Increase in Opioid Related Deaths What the Data Can Tell us. Ontario Methadone Prescriber s Conference November 7, 2014 Tara Gomes

Transcription

1 Increase in Opioid Related Deaths What the Data Can Tell us Ontario Methadone Prescriber s Conference November 7, 2014 Tara Gomes

2 Objectives Prescription Opioid Misuse and Abuse: How did we get here? Opioid Overdose Deaths in Ontario: What can they tell us? Moving Forward: Evolution of the issues

3 Presenter Disclosure Faculty: Assistant Professor Leslie Dan Faculty of Pharmacy, University of Toronto Institute for Health Policy, Management and Evaluation, University of Toronto Relationships with commercial interests: Grants/Research Support: Ontario Ministry of Health and Long-Term Care Speakers Bureau/Honoraria: None Consulting Fees: None

4 Disclosure of Commercial Support This program has not received financial support from Commercial entities Potential for conflict(s) of interest: None

5 Mitigating Potential Bias This brief introductory session will discuss Opioid prescribing and overdose deaths in Ontario. I have no financial interest in support of this topic. The Ontario Drug Policy Research Network has no financial interest in support of this topic

6 Opioid Utilization in Ontario: 1990 s

7 Dhalla et al. CMAJ 2009 Impact of OxyContin on Opioid Prescribing Trends 23 per 1000 OxyContin added to Formulary 229 per 1000

8 Rising Opioid Prescriptions linked to harm in the USA Unick et al. PLoS One. 2013

9 Rising Opioid Prescriptions linked to harm in Ontario Dhalla et al. CMAJ 2009

10 OxyContin Marketing & Purdue Settlement Long-acting formulation initially communicated as reducing the drug s potential for abuse : the company made claims that: OxyContin was less addictive than other painkillers and less subject to abuse. It could be discontinued without symptoms of withdrawal 2007: Purdue Pharma and 3 executives pleaded guilty to a felony count of fraudulently misbranding a drug by misleading the public about the safety of OxyContin and were fined $634.5 million

11 Opioid Dose Increasing prescription rates not the only consideration What about dose?

12 Clinical Guidelines Prior to 2009, few guidelines regarding dose thresholds for opioids Canadian Guidelines published in 2010 Suggested that the risks of long-term, high-dose opioid use for chronic non-cancer pain (abuse, addiction, diversion and opioid-related side effects including death) often exceed their benefits.

13 Clinical Guidelines Several recommendations, including: Chronic non-cancer pain can be managed effectively in most patients with dosages at or below 200 mg/day of morphine or equivalent. Consideration of a higher dosage requires careful reassessment of the pain and of risk for misuse, and frequent monitoring with evidence of improved patient outcomes.

14 Upper Dose Thresholds Thresholds based on clinical opinion no evidence to suggest: How frequently people are prescribed doses at this level? What is an appropriate dose threshold to avoid adverse events?

15 Gomes et al. Open Med Trends in High Dose Prescribing: >200 mg MEQ 22% 33% Median daily dose: 270 mg MEQ

16 Upper Dose Thresholds Thresholds based on clinical opinion no evidence to suggest: How frequently people are prescribed doses at this level? What is an appropriate dose threshold to avoid adverse events?

17 Gomes et al. Arch Int Med Opioid Dose and Risk of Overdose Death Doses between 50 and 200 mg MEQ Doses higher than 200 mg MEQ Double risk of overdose death Triple risk of overdose death

18 By 2010 Canada and the USA have the highest opioid consumption per capita in the world: Canada: 753 mg MEQ dispensed per capita, annually USA: 693 mg MEQ dispensed per capita Canada USA

19 Drug Overdose Deaths in the USA

20 Gomes et al. Addiction Annual Rate of Opioid-Related Mortality in Ontario to Deaths 127 Deaths

21 Opioid-Related Deaths What is the public health impact of these deaths? Estimates of burden rare due to lack of data on opioid-related deaths in Canada What populations are most often impacted? Is this impacting youth more?

22 The burden of premature opioid-related mortality Serial Cross-Sectional Study; Objective: To estimate the burden of opioid-related mortality in Ontario and the proportion of all deaths involving opioids among various age groups at the population-level

23 Characteristics of People Dying of Opioid Overdoses:

24 Characteristics of People Dying of Opioid Overdoses:

25 Proportion of all deaths that are opioid-related, by age group. 1992, 2001 and Gomes et al. Addiction. 2014

26 Gomes et al. Addiction Proportion of all deaths that are opioid-related, by age group. 1992, 2001 and % 3.3%

27 Gomes et al. Addiction YLL due to premature opioid-related deaths in Ontario. 1992, 2001 and Age Group P-Value* ,371 < ,693 2,769 5,845 < ,353 4,598 5,817 < ,030 2,444 5,733 < ,794 < Total 7,006 11,794 21,927 < *p-value for Cochrane-Armitage test for trend in proportion of deaths that are opioid-related

28 Key Findings 2010: 1 of every 170 deaths related to opioids year olds: 1 of 8 deaths involved opioids YLL: Almost doubled from 2001 to 2010 By 2010, exceeded that attributable to alcohol use disorders, pneumonia, influenza, and HIV/AIDS

29 Moving Forward: Evolution of Opioid Prescribing Environment Ontario s Narcotics Safety and Awareness Act: Enacted in November 2011 LA Oxycodone Patent Changes: February 2012: OxyContin replaced with OxyNeo in Canada December 2012: Generic LA Oxycodone becomes available in Ontario

30 Ontario Narcotics Safety and Awareness Act Objectives: Promote appropriate prescribing and dispensing practices for narcotics and other controlled substances Identify and reduce the abuse, misuse and diversion of these drugs Reduce the risk of addiction and death from the abuse or misuse of these drugs. Key Initiatives: MOH can collect, use, and disclose information (including PHI), that relates to the prescribing and dispensing of monitored drugs Narcotics Monitoring System Prescriber must be identified on prescriptions Warnings in effect for double doctoring and polypharmacy

31 However Gaps in NMS Not accessible to prescribers Multiple types of ID can be used

32 Moving Forward: Evolution of Opioid Prescribing Environment Ontario s Narcotics Safety and Awareness Act: Enacted in November 2011 LA Oxycodone Patent Changes: February 2012: OxyContin replaced with OxyNeo in Canada December 2012: Generic LA Oxycodone becomes available in Ontario

33 The impact of patent changes Tamper-deterrent products lead to shifts in type of opioids being used, but not overall rates of use Generic LA oxycodone use rose in the past year is this driven by cost or abuse potential?

34 Future considerations for methadone prescribers the changing patient Policy Changes: Restrictions on opioid labeling/dose? Persistent impact of the Narcotic Monitoring System? Introduction of other tamper deterrent formulations? Restrictions to opioid access impacting heroin use? What will be the impact of generic LA oxycodone availability? Cross-border Trafficking Re-emergence of LA oxycodone abuse/addiction?

35 Thank you!