CAN-AIM responded to 4 queries raised by the Public Health Agency of Canada’s Centre for Immunization and Respiratory Infectious Diseases and Health Canada’s Pharmaceutical Drugs Directorate and Marketed Pharmaceutical Bureau concerning opioid use. High levels of prescription opioid use in Canada are cause for concern. These queries considered the injection risk among people who inject drugs and considered the appropriateness of prescribing opioids.

Hydromorphone controlled release and the risk of infectious endocarditis, hepatitis C virus and human immunodeficiency virus infections in people who inject drugs

Injection of oral hydromorphone may lead to infections with infective endocarditis (IE),hepatitis-C virus (HCV) and human immunodeficiency virus (HIV). There are concerns of increased harm, specifically with hydromorphone controlled-release capsules (HCR). We examined the frequency of these infections in PWID. We also provide rates of HCV and HIV infection in PWID, comparing those exposed to hydromorphone controlled-release capsules(HCR) versus immediate-release (oral) hydromorphone, injectable hydromorphone, or other controlled-release products. Lastly, we describe the characteristics of HCR users who experienced HCV and HIV infection.Gathering results from several cohorts across Canada gives a better picture of the problem in the country and brings valuable insights about HCV, HIV and IE infection among PWID. We used data from prospective Canadian cohorts of people who inject drugs (PWID) in Montreal, Quebec(QC), Toronto, Ontario (ON), and Vancouver, British Columbia (BC). HCV and HIV rates varied, but all cohorts showed higher HCV infection than HIV or IE. Most PWID were around30-40 years old, white and cisgender men. There were variable rates of hydromorphone injection for QC (11.7%), BC (13.1%) and ON (35.9%). We found high incidences of HCV infection among PWID, the highest among hydromorphone users, including HCR. Comparing rates of HIV and IE infection between different opioid formulations was not feasible due to the small sample size. Our results also demonstrated that there may also be more to explore regarding neighbourhoods and how pervasive structures of socioeconomic inequity contribute to drug use, at-risk behaviours and infection risks.

Cough and cold products containing opioids: prescribing and patient utilization patterns in the pediatric population

Many cough and cold prescription products (CCOMs) contain codeine, hydrocodone or normethadone. Although these products, like opioids, may be misused and abused, no current data are available to quantify the prevalence and incidence of abuse, misuse, addiction, overdose,and dependence in children. Following a signal assessment regarding the risks in children using CCOMs, Health Canada advised that children and adolescents (under 18 years old) should not use CCOMs as a precautionary measure. Studies aiming to address the potential role of CCOMs in opioid-related risks among the pediatric population can help provide Canadian prescribers and patients with meaningful information for decision-making. They can also validate the recommendation provided in the signal assessment and help to understand the individual contribution of CCOMs to the National opioid crisis.We compared the prescribed utilization patterns of CCOMs via the Canadian Mother-Child Cohort (CAMCCO) Active Surveillance Initiative. We included prospective data on medical services, prescription drugs, and hospitalization among the pediatric population in 5 Canadianprovinces (Quebec, QC; Alberta, AB; Saskatchewan, SK; Manitoba, MB; Ontario, ON). Medication prescription drug lists vary; for example, QC only included codeine and hydrocodone, partly explaining lower exposure rates. A decrease in exposed subjects under 12years old was observed in all provinces, while an increase in exposed subjects over 12 years old was observed in QC and AB. Commonly prescribed CCOMs include codeine (AB, MB, SK,QC), dextromethorphan (MB), and hydrocodone (ON, QC). The cumulative dosage of codeine and hydrocodone in morphine milligram equivalent (MME) was higher in MB vs AB, ON and QC in each age category. General practitioners were frequent prescribers in all provinces,followed by pediatricians (AB and MB) and surgeons (ON and SK). Respiratory illness was the most prevalent indication for CCOM prescriptions and injury and poisoning (SK, ON) diseases of the central nervous system and sense organs (AB, MB, QC). Our findings suggest a decrease in the number of exposed subjects in the pediatric population.Identifying prescription patterns allows for targeted approaches to provide prescribers with meaningful evidence to support decision-making with CCOMs.

Options for appropriate prescribing

We aimed to identify interventions that target opioid prescribing, assess their effectiveness and evaluate their methodological aspects through a systematic review of studies published between January 1, 2005, and September 23, 2016. We also examined websites of relevant organizations and scanned bibliographies of included articles and reviews for additional references.A total of 95 distinct interventions were identified; over half consisted of prescription monitoring programs (PMPs) and mainly targeted healthcare professionals. Evaluation studies addressed mainly opioid prescription rates (30.6%), but fewer studies considered overdose death (9.7%) or abuse (9.7%). Although PMPs and policies are associated with a reduction in opioid prescriptions, their impact on appropriateness and restriction of access to patients in need is inconsistent. Continuing medical education and pain management programs effectively improved chronic pain management, but studies were conducted in specific settings. The impact of interventions on abuse and overdose death is conflicting. Our study suggests that existing interventions have not addressed all determinants of inappropriate opioid prescribing and usage. 

Moride et al. A systematic review of interventions and programs targeting appropriate prescribing of opioids. 2017 (ICPE abstract) Moride Y, Lemieux-Uresandi D, Castillon G, Soares de Moura C, Pilote L, Faure M, Bernatsky S. A systematic review of interventions and programs targeting appropriate prescribing of opioids. Pain Physician. 2019 May;22(3):229-240.

Predictors of chronic opioid use in non-cancer community-dwelling patients

High consumption rates of prescription opioids in Canada raised the need to understand factors associated with chronic use to counteract opioid-related harms (addiction, misuse, abuse,accidental overdose, death). This study followed a population-based cohort who started a prescription opioid in the outpatient setting. Similarly to other countries, 3.4% of the cohort became chronic users, typically in situations where the initial supply was greater or equal to 30days and with a chronic pain diagnosis.Personalized strategies to monitor patients at risk of becoming chronic opioid users may be helpful but should not compromise optimal pain care.Beliveau A, Castilloux AM, Tanenbaum C, Vincent P, Moura CS, Bernatsky S, Pujade I, MorideY. Incidence of chronic opioid use in seniors [abstract]. PDS. 2019;28(S2). Béliveau A, Castilloux AM, Tannenbaum C, Vincent P, de Moura CS, Bernatsky S, Moride Y.Predictors of long-term use of prescription opioids in the community-dwelling population of adults without a cancer diagnosis: a retrospective cohort study. CMAJ Open. 2021 Feb 9;9(1):E96-E106. doi: 10.9778/cmajo.20200076. PMID: 33563639.