Trends in Daily Dispensed Immediate Release Hydromorphone Prescribing Across Ontario: A Descriptive Analysis from 2016-2020

Samantha Young, Gillian Kolla, Tonya Campbell, Daniel McCormack, Carol Strike, Anita Srivastava,
Pamela Leece, Tony Antoniou, Ahmed M. Bayoumi, Tara Gomes

Background Results Results Discussion & Conclusions

• The overdose crisis is driven by the toxicity of the • Final sample of 534 courses (447 individual patients) Table 1. Baseline Characteristics of patients receiving • We found increasing rates of IRH prescribing in
unregulated drug supply of IRH prescribing meeting the cohort definition daily dispensed IRH Ontario during the study period, presumed to
• Some clinicians started prescribing immediate Figure 1. Number of initiations of daily dispensed Patients of Patients of Patients of reflect safer supply
all infrequent frequent
release hydromorphone (IRH) tablets for use via IRH per quarter in Ontario (n=534) prescribers prescribers prescribers SD • Patients in our cohort prescribed IRH were
injection if desired – often called safer supply Baseline Characteristics n (%) n (%) n (%) commonly male and resided in urban areas,
n=447 n=124 n=323
• This remains controversial due to concerns about Age (years)* 42 (34-50) 46 (38-54) 41 (33-49) 0.40
which parallels the demographics of those at
diversion and infection risk Male sex 269 (60.2) 76 (61.3) 193 (59.8) 0.03 highest risk for overdose death in Ontario
Urban residence 430 (96.2) 117 (94.4) 313 (96.9) 0.12
• Individuals receiving IRH had frequently received
Objectives Lowest income quintile
HIV seropositive
249 (55.7)
62 (13.9)
63 (50.8)
12 (9.7)
186 (57.6)
50 (15.5)
0.14
0.18 OAT in the 1 year prior to initiation and had high
Palliative care (≤ 180 days) 58 (13.0) 9 (7.3) 49 (15.2) 0.25
rates of HIV
1. Explore the uptake of daily dispensed IRH as a Dispensed OAT (≤ 1 year)

safer opioid supply in Ontario

Methadone 251 (56.2) 52 (41.9) 199 (61.6) 0.40 • A small number of prescribers accounted for the
Buprenorphine 108 (24.2) 19 (15.3) 89 (27.6) 0.16
SROM 56 (12.5) 65 (52.4) 244 (75.5) 0.50 majority of IRH prescribing in our cohort, and the
2. Describe the characteristics of patients receiving Dispensed benzodiazepine distribution of initiations within health regions
IRH, patterns of use, and associated prescriber (≤ 30 days) 77 (17.2) 41 (33.1) 36 (11.1) 0.55
mirrors known safer opioid supply programs
characteristics SROM=Slow release oral morphine. median (interquartile range)
*

Table 2. Outcomes by IRH dispensation episode • Nearly half of the cohort remained on IRH for at
Methods Outcomes Dispensed Dispensed Dispensed by
least a year following their first initiation, which is
by all by infrequent frequent similar to previously documented rates of
Study Design prescribers prescribers prescribers SD
methadone discontinuation in Ontario
Figure 2. Number of initiations of daily dispensed n (%) n (%) n (%)
• Retrospective cohort of people prescribed IRH as n=534 n=135 n=399 • Mortality was reassuringly low, with ≤5 deaths
safer supply in Ontario from January 2016 to March IRH per Ontario Health Region during study period Max IRH dose (mg/day)* 88 (48-144) 48 (32-72) 96 (64-160) 0.84
>1 consecutive carry 306 (57.3) 86 (63.7) 220 (55.1) 0.18
while receiving IRH or within 7 days of
2020 using ICES administrative health data Middlesex-London Max consecutive carries 2 (1-7) 3 (1-8) 2 (1-4) 0.33 discontinuation
• Cohort defined by published guidance and expert City of Toronto
Co-prescriptions
Main limitation of our analysis:
Methadone 162 (30.3) 49 (36.3) 113 (28.3) 0.17
opinion Buprenorphine 75 (14.0) 10 (7.4) 65 (16.3) 0.28
City of Ottawa • While our cohort definition was intended to
SROM 175 (32.8) 7 (5.2) 168 (42.1) 0.96
• Inclusion criteria: City of Hamilton Benzodiazepine 122 (22.8) 55 (40.7) 67 (16.8) 0.55 capture safer supply prescribing, some individuals
• Daily dispensed ≥ 4x8 mg or ≥ 8x4mg tablets of Waterloo Discontinuation reason may be receiving IRH for another indication
End of study period 232 (43.4) 36 (26.7) 196 (49.1) 0.48
IRH for at least 2 out of the 3 first days of Peel Regional Health Unit Discontinuation 280 (52.4) 92 (68.1) 188 (47.1) 0.44 Future Directions:
prescribed IRH Hospitalized ≥ 14 days 17 (3.2) ≤5 (≤0.3.7) ≤5 (≤1.3) -
Sudbury and District Death ≤5 (≤0.9) ≤5 (≤0.3.7) ≤5 (≤1.3) - • Further research is needed on the safety and
• Diagnostic code for opioid use disorder (past 2 Other (22 Health Units) Death within 7 days of efficacy of safer supply prescribing
years), previous opioid agonist therapy (OAT) discontinuation ≤5 (≤0.9) ≤5 (≤0.3.7) ≤5 (≤1.3) -
0 50 100 150 200 250 Max=maximum, SROM=Slow release oral morphine. median (interquartile range)
*
(past 4 years), or opioid overdose (past 2 years)
• Exclusion criteria: Figure 3. Time to IRH discontinuation Acknowledgements & Funding
• IRH other than 4 or 8 mg tablets in the first 3 days Prescriber characteristics:
• 132 practitioners prescribed at least one course of This study and its data are drawn from the traditional territory and
• Diagnosis or treatment for cancer (past 1 year) daily dispensed IRH during the study period home of many diverse Indigenous people from across Turtle
45.4% of
Analysis • Infrequent prescribers (n=106) prescribed 25.2% patients
Island. We thank Andrea Serada, Nanky Rai, Jess Hales, and
Emmet O’Reilly for their consultation. This project was supported
• Summarized baseline and clinical characteristics of all courses and frequent prescribers (n=26) remained
by grant funding from the CIHR (grant #153070).
on IRH at
using descriptive statistics prescribed 74.7% of all courses 1 year
• Stratified by infrequent (1-2 courses) and frequent • 81.8% family physicians, 4.5% emergency medicine
(3+ courses) prescribers, compared using physicians and 13.6% other specialties
standardized differences (SD). SD>0.1 is • 72.6% of infrequent prescribers and 96.2% of
considered to show imbalance between groups frequent prescribers also prescribed OAT during the
• Used Kaplan Meier curves for time to discontinuation study period (SD 0.68)