Canadian Medical Association Journal

Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone

¹ The Departments of Medicine and of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont.; the Department of Medicine and the Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.
² The Department of Medicine and the Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; the Institute for Clinical Evaluative Sciences, Toronto, Ont.; and the Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
³ The Departments of Emergency Medicine and of Pharmacology and Toxicology, Queen's University, Kingston, Ont.
⁴ The Institute for Clinical Evaluative Sciences, Toronto, Ont.
⁵ The Department of Family Medicine, State University of New York at Buffalo, Buffalo, USA
⁶ The Department of Medicine, University of Toronto, Toronto, Ont.; the Institute for Clinical Evaluative Sciences, Toronto, Ont.; Sunnybrook Health Sciences Centre, Toronto, Ont.

	Abstract

Background: Opioid-related mortality appears to be increasing in Canada. We examined the true extent of the problem and the impact of the introduction of long-acting oxycodone.

Methods: We examined trends in the prescribing of opioid analgesics in the province of Ontario from 1991 to 2007. We reviewed all deaths related to opioid use between 1991 and 2004. We linked 3271 of these deaths to administrative data to examine the patients' use of health care services before death. Using time-series analysis, we determined whether the addition of long-acting oxycodone to the provincial drug formulary in January 2000 was associated with an increase in opioid-related mortality.

Results: From 1991 to 2007, annual prescriptions for opioids in creased from 458 to 591 per 1000 individuals. Opioidrelated deaths doubled, from 13.7 per million in 1991 to 27.2 per million in 2004. Prescriptions of oxycodone increased by 850% between 1991 and 2007. The addition of long-acting oxycodone to the drug formulary was associated with a 5-fold increase in oxycodone-related mortality (p < 0.01) and a 41% increase in overall opioid-related mortality (p = 0.02). The manner of death was deemed unintentional by the coroner in 54.2% and undetermined in 21.9% of cases. Use of health care services in the month before death was common: for example, of the 3066 patients for whom data on physician visits were available, 66.4% had visited a physician in the month before death; of the 1095 patients for whom individual-level prescribing data were available, 56.1% had filled a prescription for an opioid in the month before death.

Interpretation: Opioid-related deaths in Ontario have increased markedly since 1991. A significant portion of the increase was associated with the addition of long-acting oxycodone to the provincial drug formulary. Most of the deaths were deemed unintentional. The frequency of visits to a physician and prescriptions for opioids in the month before death suggests a missed opportunity for prevention.