Using novel methodology to estimate the prevalence of mental disorders in British Columbia, Canada.

PURPOSE: A needs-based model of health systems planning uses a systematic estimate of service needs for a given population. Our objective was to derive annual prevalence estimates of specific mental disorders in the adult population of British Columbia, Canada and use a novel triangulation approach encompassing multiple data sources and stratifying these estimates by age, sex, and severity to inform Ministry partners, who commissioned this work. METHODS: We performed systematic literature reviews and subsequent meta-analyses to derive an annual prevalence estimate for each mental disorder. We then generated age- and sex-specific estimates by triangulating published epidemiological studies, routinely collected province-wide health administrative data, and nationally representative health survey data sources. The age- and sex-specific estimates were further stratified by severity using the Global Burden of Disease severity distributions and published literature. RESULTS: Anxiety disorders had the highest annual prevalence estimates (6.93%), followed by depressive disorders (6.42%). All other mental disorders had an annual prevalence of less than 1%. Prevalence estimates were consistently higher in younger age groups. Depressive disorders, anxiety disorders, and eating disorders were higher in women, while estimates for bipolar disorders, schizophrenia, and ADHD were slightly higher in men in younger age groups. CONCLUSION: We generated robust annual prevalence estimates stratified by age, sex, and severity using a triangulation approach. Variation by age, sex, and severity implies that these factors need to be considered when planning for mental health services. Our approach is replicable and can be used as a model for needs-based planning in other jurisdictions.

Evaluating the population-level effects of oxycodone restrictions on prescription opioid utilization in Ontario.

PURPOSE: To investigate the impact of restrictions on access to long acting oxycodone on prescription opioid use and opioid-related harms. METHODS: Administrative health data from Ontario, Canada was used to measure differences in opioids dispensed and emergency department (ED) visits for opioid-related overdose, poisoning, or substance use following provincial restrictions on access to publicly insured OxyContin (February 29, 2012) and OxyNeo (February 28, 2013). This study focused on the cohort of provincial drug insurance eligible people (people 65+ and select low-income populations) who were dispensed oxycodone prior to the restrictions. Difference-in-differences models with a propensity score matched comparison group of people who were dispensed non-oxycodone opioids were used to estimate the main effects. RESULTS: In 6 months following the delisting of OxyContin, milligrams of morphine equivalents (MMEs) per person per week for all opioids fell by an average of 7.5% in people dispensed oxycodone relative to the comparison group, and an average of 13.8% in chronic recipients of oxycodone. In the 6 months following the restrictions on OxyNeo, MMEs per person per week fell by an average of 3.1% in all people dispensed oxycodone, and 25.2% in chronic oxycodone recipients. The decline in oxycodone dispensing among chronic oxycodone recipients corresponded with an increase in dispensing of other opioid formulations, particularly hydromorphone and fentanyl. No important differences were observed for ED visits related to opioid poisoning, overdose, or substance use disorder. CONCLUSIONS: Province-wide restrictions on access to long acting oxycodone had an impact on quantities of all opioids dispensed to chronic recipients of oxycodone, but small impacts on the full population of people dispensed oxycodone; the decline in use was partially offset by increases in use of other publicly-funded opioid formulations. This study suggests that policies limiting access to specific prescription opioids led to overall reductions in publicly funded prescription opioid use, particularly in chronic oxycodone recipients, without immediate evidence of changes in opioid-related ED visits.

Estimating the Prevalence of Mental and Substance Use Disorders: A Systematic Approach to Triangulating Available Data to Inform Health Systems Planning.

OBJECTIVE: To estimate the prevalence of specific mental and substance use disorders (MSUDs), by age and sex, as a first step toward informing needs-based health systems planning by decision-makers. METHODS: We developed a conceptual framework and a systematic methodology for combining available data sources to yield prevalence estimates for specific MSUDs. Data sources used included published, peer-reviewed literature from Canada and comparable countries, Canadian population survey data, and health administrative data from British Columbia. Several well-established methodologies including systematic review and meta-analyses of published prevalence estimates, modelling of age- and sex-specific distributions, and the Global Burden of Disease severity distribution model were incorporated in a novel mode of triangulation. RESULTS: Using this novel approach, we obtained prevalence estimates for 10 MSUDs for British Columbia, Canada, as well as prevalence distributions across age groups, by sex. CONCLUSION: Obtaining reliable assessments of disorder prevalence and severity is a useful first step toward rationally estimating service need and plan health services. We propose a methodology to leverage existing information to obtain robust estimates in a timely manner and with sufficient granularity to, after adjusting for comorbidity and matching with severity-specific service bundles, inform need-based planning efforts for adult (15 years and older) mental health and substance use services.

The relationship between outpatient service use and emergency department visits among people treated for mental and substance use disorders: analysis of population-based administrative data in British Columbia, Canada.

BACKGROUND: Research findings on the association between outpatient service use and emergency department (ED) visits for mental and substance use disorders (MSUDs) are mixed and may differ by disorder type. METHODS: We used population-based linked administrative data in British Columbia, Canada to examine associations between outpatient primary care and psychiatry service use and ED visits among people ages 15 and older, comparing across people treated for three disorder categories: common mental disorders (MDs) (depressive, anxiety, and/or post-traumatic stress disorders), serious MDs (schizophrenia spectrum and/or bipolar disorders), and substance use disorders (SUDs) in 2016/7. We used hurdle models to examine the association between outpatient service use and odds of any ED visit for MSUDs as well count of ED visits for MSUDs, stratified by cohort in 2017/8. RESULTS: Having had one or more MSUD-related primary care visit was associated with lower odds of any ED visit among people treated for common MDs and SUDs but not people treated for serious MDs. Continuity of primary care was associated with slightly lower ED use in all cohorts. One or more outpatient psychiatrist visits was associated with lower odds of ED visits among people treated for serious MDs and SUDs, but not among people with common MDs. CONCLUSION: Findings highlight the importance of expanded access to outpatient specialist mental health services, particularly for people with serious MDs and SUDs, and collaborative models that can support primary care providers treating people with MSUDs.

Correlations between opioid mortality increases related to illicit/synthetic opioids and reductions of medical opioid dispensing - exploratory analyses from Canada.

BACKGROUND: North America has been experiencing a persistent epidemic of opioid-related overdose mortality, which has increasingly been driven by fatalities from illicit, toxic opioids in most recent years. Patterns of synthetic opioid availability and related mortality are heterogeneous across Canada, and differing explanations exist as to their differentiated proliferation. We examined the perspective that heterogeneous province-based variations in prescription opioid availability, facilitated by various control strategies, post-2010 may have created regionally differential supply gaps for non-medical opioid use substituted by synthetic opioid products with differential impacts on mortality risks and outcomes in Canada. METHODS: We examined annual, prescription opioid dispensing rates and changes in the ten Canadian provinces (for the periods of 1) 2011-2018, 2) 'peak-year'-to-2018) in Defined Daily Doses/1000 population/day, derived from data from a large representative, stratified sample of community pharmacies projected to a Canada total. Annual, provincial opioid-related mortality rates and changes for years 2016-2018 were calculated from federal data. We computed correlation values (Pearson's R) between respective province-based change rates for prescription opioid dispensing and opioid-related mortality for the two over-time scenarios. RESULTS: All but one province featured reductions in prescription opioid dispensing 2011-2018; seven of the ten provinces had increases in opioid mortality 2016-2018. The correlation between changes in opioid dispensing (2011-2018) and in opioid-mortality (2016-2018) was r = 0.63 (df = 8, p-value: 0.05); the correlation was r = 0.57 (df = 8, p-value: 0.09) for changes in opioid dispensing 'peak year'-to-2018, respectively. CONCLUSIONS: Quasi-significant results indicate that recent increases in opioid-related deaths driven by illicit, synthetic opioids tended to be larger in provinces where reductions in prescription opioid availability have been more extensive. It is a plausible explanation that these reductions created supply gaps for non-medical opioid use increasingly filled by illicit, synthetic opioids differentially contributing to opioid-related deaths, generating un-intended adverse effects for previous interventions. General prevention measures to reduce opioid availability, and targeted prevention for at-risk opioid users exposed to toxic drug supply may be include counteractive effects and require coordinated reconciliation.

Examining correlations between opioid dispensing and opioid-related hospitalizations in Canada, 2007-2016.

BACKGROUND: High levels of opioid-related mortality, as well as morbidity, contribute to the excessive opioid-related disease burden in North America, induced by high availability of opioids. While correlations between opioid dispensing levels and mortality outcomes are well-established, fewer evidence exists on correlations with morbidity (e.g., hospitalizations). METHODS: We examined possible overtime correlations between medical opioid dispensing and opioid-related hospitalizations in Canada, by province, 2007-2016. For dispensing, we examined annual volumes of medical opioid dispensing derived from a representative, stratified sample of retail pharmacies across Canada. Raw dispensing information for 'strong opioids' was converted into Defined Daily Doses per 1000 population per day (DDD/1000/day). Opioid-related hospitalization rates referred to opioid poisoning-related admissions by province, for fiscal years 2007-08 to 2016-17, drawn from the national Hospital Morbidity Database. We assessed possible correlations between opioid dispensing and hospitalizations by province using the Pearson product moment correlation; correlation values (r) and confidence intervals were reported. RESULTS: Significant correlations for overtime correlations between population-levels of opioid dispensing and opioid-related hospitalizations were observed for three provinces: Quebec (r = 0.87, CI: 0.49-0.97; p = 0.002); New Brunswick (r = 0.85;CI: 0.43-0.97; p = 0.004) and Nova Scotia (r = 0.78; CI:0.25-0.95; p = 0.012), with an additional province, Saskatchewan, (r = 0.073; CI:-0.07-0.91;p = 0.073) featuring borderline significance. CONCLUSIONS: The correlations observed further add to evidence on opioid dispensing levels as a systemic driver of population-level harms. Notably, correlations were not identified principally in provinces with reported high contribution levels (> 50%) of illicit opioids to mortality, which are not captured by dispensing data and so may have distorted or concealed potential correlation effects due to contamination.

Tramadol dispensing patterns and trends in Canada, 2007-2016.

PURPOSE: Opioid use and associated mortality and morbidity have substantially increased in Canada, which recent interventions have aimed to reduce. Tramadol is an atypical prescription-only (but unscheduled under Canada's narcotics law) opioid analgesic and not subject to controls for other (eg, strong) opioids. Given experiences in different jurisdictions, tramadol may have been increasingly dispensed as a "substitute" drug during a period with increasingly restrictive controls for other (scheduled) opioids. METHODS: We examined the annual population-level retail dispensing (as a proxy for use) of tramadol and (scheduled) "strong opioids" in Canadian provinces for 2007-2016 based on data from a representative national sample of community pharmacies, covering the majority of episodes of opioid dispensing. Data for both aforementioned formulation categories were converted into defined daily doses (DDD)/1000 population/day and examined descriptively and by segmented regression analyses (to identify significant breakpoints in trends). RESULTS: Tramadol use strongly increased in all provinces until 2009. After 2009, tramadol dispensing levels either decelerated their increase or plateaued; "strong opioid" dispensing levels, in comparison, increased strongly until 2011 and decelerated or decreased for the remaining period. Tramadol was consistently dispensed at lower levels than "strong opioids." CONCLUSIONS: Tramadol and "strong opioids" showed similar (bifurcated) use trends, with initial increases and subsequent inflections, yet reductions in dispensing occurred earlier for tramadol than for "strong opioids" (the latter occurring following with recent interventions). Distinct from experiences with differential opioid control regimes elsewhere, there is no evidence that tramadol figured as a "substitution" drug for increasingly restricted "strong opioids" in Canada.

Correlations between population-levels of prescription opioid dispensing and related deaths in Ontario (Canada), 2005-2016.

Canada is experiencing an ongoing opioid-related public health crisis, including persistently rising opioid (e.g., poisoning) mortality. Previous research has documented marked correlations between population-levels of opioid dispensing and deaths. We examined possible correlations between annual population-level dispensing of specific opioid formulations and related poisoning deaths in Ontario (Canada), for the period 2005-2016. Annual coroner statistics-based numbers of poisoning deaths associated with six main opioid formulations (codeine, fentanyl, hydromorphone, methadone, morphine, and oxycodone) for Ontario were converted into annual death rates (per 100,000 population). Annual dispensing data for the opioid formulations under study were based on commercial retail-sales data from a representative, stratified sample of community pharmacies (IMSQuintiles/IQVIA CompuScript), converted into Defined Daily Doses (DDD/1,000 population/day). Possible relationships between the annual death and dispensing rates were assessed by Pearson's correlation coefficient analyses. Death rates increased for almost all, while dispensing rates increased for half of the opioid categories. A significant positive correlation between death and dispensing rates was found for hydromorphone (r = 0.97, 95% CI: 0.88-0.99) and oxycodone (r = 0.90, 95% CI: 0.68-0.97) formulations; a significant negative correlation was found for codeine (r = -0.78, 95% CI: -0.93 to -0.37). No significant correlations were detected for fentanyl, methadone, and morphine related deaths. Strong correlations between levels of dispensing and deaths for select opioid formulations were found. For select others, extrinsic factors - e.g., increasing involvement of non-medical opioid products (e.g., fentanyl) in overdose deaths - likely confounded underlying correlation effects. Opioid dispensing levels continue to influence population-level mortality levels, and need to be addressed by prevention strategies.

The fundamental association between mental health and life satisfaction: results from successive waves of a Canadian national survey.

BACKGROUND: A self-reported life satisfaction question is routinely used as an indicator of societal well-being. Several studies support that mental illness is an important determinant for life satisfaction and improvement of mental healthcare access therefore could have beneficial effects on a population's life satisfaction. However, only a few studies report the relationship between subjective mental health and life satisfaction. Subjective mental health is a broader concept than the presence or absence of psychopathology. In this study, we examine the strength of the association between a self-reported mental health question and self-reported life satisfaction, taking into account other relevant factors. METHODS: We conducted this analysis using successive waves of the Canadian Community Health Survey (CCHS) collected between 2003 and 2012. Respondents included more than 400,000 participants aged 12 and over. We extracted information on self-reported mental health, socio-demographic and other factors and examined correlation with self-reported life satisfaction using a proportional ordered logistic regression. RESULTS: Life satisfaction was strongly associated with self-reported mental health, even after simultaneously considering factors such as income, general health, and gender. The poor-self-reported mental health group had a particularly low life satisfaction. In the fair-self-reported mental health category, the odds of having a higher life satisfaction were 2.35 (95% CI 2.21 to 2.50) times higher than the odds in the poor category. In contrast, for the "between 60,000 CAD and 79,999 CAD" household income category, the odds of having a higher life satisfaction were only 1.96 (95% CI 1.90 to 2.01) times higher than the odds in the "less than 19,999 CAD" category. CONCLUSIONS: Subjective mental health contributes highly to life satisfaction, being more strongly associated than other selected previously known factors. Future studies could be useful to deepen our understanding of the interplay between subjective mental health, mental illness and life satisfaction. This may be beneficial for developing public health policies that optimize mental health promotion, illness prevention and treatment of mental disorders to enhance life satisfaction in the general population.

Trends and changes in prescription opioid analgesic dispensing in Canada 2005-2012: an update with a focus on recent interventions.

BACKGROUND: Prescription opioid analgesic (POA) utilization has steeply increased globally, yet is far higher in established market economies than elsewhere. Canada features the world's second-highest POA consumption rates. Following increases in POA-related harm, several POA control interventions have been implemented since 2010. METHODS: We examined trends and patterns in POA dispensing in Canada by province for 2005-2012, including a focus on the potential effects of interventions. Data on annual dispensing of individual POA formulations--categorized into 'weak opioids' and 'strong opioids'--from a representative sub-sample of 5,700 retail pharmacies across Canada (from IMS Brogan's Compuscript) were converted into Defined Daily Doses (DDD), and examined intra- and inter-provincially as well as for Canada (total). RESULTS: Total POA dispensing--driven by strong opioids--increased across Canada until 2011; four provinces indicated decreases in strong opioid dispensing; seven provinces indicated decreases specifically in oxycodone dispensing, 2011-2012. The dispensing ratio weak/strong opioids decreased substantively. Major inter-provincial differences in POA dispensing levels and qualitative patterns of POA formulations dispensed persisted. Previous increasing trends in POA dispensing were reversed in select provinces 2011-2012, coinciding with POA-related interventions. CONCLUSIONS: Further examinations regarding the sustained nature, drivers and consequences of the recent trend changes in POA dispensing--including possible 'substitution effects' for oxycodone reductions--are needed.

High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005-2009.

PURPOSE: Prescription opioid analgesic (POA)-related burden of disease - including mortality - is high and constitutes a major public health problem in the US and Canada. Associations between the overall levels of POA consumption and key related morbidity indicators in the population have been demonstrated. We examined potential correlations between levels of consumption of four commonly used POAs and related mortality in British Columbia (BC) and Ontario. METHODS: We investigated the correlation between annual population standardized rates of fentanyl, hydromorphone, morphine and oxycodone-related mortality (based on provincial coroners' data) and the annual Defined Daily Doses per 1000 population/day for each of the drugs dispensed (based on representative retail pharmacy sales data) in the two provinces, 2005-2009. RESULTS: Death rates increased for three (Ontario) and two (BC) of the four POA drugs; the rate of deaths for each POA drug was consistently higher in the jurisdiction with higher use levels. For each drug, strong correlations (range 0.83 to 0.97; p < 0.003) were found between POA use and mortality levels; consistent within-province correlations were found for two drugs (hydromorphone and oxycodone). CONCLUSIONS: Our findings of strong correlations between select POA use and mortality levels reflect similar evidence from elsewhere on correlations between POA consumption and morbidity or mortality indicators. In the context of high and increasing levels of POA consumption in Canada, efforts to reduce POA-related mortality may require a comprehensively revised approach towards more appropriate and safer prescribing to reduce POA use volumes together with more effective monitoring of POA medications.

Use and nonmedical use of prescription opioid analgesics in the general population of Canada and correlations with dispensing levels in 2009.

BACKGROUND: In Canada, harm from nonmedical prescription opioid analgesic (POA) use (NMPOU) has increased in recent years; however, there are limitations to the current estimates of NMPOU. The 2009 Canadian Alcohol and Drug Use Monitoring Survey presents an opportunity to produce more accurate estimates of NMPOU. OBJECTIVES: To determine the prevalence of POA use, NMPOU and use of pain relievers to 'get high', and to assess correlations of these indicators with age, sex and provincial levels of dispensed POAs in Canada in 2009. METHODS: Data regarding POA use were obtained from the 2009 Canadian Alcohol and Drug Use Monitoring Survey (n=13,032). The amount of POAs dispensed in standardized daily doses was obtained from a representative sample of 2700 retail pharmacies across Canada. Associations among POA use, age, sex and the amount of POAs dispensed were evaluated using regression models. Differences in POA use across provinces were assessed using the Wald test. RESULTS: In Canada in 2009, the prevalence of POA use was 19.2% (95% CI 18.0% to 20.5%), NMPOU was 4.8% (95% CI 4.1% to 5.5%) and the use of pain relievers to get high was 0.4% (95% CI 0.1% to 0.8%). NMPOU was significantly associated with age. The use of pain relievers to get high varied significantly across provinces, while POA use and NMPOU did not show significant variations. The amount of POAs dispensed per province was not significantly correlated with any type of POA use. CONCLUSIONS: These findings confirm high POA use and NMPOU across Canada. Research is required to identify determinants of NMPOU.

Electrically conducting polymers as templating interfaces for fabrication of copper nanotubes.

Submicrometer tubes have been fabricated by a polymer-based template approach using electroless deposition. The copper was deposited on polystyrene fibers functionalized with an interfacial electrically conducting polyaniline thin film layer. Thermal degradation of the functionalized fiber templates resulted in copper tubes of diameter 1600 ± 50 nm with wall thicknesses ranging between 100 and 200 nm. The morphology and elemental analysis of copper coaxial fibers was analyzed using SEM and EDS. Electrical properties were analyzed using FTIR and PXRD was used to study crystal structure of copper nanotubes.

The role of intermolecular interactions in solid state fluorescent conjugated polymer chemosensors.

A functionalized fluorescent conjugated polymer, tolylterpyridine poly(p-phenyleneethynylene-thienyleneethynylene (ttp-PPETE), was designed and synthesized to detect trace amounts of toxic transition metal pollutants in ground water. Photophysical studies in tetrahydrofuran (THF) successfully demonstrated this polymer as a selective and sensitive chemosensor for Ni(2+) and Co(2+) in aqueous solution. Solid state composites of these chemosensors have now been prepared which can be modified to provide for inexpensive and portable field based chemical detection. A solid composite of ttp-PPETE, blended with poly (methyl methacrylate) shows UV-vis absorption and fluorescence emission spectra which are red- shifted when compared to solution phase spectra, suggesting an increase in conjugation in the solid state. An additional absorption peak, not present in solution, is also observed in the solid state. The presence of this new peak provides evidence of interacting FCP chains in the solid state. Concentration dependent experiments were done on the solid composite showing red-shifted emission peaks accompanied by a significant reduction in the fluorescent quantum yield. These observations are consistent with the formation of aggregated polymer species in the solid state. Intermolecular interactions of this type can be manipulated in the design of sensitive and selective solid state fluorescent conjugated polymer sensors.

METAL-CONTAINING CONJUGATED POLYMERS AS FLUORESCENT CHEMOSENSORS IN THE DETECTION OF TOXICANTS.

Fluorescent conjugated polymers have received a great deal of recent interest due to their ability to act as chemosensors to detect various chemical species in both environmental and biological systems with sensitivity and selectivity. Examples from the literature include polymer chemosensors that operate on either fluorescence "turn-on" or "turn-off" as mechanisms of sensor response. These responses can be related to either photoinduced electron transfer or electronic energy transfer mechanisms. Recently, a series of metal-containing polymers or metallopolymers have been explored by various research groups for their use as chemosensors. In many cases, these metallopolymers have been shown to be more sensitive and selective for specific chemical species. This review focuses on fluorescent conjugated polymers as chemosensors, with a specific concentration on recent advances in metallopolymer chemosensors.

Trends in dispensing of individual prescription opioid formulations, Canada 2005-2020.

BACKGROUND: Canada has experienced a distinctly bifurcated pattern of (strong) opioid utilization post-2000, with multifold increases rendering it one of the world's highest opioid consumption rates, followed by subsequent substantive declines since 2011/2012. Several interventions to control especially high-risk opioid use have been implemented post-2010 at different levels, yet with their effects assessed mostly for overall opioid utilization. Little knowledge exists for over-time patterns of individual opioid formulations. METHODS: Raw information on community-based prescription opioid dispensing for years 2005-2020 were obtained from a large national database based on a stratified sample of 6500 retail pharmacies across Canada (IQVIA/Compuscript), These data were converted into Defined-Daily-Doses/1000 population/day (DDD/1000/day) for individual (strong and weak) opioid formulations-specifically: fentanyl, hydromorphone, hydrocodone, morphine, oxycodone, codeine-per standard methods. Descriptive data on individual opioid dispensing were computed, and segmented regression (or 'broken-stick') analysis was applied to the overtime dispensing towards assessing potentially significant 'breakpoints' interrupting linear utilization trends. Akaike information criterion (AIC) values were computed to assess the resulting models' quality-of-fit. RESULTS: Five of the six opioid formulations featured a lower dispensing level in 2020 compared with 2005, but mostly with peak values in years between, contributing to the overall inversion pattern. For five of the six opioid formulations, a three-segmented model emerged as the best fit for the dispensing observed; only hydrocodone presented a linear (downward) dispensing trend. Among the five interrupted trend models for individual formulations, four (fentanyl, morphine, oxycodone, codeine but not hydromorphone) indicated their initial breakpoint during 2011-2014 introducing a downward dispensing trend. Inconsistently, morphine also featured a recent breakpoint (2018) towards a dispensing increase. CONCLUSIONS: While all opioids showed marked declines, we found heterogeneous patterns of dispensing for individual opioid formulations. While we cannot estimate direct causal effects, opioid control interventions appear to have had differential impacts on dispensing of individual formulations. The earliest breakpoint occurred towards substantive decreases for oxycodone dispensing in 2011; subsequently, there were increases in dispensing of hydromorphone and fentanyl likely due to substitution effects, followed by across-the-board declines post-2015/2016. Recent 'safer opioid' distribution programs to reduce illicit/toxic opioid exposure linked with high levels of poisoning fatalities seem to fuel resurgences in select opioid (e.g., morphine) dispensing.

Emergency department use for mental and substance use disorders: descriptive analysis of population-based, linked administrative data in British Columbia, Canada.

OBJECTIVES: Information on emergency department (ED) visits for mental and substance use disorders (MSUDs) is important for planning services but has not been explored in British Columbia (BC), Canada. We describe all MSUD ED visits for people ages 15 and older in the province of BC in 2017/2018 and document trends in MSUD ED visits between 2007/2008 and 2017/2018 by disorder group. DESIGN: Population-based linked administrative data comprised of ED records and physician billings capturing all MSUD ED visits in BC. SETTING: BC is Canada's westernmost province with a population of approximately 5 million. Permanent residents receive first-dollar coverage for all medically necessary services provided by licensed physicians or in hospitals, including ED services. POPULATION: All people age >15 with MSUD ED visits during the study period. MEASURES: All claims with a service location in the ED or corresponding to fee items billed only in the ED were examined alongside ED visits reported through a national reporting system. Patient characteristics (sex/gender, age, location of residence, income, treated disorders and comorbidities) and previous outpatient service use for all ED visits by visit diagnosis are also described. RESULTS: A total of 72 363 people made 134 063 visits to the ED in 2017/2018 for needs related to MSUD. MSUD ED visits have increased since 2010, particularly visits for substance use and anxiety disorders. People with more frequent visits were more likely to be male, on public prescription drug plans for income assistance, prescribed psychiatric medications, and living in lower-income neighbourhoods. They used more community-based primary care and psychiatry services and had lower continuity of primary care. CONCLUSIONS: MSUD ED visits are substantial and growing in BC. Findings underscore a need to strengthen and target community healthcare services and adequately resource and support EDs to manage growing patient populations.

Differences and over-time changes in levels of prescription opioid analgesic dispensing from retail pharmacies in Canada, 2005-2010.

PURPOSE: To examine qualitative and quantitative levels and trends of prescription opioid analgesics ("opioids") use and the potential impact of prescription monitoring programs (PMPs), in the 10 Canadian provinces, for 2005-2010. METHODS: Opioid dispensing data from a representative sample of 2700 retail pharmacies were obtained. Individual opioid dispensing values were translated into defined daily doses per day/1000 population and categorized into "weak opioids" and "strong opioids" by standardized methods. Opioid prescription rates between provinces and over time, as well as the impact of PMPs, were examined using regression analyses techniques (i.e., Poisson, ANOVAs). RESULTS: Significant differences between provinces in the overall standardized rates of dispensing for total opioids, as well as for "weak opioids" and "strong opioids" categories, were found. The majority of provinces featured increases or curvilinear trends in the standardized amounts of opioids dispensed over time, mainly driven by increases in "strong opioids" use. In addition, significant inter-provincial differences in the levels of dispensing of individual opioids were found. Comparisons of changes in opioid dispensing between provinces with and without PMPs did not indicate significant differences. CONCLUSIONS: Opioid use featured significant quantitative and qualitative differences between provinces in Canada and showed an overall increasing trend mainly driven by changes in "strong opioids" in the study period. Reasons for the observed differences are not clear yet require systematic examination to allow evidence-based interventions in the interest of equitable pain treatment as well as the reduction of high levels of opioid-related morbidity and mortality in Canada.

Access to and waiting time for psychiatrist services in a Canadian urban area: a study in real time.

OBJECTIVE: To obtain improved quality information regarding psychiatrist waiting times by use of a novel methodological approach in which accessibility and wait times are determined by a real-time patient referral procedure. METHOD: An adult male patient with depression was referred for psychiatric assessment by a family physician. Consecutive calls were made to all registered psychiatrists (n = 297) in Vancouver. A semistructured call procedure was used to collect information about the psychiatrists' availability for receipt of this and similar referrals, identify factors that affect psychiatrist accessibility, and determine the availability of cognitive-behavioural therapy (CBT). RESULTS: Efforts were made to contact 297 psychiatrists and 230 (77%) were reached successfully. Among the 230 psychiatrists contacted, 160 (70%) indicated that they were unable to accept the referral. Although 70 (30%) indicated that they might be able to consider accepting a referral, 64 (91% of those who would consider accepting the referral) indicated that they would need to review detailed, written referral information and could not provide estimates of the length of wait times if the patient was to be accepted. Only 6 (3% of the 230 psychiatrists contacted) offered immediate appointment times and their wait times ranged from 4 to 55 days. When asked whether they could provide CBT, most (56%) psychiatrists in clinical practice answered maybe. CONCLUSIONS: Substantial barriers exist for family physicians attempting to refer patients for psychiatric referral. Consolidated efforts to improve access to psychiatric assessment are needed.

Patterns, trends and determinants of medical opioid utilization in Canada 2005-2020: characterizing an era of intensive rise and fall.

BACKGROUND: Into the 21st century, the conflation of high rates of chronic pain, systemic gaps in treatment availability and access, and the arrival of potent new opioid medications (e.g., slow-release oxycodone) facilitated strong increases in medical opioid dispensing in Canada. These persisted until post-2010 alongside rising opioid-related adverse (e.g., morbidity/mortality) outcomes. We examine patterns, trends and determinants of opioid dispensing in Canada, and specifically its 10 provinces, for the years 2005-2020. METHODS: Raw data on prescription opioid dispensing were obtained from a large national community-based pharmacy database (IQVIA/Compuscript), converted into Defined-Daily-Doses/1,000 population/day for 'strong' and 'weak' opioid categories per standard methods. Dispensing by opioid category and formulations by province/year was assessed descriptively; regression analysis was applied to examine possible segmentation of over-time strong opioid dispensing. RESULTS: All provinces reported starkly increasing strong opioid dispensing peaking 2011-2016, and subsequent marked declines. About half reported lower strong opioid dispensing in 2020 compared to 2005, with continuous inter-provincial differences of > 100 %; weak opioids also declined post-2011/12. Segmented regression suggests breakpoints for strong opioids in 2011/12 and 2015/16, coinciding with main interventions (e.g., selective opioid delisting, new prescribing guidelines) towards more restrictive opioid utilization control. CONCLUSIONS: We characterized an era of marked rise and fall, while featuring stark inter-provincial heterogeneity in opioid dispensing in Canada. While little evidence for improvements in pain care outcomes exists, the starkly inverting opioid utilization have been associated with extensive population-level harms (e.g., misuse, morbidity, mortality) over-time. This national case study raises fundamental questions for opioid-related health policy and practice.