Contributions of prescribed and non-prescribed opioids to opioid-related deaths: a population-based cohort study in Ontario, Canada
Importance — There is an urgent need for timely data on the relative contributions of prescribed, diverted and illicit opioids to opioid-related deaths.
Objective — To describe the contributions of prescribed and non-prescribed opioids to opioid-related deaths.
Design — Population-based cohort study
Setting — Ontario, Canada, from January 1, 2013 to December 31, 2016.
Participants — All Ontarians who died of an opioid-related cause.
Exposure — We defined active opioid prescriptions as those with a duration overlapping the date of death, and recent opioid prescriptions as those dispensed in the 30 and 180 days preceding death. We used post-mortem toxicology results from the Drug and Drug/Alcohol Related Death database to characterize deaths on the basis of presence of prescribed and non-prescribed (i.e. diverted or illicit) opioids, overall and stratified by year and age.
Results — We studied 2,833 opioid-related deaths. An active opioid prescription on the date of death was relatively common, but declined slightly throughout the study period (38.2% in 2013 and 32.5% in 2016; p-value for trend=0.03). Older individuals and women were relatively more likely to have an active opioid prescription at time of death. In 2016, 46.4% of those aged 45 to 64 had an active opioid prescription compared with only 11.6% among those aged 24 or younger (p-value for trend <.001). Similarly, 45.6% of women had an active opioid prescription at time of death compared to 26.4% of men (p<.001). Among people with active opioid prescriptions at time of death, 37.8% also had evidence of a non-prescribed opioid on postmortem toxicology. By 2016, the most commonly identified non-prescribed opioid post-mortem was fentanyl (40.4% of cases). Among those without an active opioid prescription at time of death, fentanyl was detected in 20% of deaths in 2013, increasing to 47.5% by 2016 (p<0.001).
Conclusions and Relevance — Prescribed, diverted and illicit opioids all play an important role in opioid-related deaths. Although more than half of all opioid-related deaths still involved prescription drugs (either dispensed or diverted) in 2016, the increased rate of deaths involving fentanyl between 2015 and 2016 is concerning and suggests the need for a multi-factorial approach to this issue that considers both the prescribed and illicit opioid environment.
Information
Citation
Gomes T, Khuu W, Martins D, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. BMJ. 2018; 362:k3207. Epub 2018 Aug 29.