title: High-Dose Opioid Prescribing and Opioid-Related Hospitalization: A Population-Based Study.
abstract: OBJECTIVE
  To 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.
  
  
  METHODS
  Interventional time-series analysis.
  
  
  METHODS
  Ontario, Canada, from 2003 to 2014.
  
  
  METHODS
  Ontario Drug Benefit (ODB) beneficiaries aged 15 to 64 years from 2003 to 2014.
  
  
  METHODS
  Publication 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).
  
  
  METHODS
  Three 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.
  
  
  RESULTS
  Over 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).
  
  
  CONCLUSIONS
  Although 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.
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Fernandes
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Diana
authors.initials: D
authors.lastname: Martins
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.|Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Juurlink
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.|Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.|Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.|Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.|Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Mamdani
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.|Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.|Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: J Michael
authors.initials: JM
authors.lastname: Paterson
authors.affiliation: Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada.
authors.forename: Luke
authors.initials: L
authors.lastname: Spooner
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Samantha
authors.initials: S
authors.lastname: Singh
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.|Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.|Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.|Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Tara
authors.initials: T
authors.lastname: Gomes
mesh_terms: D000293:Adolescent; D000328:Adult; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use*; D002170:Canada; D004334:Drug Administration Schedule; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D009293:Opioid-Related Disorders / Q000453:epidemiology; D010098:Oxycodone / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D009020:Morphine; D010098:Oxycodone; D005283:Fentanyl