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Opioids

2.1 Medical Use and Dispensing

General Population

  • Ontario had the highest total dispensing rate for oral and transdermal opioids of any province consistently between 2007 and 2013 (~50,000-60,000 morphine equivalents [MEQ]/1,000 population), based on Canadian retail pharmacy dispensing data in the IMS Brogan database.27
  • Ontario's high opioid consumption relative to other provinces was driven by long-acting opioids (e.g., codeine, fentanyl, hydromorphone, morphine, oxycodone) in 2013.  Approximately 33,500 long-acting MEQ per 1,000 population/month were dispensed in Ontario compared to the national average of 25,350; however, similar amounts of short-acting opioids were dispensed in Ontario (approximately 18,500 MEQ/1,000) compared to the national average (18,100 MEQ/1,000). In 2013, oxycodone accounted for the highest portion of long-acting opioids dispensing in Ontario, with approximately 12,500 MEQ dispensed per 1,000 population/month. Hydromorphone (~8,000 MEQ/1,000 population), fentanyl (~6,000 MEQ/1,000 population) and morphine (~5,500 MEQ/1,000 population) accounted for the bulk of the remaining long-acting opioids dispensed in Ontario during that period, as reported in the IMS Brogan database of retail pharmacy dispensing.27
  • Annual prescriptions for all opioid analgesics increased by 29% in Ontario between 1991 (458 prescriptions/1,000 population) and 2007 (591 prescriptions/1,000 population) and for oxycodone increased by 850% (from 23 to 197/1,000 population), according to the IMS Brogan database of retail pharmacy dispensing.28
  • Ontario's dispensing rate for all opioids peaked in 2010-11 at over 60,000 MEQ/1,000 population/month and decreased to slightly over 50,000 MEQ/1,000 population/month in mid-2013, primarily because of decreased oxycodone dispensing following the introduction of OxyNeo (IMS Brogan database).27 Prescribing of oxycodone formulations decreased 44.2% between 2010-13, whereas hydromorphone (+56.0%) and fentanyl (+15.9%) prescribing rates increased during the same time period according to the IMS Brogan database of retail pharmacy dispensing.29
  • Ontario's dispensing rates for strong opioids (i.e., fentanyl, hydrocodone, hydromorphone, oxycodone, meperidine and morphine) also peaked in 2011 to approximately 14 defined daily doses per 1,000 population/day, and subsequently decreased by 15.2% in 2012, as per data from the IMS Brogan database of retail pharmacy dispensing.30
  • One in five (20.5%) Ontario public drug plan recipients received opioids in 2015.31 In 2012-13, Ontario public drug plan recipients received the highest proportion in Canada based on data from the National Prescription Drug Utilization Information System.32
  • 22.6% of Ontario adults (aged 18+) reported past-year use of any prescription opioids (POs) (2015 CAMH Monitor, n=5,013).2 One in five (19.3%) Ontario adults (15+ years) reported using PO analgesics in the previous year based on an Ontario sub-sample (n=1,008) from the 2009 CADUMS1; this Ontario rate was very similar to the national average of 19.2%.33

Youth and Young Adults

  • Use of any POs in the past year was similar among young adults (20.3% among ages 18-29) and older adults (24.1% among those 30+) in Ontario, according to the CAMH Monitor (n=5,013; 2015).2 

Special populations

Indigenous Populations

  • The percent of First Nations people (on- and off-reserve, 15 years and older) in Ontario who received an opioid prescription through the Non-Insured Health Benefits remained relatively stable around 20% between 2000 and 2009. The quantity of opioids dispensed (tablets /1000 people) and the percent receiving short-acting oxycodone products increased during the same period, based on the Non-Insured Health Benefits pharmacy claims database.34

Pregnant and Parenting Women

  • Among women who gave birth to an infant with neonatal abstinence syndrome (NAS) and were eligible for publicly funded prescription drugs in Ontario, 70% received a prescription for an opioid in the 100 days prior to delivery. Prescriptions for non-methadone opioids decreased as delivery approached (from 22.7% in the 1-2 years before delivery to 11.5% in the 100 days before delivery) and prescriptions for methadone increased (from 28.6% in the 1-2 years before delivery to 53.3% in the 100 days before delivery), based on administrative health data from 2007-2011.35

Racialized Populations

  • There are no publicly available provincial data on opioid use among racialized populations.

2.2 Non-medical and Illicit Use

General Population

  • An estimated 115,000 to 327,000 non-medical PO users existed in the Ontario adult (15-49 years) population in 2003 (1,805 to 5,139 per 100,000 population), based on US data and various Canadian data sources (e.g., key informant estimates, narcotic drug consumption). It was estimated that 18,000 to 36,000 of the street drug-using population in Ontario used non-medical POs, heroin, or both in 2002-03 based on overdose death data and a key informant survey.36
  • In 2015, 4.1% of Ontario adults (aged 18+; n=5,013) reported past-year non-medical prescription opioid use (NMPOU) (i.e., without a prescription or doctor's instructions), which was a significant decrease from 7.7% in 2010, according to the 2015 CAMH Monitor.2
  • Less than 1% of Ontario adults had a lifetime history of heroin use in 2004, according to the national Canadian Addiction Survey (CAS), a cross-sectional, representative survey including a sub-sample of (n=1,000) Ontario adults (aged 15+).37 Estimates for subsequent years (both lifetime and past-year use) have not been released due to high sampling variability.

Youth and Young Adults

  • NMPOU rate was 5.1% among young adults (18-29 years) in 2015 and has remained relatively steady (around 7%) since 2010, according to the CAMH Monitor (n=5,013).2
  • One in ten (10.0%) Ontario students (grades 7-12) reported (past-year) NMPOU (2015), which was a significant decrease from 20.6% in 2007, according to the OSDUHS  (n=10,426).3 Grade 12 students were more likely (13.0%) than younger grades (6.9-10.9%) to report (past-year) NMPOU in 2015. 3.7% of all grade 7-12 students reported frequent (6+ times/year) NMPOU use; the majority (55.7%) of students who reported NMPOU obtained POs from a parent or a sibling.
  • Less than 1% (0.5%) of grade 9-12 students reported (past-year) heroin use in the 2015 OSDUHS (n=10,426).3
  • 6.1% of Ontario postsecondary students reported (past-year) NMPOU and 1.2% heroin (0.3% in the past month) according to the 2013 NCHA Canadian survey (Ontario sub-sample n=16,123).6

Special populations

Indigenous Populations

  • 6.8% of Ontario First Nations adults (aged 18+) reported NMPOU in the past year (2.3% daily or almost daily). Rates were highest (~14%) among 18-29 year olds, according to the 2008-10 Regional Health Survey (n=1,500) representative of Ontario First Nation adults living on reserve.9
  • In non-reserve contexts, 19% of a sample of (n=554) First Nations adults (aged 18+) in Hamilton, Ontario reported PO use (past-year) according to a (2009-10) respondent-driven sample.38
  • In North Caribou Lake First Nation in northwestern Ontario, 41% of adults had participated in opioid substitution therapy between 2012 and 2014, indicating high rates of opioid dependence in the community.39
  • In 2009, the Nishnawbe Aski Nation Chiefs declared a PO misuse state of emergency. An estimated 50-80% of First Nations adults, and up to 50% of youth, were PO addicted/dependent in some remote Northern Ontario reserve communities according to anecdotal evidence from the Nishnawbe Aski Nation.40

Racialized Populations

  • Among a sub-sample (n=124) of regular illicit opioid users in Toronto, 16.1% identified as an ethnicity other than white or Aboriginal based on 2005 data from the national multi-site (5 Canadian cities), multi-phase (2002, 2005) convenience sample of illicit opioid users (aged 18+) outside of treatment (OPICAN study).41
  • Seven percent of (n=183) Toronto- and Kingston-based opioid dependent adults (18+) recruited into methadone maintenance therapy (MMT) (2001-04) reported a race other than Caucasian, First Nations or Métis.42

Homeless and Street Involved Populations

  • 8% of (n=1,191) Toronto-based homeless adults reported opioid use (other than heroin and methadone) in the past two years and 3% reported heroin use in a 2004-05 stratified random sample.12
  • 15% of a 2006-07 sample of (n=368) homeless adults in Toronto reported regular (3+ times/week) use of OxyContin (past year), 16% other POs, 7% heroin.11
  • Oxycodone was the most frequently used PO among a sample of street-entrenched adults who use drugs in Toronto; roughly half (52%) reported oxycodone use (past-year), 41% codeine, 34% morphine, and 32% heroin (2012-13 Health Canada High Risk Populations study).13
  • One third (29%) of a sample of 'street-involved' youth who used drugs reported (past-year) oxycodone use, 15% codeine use,  and 13% heroin use (2012-13 Health Canada High Risk Populations study).13
  • 63% of females and 36% of males reported oxycodone use (past 6 months) and 21% females and 30% males reported heroin use among a convenience sample of (n=100) substance-using homeless youth (aged 16-24) in Toronto (Drugs, Homelessness and Health survey, 2008-09).14

Correctional Populations

  • Almost one in three (29.7%) Ontario-based Federal inmates reported Oxycodone use (in the year prior to MMT initiation), 51.2% morphine/hydromorphone, and 47.1% heroin, based on an Ontario sub-sample (27.4% of a total national sample of n=1,272) initiated into Correctional Service Canada's MMT program between 2003 and 2008.43
  • 35.3% of a sample of the Ontario correctional population reported opioid use (other than heroin) in the year prior to incarceration and 7.4% reported heroin use, based on a 2009 representative sample of (n=499) male adults (aged 18+) in an Ontario provincial detention centre.44

Pregnant and Parenting Women

  • There are no publicly-available provincial data on women's non-medical opioid use during pregnancy.
  • Poly-substance use was common among (n=44) opioid dependent women who attended a comprehensive substance use program for pregnant women in Toronto; at the first visit, 48% used POs, 34% used cocaine or crack-cocaine, 32% used marijuana, and 16% used heroin, based on a retrospective (1997-2009) chart review.  By delivery, 11% used each of POs, cocaine/crack-cocaine, and marijuana and 3% used heroin.45 Among (n=121) women attending the program between 2000 and 2006, decreased drug use from the first visit to delivery was most common among women who presented to the program during the first trimester of pregnancy.46
  • Incidence of narcotic use during pregnancy rose from 8.4% in 2009 to 28.6% in 2013 in the Meno Ya Win Health Centre in the Sioux Lookout, which provides obstetric services to a primarily First Nations population in Northern Ontario.47,48

Opioid Users

  • Among a sub-sample (n=124) of regular illicit opioid users in Toronto, most (75.5%) used only POs, a minority (23.6%) used POs and heroin, and few (0.9%) used heroin only (past 30 days).  Some of the commonly reported opiates used were morphine (37.9%) and oxycodone (32.3%)41 based on 2005 data from the national multi-site (5 Canadian cities), multi-phase (2002, 2005) convenience sample of illicit opioid users (aged 18+) outside of treatment (OPICAN study).49
  • Based on a retrospective chart review of (n=250) MMT patients in 3 Ontario MMT clinics (Oshawa, Peterborough, and Scarborough), there was a decrease in oxycodone-positive urine drug screens from the period when only non-tamper resistant oxycodone (i.e., OxyContin) was available to when only tamper-resistant oxycodone (i.e., OxyNEO) was available.50

Injection Drug Users

  • Almost half (44.5%) of a sample of IDUs in Ontario sites reported non-injection oxycodone use (past 6 months), 41.4% methadone, 37.7% Tylenol with Codeine, 24.3% hydromorphone, 35.4% non-prescribed morphine, and 14.7% heroin among an Ontario sub-sample of (n=775) IDUs from the national I-Track survey (2005-08).18

Recreational Drug Users

2.3 Risks and Harms

Improper and Anomalous Opioid Prescribing

  • Between 2007 and 2013, 1.6% of publicly-funded opioid prescriptions in Ontario were dispensed within 7 days of another large prescription of opioids from a different physician/pharmacy. The prevalence of potentially inappropriate opioid prescriptions decreased by 12.5% (from 1.6% to 1.4%) in the 6 months following 2011 legislation allowing the collection of information on opioid prescriptions, based on data from the Ontario Public Drug Benefit Database.52
  • Almost one fifth (18.4%)  of patients (aged 15-64) who received at least 30 consecutive days of publicly-funded MMT were also prescribed a non-methadone opioid for more than 7 days, most commonly oxycodone and codeine. Nearly half (45.8%) of those prescriptions originated from a physician or pharmacy not involved in the patient's MMT, based on a retrospective cohort study of 18,759 patients who received  publicly-funded drug coverage in Ontario between 2003 and 2010.53
  • An estimated 242,075 excess non-tamper-resistant OxyContin tablets were dispensed in Windsor near the Detroit-Windsor border crossing following the introduction of tamper-resistant oxycodone in the United States (2010-11) according to the IMS Brogan database of retail pharmacy dispensing.54
  • Family physicians falling into the upper quintile of opioid prescribing - with an average of 931.5 opioid prescriptions/1,000 population, a rate 55 times higher than physicians in the lowest quintile – issued the final prescription before death to 62.7% of the 102 individuals enrolled in the Ontario Public Drug Plan whose 2006 deaths were related to opioids. These figures were based on an analysis of Ontarians (aged 15-64) enrolled in the Ontario Public Drug Plan in 2006.55
  • The vast majority (96%) of Ontario pharmacists surveyed (n=668; 2014) were knowledgeable that inadvertent prescription opioid overdoses have been increasing but only half (48%) were familiar with the Canadian Guideline For The Safe And Effective Use Of Opioids In Chronic Non-Cancer Pain and only half (52%) knew the 'watchful dose' of opioids per day recommended in the guideline.56

Prescription Opioids and Driving

  • Opioids were the fourth most common drugs detected in toxicological testing of drivers involved in fatal MVCs in Ontario, among (n=229) samples that were submitted for testing between 2011 and 2012; drugs were detected in 44% of cases and opioids were detected in 15% of those.19
  • The odds of road trauma increased by 23% among Ontario adults who were prescribed a very high dose of opioids (>200 MEQ /day) compared with patients who were prescribed a very low dose (<20 MEQ). Odds increased by 42%, 29% and 21% for high (100-199 MEQ), moderate (50-99 MEQ) and low (20-49 MEQ) doses, respectively, according to a population-based nested case-control study of Ontario adults (aged 18-64) who received at least 1 publicly-funded prescription for an opioid in 2003-11.57

Morbidity and Mortality

Neonatal Abstinence Syndrome

  • Neonatal Abstinence Syndrome in Ontario has increased approximately 5 times between 2002-03 and 2011-12 from 1/1,000 to 5/1,000 hospital births, and nearly 15 times since 1992. Population-based administrative health records show that NAS was highest (~9/1,000 hospital births) among babies of young (<19 years) mothers compared older (19+ years) mothers (<2/1,000 hospital births) and NAS rates were high (55 per 1,000 hospital births) in the North West LHIN (Mental Health of Children and Youth in Ontario Baseline Scorecard).26,35

Burden of Disease

  • A 3-fold increase in annual Years of Potential Life Lost due to premature opioid-related mortality occurred in Ontario from 1.3 per 1,000 population in 1992 to 3.3 per 1,000 population in 2010. Nearly 1 in every 8 deaths (12.1%) among individuals aged 25-34 were opioid-related by 2010, based on administrative health records.58
  • There were an estimated 10,762 Health-Adjusted Life Years Lost (a health gap measure that incorporates mortality and morbidity associated with disease or injury) due to 24,308 new cases of NMPOU in Ontario in 2009. The burden of PO misuse was highest among adults aged 25-44 years, according to diverse data sources.59

Overdose

  • There were approximately 685 deaths related to codeine, fentanyl, heroin, hydromorphone, methadone, morphine, and oxycodone in Ontario in 2015. Fentanyl was present in the most deaths (198), followed by hydromorphone (148), oxycodone (144), methadone (120), and morphine (110) (Office of the Chief Coroner of Ontario).60
  • PO-related deaths in Ontario more than doubled, from 258/year in 2005 to 577/year in 2013. Between 2005 and 2011, fentanyl-related deaths increased 3.6 times, hydromorphone-related deaths increased almost 3 times, oxycodone-related deaths increased almost 2.5 times and morphine-related deaths increased 1 time. Further, there were strong positive correlations between PO dispensing and PO-related mortality rates between 2005 and 2011 for fentanyl, hydromorphone, and oxycodone but not morphine, based on data from the Office of the Chief Coroner of Ontario and the IMS Brogan database of retail pharmacy dispensing.29,61
  • A 5-fold increase in oxycodone-related mortality and a 41% increase in overall opioid-related mortality occurred between 1999 and 2004, associated with the introduction of long-acting oxycodone to Ontario's drug formulary in 2000, based on data from the Office of the Chief Coroner of Ontario and the IMS Brogan database of retail pharmacy dispensing.28
  • At least 7% of (n=1,359) individuals who died due to opioid-related causes between 2006 and 2008 used diverted POs. One in five (19.2%) inappropriately self-administered opioids (injection, inhalation, chewed patch) and 5% had recently been switched to a more potent opioid medication as per an analysis of drug-related deaths in Ontario in 2006-08 (Office of the Chief Coroner of Ontario, medical, toxicology, pathology, and police reports).62
  • Two-year opioid-related mortality rates were 7.92/1,000 population and 9.94/1,000 population among patients whom high (201-400 MEQ) or very high (>400 MEQ) doses of opioids were dispensed in 2004 among beneficiaries (aged 15-64) of Ontario's public drug plan.63
  • 175 Ontario patients receiving MMT died of opioid-related causes between 1994 and 2010, and a 2-fold increased risk of opioid-related death was associated with psychotropic drug use (mainly benzodiazepines and antipsychotics), as per a population-based nested case-control study linking prescription and coroner's records among (n=43,545) MMT-enrolled beneficiaries of Ontario's public drug plan.64
  • For every 10,000 Ontarians (aged 15-64 years) there were 1.1 hospitalizations related to opioid toxicity annually between 2006 and 2010; this rate increased to 1.5 in 2011-13 and decreased to 1.2 in 2014 (compared to a national average of 1.3).31,65 Rates were elevated among older adults (65 years and older; 1.3 in 2006-10 and 1.8 in 2011-13) and in some counties in Northern Ontario (e.g., as high as 4.0/10,000 younger adults in Algoma District in 2010-13), according to provincial administrative data.31,66,67 Similarly, emergency department visits related to opioid toxicity in 2014 were highest among adults 25-44 years (3.1 visits/10,000 Ontarians), elevated in Northern Ontario (4.4/10,000 in the North East LHIN and 4.1 in the North West LHIN), and increased from 2006-10 (2.2 annual visits/10,000 Ontarians 15-64 years).31,67
  • For every 10,000 Ontarians there were 2.6 emergency department visits for mental and behavioural disorders due to the use of opioids in 2008-09; this rate increased to 3.7 in 2010-11. Rates were elevated in Northern Ontario (22.9/10,000 population) and among First Nations (55/10,000 population) in 2010-11, according to provincial administrative data.66
  • Between 2002 and 2005, the rate of nonfatal overdose (past 6 months) fell from 19.9% to 5.6% among a sub-sample (n=141 in 2002; n=124 in 2005) of illicit opioid users in Toronto, based on the pan-Canadian OPICAN study.41,68

2.4 Interventions

Treatment

  • Nearly one fifth (18.2%; 18,323 admissions) of patients admitted to publicly-funded substance abuse treatment in Ontario (2012-13) reported POs as a problem drug, which was the third most common presenting problem drug behind cannabis and cocaine. More women (26.4%) reported opiates as a presenting problem substance than men (21.5%). In addition 3.4% reported heroin/opium as a problem drug and 1.4% reported over-the-counter codeine preparations, according to data obtained from DATIS.25
  • There were roughly 9 per 10,000 children and youth (aged 0-24) in treatment for opioid use in 2011-12 in Ontario, which was an increase from about 3/10,000 in 2003-04; this increase was most marked among 20-24 year olds where it increased from ~9 to ~34/10,000. Further, the North East and North West LHINs held the highest rates (among 0-24 year-olds in 2009-12). Opioids were the second most common drug for which children and youth received treatment in 2011-12, according to administrative health data reported in the Mental Health of Children and Youth in Ontario Baseline Scorecard report.26

Opioid Agonist Maintenance Treatment

  • In Ontario, the current gold standard for treatment of opioid dependence is MMT. Suboxone - a combination of buprenorphine and naloxone – is another form of opioid agonist maintenance therapy that has a lower risk of overdose than methadone. In its 2016 Strategy to Prevent Opioid Addiction and Overdose, Ontario's Ministry of Health and Long Term Care announced it would expand access to Suboxone, including making it available as a General Benefit on the Ontario Drug Benefit Formulary.69
  • The number of Ontarians enrolled in MMT was approximately 50,000 in 2014, an increase from under 30,000 in 2010, based on administrative data.70 The average daily cost of MMT in Ontario was estimated at $15.48 per patient in 2010, corresponding to $5,651.00/year (comprised of 9.8% physician billing, 39.8% pharmacy costs, 3.8% methadone and 46.7% urine toxicology screens), according to a (2003-09) database from a group of methadone clinics which provide ~25% of MMT in Ontario.71 Based on these annual enrolment and cost estimates, the total annual cost of MMT in Ontario could be over $280,000,000.
  • Overall, 6.2% of people enrolled in publicly-funded drug treatment in Ontario were prescribed opioid substitution therapy in 2012-13, an increase from 4.0% in 2007-08 (DATIS).25 One percent of Ontario public drug plan recipients received MMT in 2015.31 Of the (n=5,127) people in publicly-funded opioid substitution treatment in Ontario (2012-13), the majority (52.8%) were male. The largest proportion (43.3%) was among those aged 25-34, followed by those aged 35-44 (21.9%) and 18-24 year olds (18.6%), based on information from DATIS, compiled in the National Treatment Indicators Report.72
  • Among a sample of people with opioid dependence (DSM-IV diagnosed) receiving MMT (n=492) from 13 clinics, almost half (44.2%) reported their first opioid use was from a prescription - especially among women (51.6%) - and over one third (35.0%) reported chronic pain.73
  • Among (n=233) patients on MMT recruited from 13 clinics across Ontario, past history of injection drug use (hazard ratio=2.25, 95% CI: 1.12-4.47) and days of benzodiazepine use (hazard ratio=1.06, 95% CI: 1.01-1.10) were predictive of relapse (i.e., using opioids) while on MMT, based on interviews.74
  • IDU decreased significantly from 83% to 66% in the 6 months after enrolling into MMT among (n=183) Toronto- and Kingston-based opioid dependent (DSM-IV diagnosed) adults (18+) recruited into one of two low-threshold MMT programs (2001-04).42
  • Among women from rural and remote communities in Northwestern Ontario, treatment with buprenorphine and naloxone (n=62) decreased the odds of polysubstance use in pregnancy (OR=0.13, 95% CI: 0.06-0.29) compared to women with ongoing illicit opioid use (n=159). Compared to women taking no opioids during pregnancy (n=618), there was no difference in birth weight, number of preterm deliveries, congenital malformations or stillbirths in women taking buprenorphine and naloxone, based on consecutive births in a district hospital (2010-15).75
  • 462 physicians in Ontario held exemptions to prescribe methadone in 2014 according to the College of Physicians and Surgeons of Ontario.76

Naloxone distribution

  • Ontario's take-home naloxone program has been in operation since 2013. In 2016, in response to the growing opioid-overdose crisis, naloxone was reclassified as a Schedule II drug in Canada, making it available without a prescription.77 Ontario's comprehensive Strategy to Prevent Opioid Addiction and Overdose includes initiatives to increase the accessibility of naloxone, such as providing take-home naloxone kits free of charge to people currently using opioids, people at risk of returning to opioid use, people likely to witness an opioid overdose, and at-risk inmates released from provincial correctional institutions.69,78
  • As of March 2016, over 2,700 naloxone kits have been distributed across Ontario, almost 500 clients have reported administering naloxone and almost 100 reported receiving naloxone to reverse an overdose.79 Although take-home naloxone kits are available in pharmacies and other organizations across the province, data on the number of pharmacies dispensing naloxone kits and the number of kits dispensed since naloxone was made available without a prescription is not yet available.