Initiation of opioid agonist therapy after hospital visits for opioid poisonings in Ontario.

BACKGROUND: Emergency department visits and hospital admissions for opioid toxicity are opportunities to initiate opioid agonist therapy (OAT), which reduces morbidity and mortality in patients with opioid use disorder (OUD). The study objectives were to evaluate OAT initiation rates after a hospital encounter for opioid toxicity in Ontario, Canada, and determine whether publication of a 2018 Canadian OUD management guideline was associated with increased initiation. METHODS: We conducted a retrospective, population-based serial cross-sectional study of hospital encounters for opioid toxicity among patients with OUD between Jan. 1, 2013, and Mar. 31, 2020, in Ontario, Canada. The primary outcome was OAT initiation (methadone, buprenorphine-naloxone, or slow-release oral morphine) within 7 days of discharge, measured quarterly. We examined the impact of the release of the OUD management guideline on OAT initiation rates using Autoregressive Integrated Moving Average models. RESULTS: Among 20 702 hospital visits for opioid toxicity among patients with OUD, the median age was 35 years, and 65.1% were male. Over the study period, the percentage of visits leading to OAT initiation within 7 days rose from 1.7% or less (Q1 2013) to 5.6% (Q1 2020); however, the publication of the Canadian OUD management guideline was not associated with a significant increase in these rates (0.14% slope change, 95% confidence interval -0.11% to 0.38%; p = 0.3). INTERPRETATION: Among hospital encounters for opioid toxicity, despite rising prevalence over time, only 1 in 18 patients were dispensed OAT within a week of discharge in early 2020. These findings highlight missed opportunities to initiate therapies proven to reduce mortality in patients with OUD.

Association Between Increased Dispensing of Opioid Agonist Therapy Take-Home Doses and Opioid Overdose and Treatment Interruption and Discontinuation.

Importance: During the COVID-19 pandemic, modified guidance for opioid agonist therapy (OAT) allowed prescribers to increase the number of take-home doses to promote treatment retention. Whether this was associated with an increased risk of overdose is unclear. Objective: To evaluate whether increased take-home doses of OAT early in the COVID-19 pandemic was associated with treatment retention and opioid-related harm. Design, Setting, and Participants: A retrospective propensity-weighted cohort study of 21 297 people actively receiving OAT on March 21, 2020, in Ontario, Canada. Changes in OAT take-home dose frequency were assessed between March 22, 2020, and April 21, 2020, and individuals were observed for up to 180 days to assess outcomes (last date of follow-up, October 18, 2020). Exposures: Exposure was defined as extended take-home doses in the first month of the pandemic within each of 4 cohorts based on OAT type and baseline take-home dose frequency (daily dispensed methadone, 5-6 take-home doses of methadone, daily dispensed buprenorphine/naloxone, and 5-6 take-home doses of buprenorphine/naloxone). Main Outcomes and Measures: Primary outcomes were opioid overdose, interruption in OAT, and OAT discontinuation. Results: Among 16 862 methadone and 4435 buprenorphine/naloxone recipients, the median age ranged between 38 and 42 years, and 29.1% to 38.2% were women. Among individuals receiving daily dispensed methadone (n = 5852), initiation of take-home doses was significantly associated with lower risks of opioid overdose (6.9% vs 9.5%/person-year; weighted hazard ratio [HR], 0.73 [95% CI, 0.56-0.96]), treatment discontinuation (51.0% vs 63.6%/person-year; weighted HR, 0.80 [95% CI, 0.72-0.90]), and treatment interruption (19.0% vs 23.9%/person-year; weighted HR, 0.80 [95% CI, 0.67-0.95]) compared with no change in take-home doses. Among individuals receiving daily dispensed buprenorphine/naloxone (n = 662), there was no significant difference in any outcomes between exposure groups. Among individuals receiving weekly dispensed OAT (n = 11 010 for methadone; n = 3773 for buprenorphine/naloxone), extended take-home methadone doses were significantly associated with lower risks of OAT discontinuation (14.1% vs 19.6%/person-year; weighted HR, 0.72 [95% CI, 0.62-0.84]) and interruption in therapy (5.1% vs 7.4%/person-year; weighted HR, 0.69 [95% CI, 0.53-0.90]), and extended take-home doses of buprenorphine/naloxone were significantly associated with lower risk of interruption in therapy (9.5% vs 12.9%/person-year; weighted HR, 0.74 [95% CI, 0.56-0.99]) compared with no change in take-home doses. Other primary outcomes were not significantly different between groups. Conclusions and Relevance: In Ontario, Canada, during the COVID-19 pandemic, dispensing of increased take-home doses of opioid agonist therapy was significantly associated with lower rates of treatment interruption and discontinuation among some subsets of patients receiving opioid agonist therapy, and there were no statistically significant increases in opioid-related overdoses over 6 months of follow-up. These findings may be susceptible to residual confounding and should be interpreted cautiously.

Inequities in access to primary care among opioid recipients in Ontario, Canada: A population-based cohort study.

BACKGROUND: Stigma and high-care needs can present barriers to the provision of high-quality primary care for people with opioid use disorder (OUD) and those prescribed opioids for chronic pain. We explored the likelihood of securing a new primary care provider (PCP) among people with varying histories of opioid use who had recently lost access to their PCP. METHODS AND FINDINGS: We conducted a retrospective cohort study using linked administrative data among residents of Ontario, Canada whose enrolment with a physician practicing in a primary care enrolment model (PEM) was terminated between January 2016 and December 2017. We assigned individuals to 3 groups based upon their opioid use on the date enrolment ended: long-term opioid pain therapy (OPT), opioid agonist therapy (OAT), or no opioid. We fit multivariable models assessing the primary outcome of primary care reattachment within 1 year, adjusting for demographic characteristics, clinical comorbidities, and health services utilization. Secondary outcomes included rates of emergency department (ED) visits and opioid toxicity events. Among 154,970 Ontarians who lost their PCP, 1,727 (1.1%) were OAT recipients, 3,644 (2.4%) were receiving long-term OPT, and 149,599 (96.5%) had no recent prescription opioid exposure. In general, OAT recipients were younger (median age 36) than those receiving long-term OPT (59 years) and those with no recent prescription opioid exposure (44 years). In all exposure groups, the majority of individuals had their enrolment terminated by their physician (range 78.1% to 88.8%). In the primary analysis, as compared to those not receiving opioids, OAT recipients were significantly less likely to find a PCP within 1 year (adjusted hazard ratio [aHR] 0.55, 95% confidence interval [CI] 0.50 to 0.61, p < 0.0001). We observed no significant difference between long-term OPT and opioid unexposed individuals (aHR 0.96; 95% CI 0.92 to 1.01, p = 0.12). In our secondary analysis comparing the period of PCP loss to the year prior, we found that rates of ED visits were elevated among people not receiving opioids (adjusted rate ratio (aRR) 1.20, 95% CI 1.18 to 1.22, p < 0.0001) and people receiving long-term OPT (aRR 1.37, 95% CI 1.28 to 1.48, p < 0.0001). We found no such increase among OAT recipients, and no significant increase in opioid toxicity events in the period following provider loss for any exposure group. The main limitation of our findings relates to their generalizability outside of PEMs and in jurisdictions with different financial incentives incorporated into primary care provision. CONCLUSIONS: In this study, we observed gaps in access to primary care among people who receive prescription opioids, particularly among OAT recipients. Ongoing efforts are needed to address the stigma, discrimination, and financial disincentives that may introduce barriers to the healthcare system, and to facilitate access to high-quality, consistent primary care services for chronic pain patients and those with OUD.

The impact of access to health services on prediabetes awareness: A population-based study.

Research demonstrates that prediabetes awareness has important implications for participation in diabetes risk-reducing behaviors. We examined the impact of levels of access to health services on prediabetes awareness. In 2016, we conducted an analysis among U.S. adults with prediabetes using cross-sectional data from three cycles (2007-2008, 2009-2010, and 2011-2012) of the National Health and Nutrition Examination Survey. Participants aware and unaware of their prediabetes were classified as having full, partial, or no access to health services based on current health insurance coverage and having a routine place to go for health care. Multivariable logistic regression was used to estimate the association between access to health services and prediabetes awareness. Among a total sample of 2999U.S. adults with prediabetes, an estimated 92.0% were unaware of their prediabetes status. Participants that were unaware of their prediabetes tended to be younger, male, and were less likely to be obese or have a family history of diabetes. Having no access to health services significantly increased the odds of being prediabetes unaware (AOR: 2.65; 95% CI: 1.10-6.38). However, participants with insurance but no place of regular care had the greatest odds of being prediabetes unaware (AOR: 3.21; 95% CI: 1.21-8.55). These findings suggest that access to health services is a key factor for prediabetes awareness. Health policies and interventions should strive to ensure equitable access to health services in order to detect prediabetes, and promote awareness and engagement in risk-reducing behaviors to decrease the incidence of diabetes.

The epidemiology of benzodiazepine-related toxicity in Ontario, Canada: a population-based descriptive study.

OBJECTIVES: Despite the widespread use of prescription benzodiazepines, there are few studies examining trends and patterns of benzodiazepine-related toxicity. We describe the epidemiology of benzodiazepine-related toxicity in Ontario, Canada. METHODS: We conducted a population-based, cross-sectional study of Ontario residents who had an emergency department visit or hospitalization for benzodiazepine-related toxicity between January 1, 2013 and December 31, 2020. We reported annual crude and age-standardized rates of benzodiazepine-related toxicity overall, by age, and by sex. In each year, we characterized the history of benzodiazepine and opioid prescribing among people who experienced benzodiazepine-related toxicity, and reported the percentage of encounters with opioid, alcohol, or stimulant co-involvement. RESULTS: Between 2013 and 2020, there were 32,674 benzodiazepine-related toxicity encounters among 25,979 Ontarians. During this period, the crude rate of benzodiazepine-related toxicity declined overall, from 28.0 to 26.1 per 100,000 population (age-standardized rate: 27.8 to 26.4 per 100,000), but increased among young adults aged 19 to 24 (39.9 to 66.6 per 100,000 population). Moreover, by 2020, the percentage of encounters associated with active benzodiazepine prescriptions had declined to 48.9%, while the percentage of encounters that had opioid, stimulant, or alcohol co-involvement rose to 28.8%. CONCLUSION: Benzodiazepine-related toxicity has declined in Ontario overall, but has increased among youth and young adults. Furthermore, there is growing co-involvement of opioids, stimulants, and alcohol, which may reflect the recent emergence of benzodiazepines in the unregulated drug supply. Multifaceted public health initiatives comprising harm reduction, mental health supports, and promotion of appropriate prescribing are needed to reduce benzodiazepine-related harm.

RéSUMé: OBJECTIFS: Malgré l'utilisation généralisée des benzodiazépines sur ordonnance, peu d'études portent sur les tendances et les schémas de toxicité de ces médicaments. Nous décrivons l'épidémiologie de la toxicité liée aux benzodiazépines en Ontario, au Canada. MéTHODE: Nous avons mené une étude populationnelle transversale des résidentes et résidents de l'Ontario ayant visité le service des urgences ou été hospitalisés pour toxicité liée aux benzodiazépines entre le 1er janvier 2013 et le 31 décembre 2020. Nous avons rapporté globalement, par âge et par sexe les taux annuels de toxicité liée aux benzodiazépines, bruts et standardisés pour l'âge. Pour chaque année, nous avons caractérisé les antécédents de prescription de benzodiazépines et d'opioïdes chez les personnes ayant présenté une toxicité liée aux benzodiazépines, et rapporté le pourcentage de rencontres présentant une co-implication avec les opioïdes, l'alcool ou les stimulants. RéSULTATS: Entre 2013 et 2020, il y a eu 32 674 rencontres pour toxicité liée aux benzodiazépines avec 25 979 Ontariens et Ontariennes. Durant cette période, le taux brut de toxicité liée aux benzodiazépines a baissé dans l'ensemble, passant de 28 à 26,1 pour 100 000 habitants (taux standardisé pour l'âge : 27,8 à 26,4 p. 100 000), mais il a augmenté chez les jeunes adultes de 19 à 24 ans (de 39,9 à 66,6 p. 100 000). De plus, en 2020, le pourcentage de rencontres associées à des ordonnances actives de benzodiazépines avait baissé à 48,9 %, tandis que le pourcentage de rencontres présentant une co-implication avec les opioïdes, les stimulants ou l'alcool avait augmenté à 28,8 %. CONCLUSION: La toxicité liée aux benzodiazépines a diminué en Ontario dans l'ensemble, mais elle a augmenté chez les jeunes et les jeunes adultes. De plus, cette toxicité présente une co-implication croissante avec les opioïdes, les stimulants ou l'alcool, ce qui peut refléter l'émergence récente des benzodiazépines dans l'approvisionnement non réglementé en drogues. Des initiatives de santé publique multidimensionnelles incluant la réduction des méfaits, le soutien en santé mentale et la promotion de la prescription appropriée sont nécessaires pour réduire les méfaits liés aux benzodiazépines.

Changing patterns of opioid initiation for pain management in Ontario, Canada: A population-based cross-sectional study.

INTRODUCTION: The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release. METHODS: We conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015-March 2016; fiscal year [FY] 2015) and in the most recent year available (January-December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication. RESULTS: In FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%). CONCLUSION: Despite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing.

Impact of the COVID-19 pandemic on the provision of take-home doses of opioid agonist therapy in Ontario, Canada: A population-based time-series analysis.

BACKGROUND: In March 2020, the Ontario government declared a state of emergency due to the growing risk of COVID-19. In response, new guidance for the management of opioid agonist therapy (OAT) was released, which included the expansion of eligibility for take-home doses. We investigated the impact of these changes on trends in the distribution of take-home doses of OAT. METHODS: We conducted a population-based time series analysis among residents of Ontario, Canada who were dispensed OAT between June 25, 2019 and November 30, 2020. For each week of the study period, we calculated the percentage of people dispensed (a) methadone and (b) buprenorphine/naloxone by the number of take-home doses received. We used interventional autoregressive integrated moving average models to estimate changes in the percentage of people dispensed each category of take-home doses in the weeks following the declaration of the state of emergency and release of the OAT dispensing guidance. RESULTS: Following the state of emergency and release of the OAT dispensing guidance, there was a significant increase in the percentage of Ontarians dispensed 7 to 13 (3.6% increase; p = 0.033) and 14 or more (0.8% increase; p<0.001) take-home doses of methadone, and in the percentage of people dispensed 7 to 13 (4.3% increase; p = 0.001), 14 to 27 (2.8% increase; p<0.001), and 28 or more (0.3% increase; p = 0.008) take-home doses of buprenorphine/naloxone. There were significant decreases in the percentage of Ontarians receiving daily dispensed buprenorphine/naloxone (-3.1%; p = 0.001), as well as the percentage dispensed 1 to 6 take-home doses of methadone (-4.5%; p = 0.001) and buprenorphine/naloxone (-4.9%; p = 0.001). CONCLUSION: The new guidance for dispensing OAT in Ontario resulted in increases in the duration of take-home doses of methadone and buprenorphine/naloxone supplied. However, given that changes were small, strategies to improve retention in OAT and ensure equitable access to take-home dosing should continue.

Impact of the COVID-19 pandemic on the prevalence of opioid agonist therapy discontinuation in Ontario, Canada: A population-based time series analysis.

BACKGROUND: We assessed the impact of COVID-19, which includes the declaration of a state of emergency and subsequent release of pandemic-specific OAT guidance (March 17, 2020 to March 23, 2020) on the prevalence of OAT discontinuation. METHODS: We conducted a population-based time series analysis using interventional autoregressive integrated moving average models among Ontario residents who were stable (>60 days of continuous use) and not yet stable on OAT. Specifically, we examined whether COVID-19 impacted the weekly percentage of individuals who discontinued OAT, overall and stratified by treatment type (methadone vs. buprenorphine/naloxone). Additionally, we compared demographic characteristics and patient outcomes among people stable on OAT who discontinued treatment during (March 17, 2020 to November 30, 2020) and prior (July 3, 2019 to March 16, 2020) to the pandemic. RESULTS: The weekly prevalence of OAT discontinuation across the study period ranged between 0.6% and 1.1%, among those stable on treatment compared to 7.3% and 16.6%, among those not stable on treatment. Following COVID-19, there was no significant change in the percentage of Ontarians who discontinued OAT, regardless of whether they were stabilized on treatment. Among those stable on OAT, a similar proportion of patients restarted therapy and experienced opioid-related harm following an OAT discontinuation. However, mortality following OAT discontinuation must be noted, as approximately 1.4% and 0.8% of people who discontinued methadone and buprenorphine/naloxone respectively, died within 30 days of discontinuation. CONCLUSIONS: Trends in the prevalence of OAT discontinuation did not significantly change during the first eight months of the COVID-19 pandemic.

Dental Opioid Prescription Characteristics and the Risk of New, Persistent Use.

INTRODUCTION: Dentists are a common source of opioid exposure. This study investigates the association between initial dental opioid prescription characteristics and subsequent persistent use and examines the rate of opioid overdose after initiation. METHODS: A retrospective cohort study was conducted among Ontario residents who were dispensed an initial opioid prescription originating from a dentist between October 2014 and September 2018 (data were analyzed in October 2019-May 2020). Exposures were characterized on the basis of the average daily dose in milligram morphine equivalents and the duration and formulation (long versus short acting) of the initial prescription. New, persistent use was defined as ≥1 opioid prescription within 90 days and another within 91-365 days after the initial prescription. The rate of an opioid overdose within 90 days after initiation was examined. RESULTS: Among 786,125 Ontarians who initiated a dentist-prescribed opioid, 34,880 (4.4%) developed persistent use, whereas 140 (0.72 per 1,000 person-years) had evidence of an overdose within 90 days. People dispensed an initial daily dose >90 milligram morphine equivalents (n=5,644, 0.7%) had significantly greater odds of persistence (AOR=1.20, 95% CI=1.07, 1.34) than those dispensed ≤20 milligram morphine equivalents (n=179,884, 22.9%). Persistence was also significantly associated with receiving longer prescription durations and a long-acting opioid on initiation. CONCLUSIONS: Among people who initiated a dentist-prescribed opioid, 1 in 23 experienced persistent use, and persistence was associated with the characteristics of the prescription. Prescribing lower doses, prescribing for shorter durations, and avoiding long-acting formulations may be an opportunity to lessen the risk of persistent opioid use.

Every antibiotic, every day: Maximizing the impact of prospective audit and feedback on total antibiotic use.

BACKGROUND: The success of antimicrobial stewardship is dependent on how often it is completed and which antimicrobials are targeted. We evaluated the impact of an antimicrobial stewardship program (ASP) in three non-ICU settings where all systemic antibiotics, regardless of spectrum, were targeted on the first weekday after initiation. METHODS: Prospective audit and feedback (PAAF) was initiated on the surgical, respiratory, and medical wards of a community hospital on July 1, 2010, October 1, 2010, and April 1, 2012, respectively. We evaluated rates of total antibiotic use, measured in days on therapy (DOTs), among all patients admitted to the wards before and after PAAF initiation using an interrupted time series analysis. Changes in antibiotic costs, rates of C. difficile infection (CDI), mortality, readmission, and length of stay were evaluated using univariate analyses. RESULTS: Time series modelling demonstrated that total antibiotic use decreased (± standard error) by 100 ± 51 DOTs/1,000 patient-days on the surgical wards (p = 0.049), 100 ± 46 DOTs/1,000 patient-days on the respiratory ward (p = 0.029), and 91 ± 33 DOTs/1,000 patient-days on the medical wards (p = 0.006) immediately following PAAF initiation. Reductions in antibiotic use were sustained up to 50 months after intervention initiation, and were accompanied by decreases in antibiotic costs. There were no significant changes to patient outcomes on the surgical and respiratory wards following intervention initiation. On the medical wards, however, readmission increased from 4.6 to 5.6 per 1,000 patient-days (p = 0.043), while mortality decreased from 7.4 to 5.0 per 1,000 patient-days (p = 0.001). CDI rates showed a non-significant declining trend after PAAF initiation. CONCLUSIONS: ASPs can lead to cost-effective, sustained reductions in total antibiotic use when interventions are conducted early in the course of therapy and target all antibiotics. Shifting to such a model may help strengthen the effectiveness of ASPs in non-ICU settings.