphone and morphine increased from 2006 to 2016, while that of the other main opioids of interest was stable (fentanyl and oxycodone) or declined (codeine). The mean duration of treatment for the users’ opioid prescriptions increased from 41.3 days to 54.8 days from 2006 to 2016. In the new users, it remained stable at approximately 14 days. The annual mean daily morphine equivalent dose was approximately 40.0 mg in the prevalent users, while on the whole, the new users were taking 31.0 mg morphine equivalent daily. The daily doses were higher than these values and increased in the prevalent users and the new users who obtained at least one prescription for a long-acting opioid. Using multiple doctors was reported in approximately ¼ of the prevalent users and ⅕ of the new users. Only 4.8% of the new users used opioids for a long period of time, the mean being 841 days, and the mean daily dose was approximately 1.5 times that for the short and moderate periods of use. The annual proportion of new users to whom at least 1 of the 5 indicators of potentially inappropriate opioid use applied decreased from 15.4% in 2006 to 12.3% in 2013. It was mainly the following three indicators that contributed the most to these proportions in 2013: (1) overlapping opioid prescriptions (5.8%), (2) overlapping opioid and benzodiazepine prescriptions (8.2%), and (3) the use of long-acting opioids at the start of treatment (1.8%). The vast majority of the new users had one medical visit, all reasons combined, within 1 (80.8%) or 3 years (92.9%) following the start of a new period of opioid therapy. The rate of new users who had at least one emergency department visit and the rate of new users who were hospitalized at least once for opioid intoxication were slightly less then 4 per 10,000 person-years when estimated using data from a 1-year follow-up. These rates were more than double when estimated using data from a 3-year follow-up. Age, the prescriber’s medical discipline, a history of antipsychotic or antiepileptic use and a history of substance abuse were the variables associated with a risk of an emergency department visit for opioid intoxication at 3 years (p < 0.01). Similarly, age, the number of pharmacotherapeutic classes, the prescriber’s medical discipline, a history of antidepressant, antipsychotic, acetaminophen, antiepileptic or muscle relaxant use, and a history of substance abuse, depression, abdominal pain, fracture, or neck and back problem were the variables associated with a risk of hospitalization for opioid intoxication at 3 years (p

Authors' methods: A cross-sectional study and a retrospective longitudinal cohort study were conducted using administrative databases stored at the Régie de l’assurance maladie du Québec (RAMQ) to describe, respectively, prevalent users and new users of opioids in oral form or skin patches. The study population for each year examined consisted of the opioid users continuously covered by the RPAM from January 1 to December 31. New users had to have had no history of cancer diagnosed during the five years preceding the date of the first opioid prescription (index date) or during the year following that date. These new users also had to have had been covered continuously by the RPAM for at least 6 months before and 1 year after the index date, unless they died during the follow-up. The prevalence of opioid use and the cumulative incidence of new opioid users were estimated for each study year, both globally and for the opioids considered. These measures were adjusted by direct standardization using the 5-year age group distribution of the population continuously covered by the RPAM in 2016. Prevalent users and new users of opioids were described in terms of sociodemographic variables, the opioid prescriptions dispensed and certain medical services provided to the new users, at 1 and 3 years following the initiation of opioid therapy. The annual proportion of new users to whom at least one of the five indicators of potentially inappropriate opioid use applied was estimated. These indicators are (1) overlapping opioid prescriptions, (2) overlapping opioid and benzodiazepine prescriptions, (3) the use of long-acting opioids at the start of treatment, (4) a high mean daily dose, and (5) a rapid increase in the opioid dose. The documented variables were supplemented with the number of medical visits, all reasons combined, and the number of emergency department visits or hospitalizations due to the opioid intoxications that occurred during the new user follow-up. Only the new users who started a new treatment period during the period from 2006 to 2013 and who were covered for at least 3 years following the index date were considered during the follow-up aimed at documenting the length of the new periods and the proportion of new users who had at least one medical visit, all reasons combined. The incidence rate of emergency department visits and the incidence rate of hospitalizations due to opioid intoxication were estimated over a period of 1 year and over a period of 3 years. The new users who died during the follow-up were not excluded from the analyses. The adjusted relative risk was estimated for the incidence rate of emergency department visits and hospitalizations due to opioid intoxication.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/portrait-de-lusage-des-opioides-chez-les-personnes-couvertes-par-le-regime-public-dassurance-medicaments-du-quebec.html

Year Published: 2018

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/portrait-de-lusage-des-opioides-chez-les-personnes-couvertes-par-le-regime-public-dassurance-medicaments-du-quebec.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec