Types of Opioid Harms in Canadian Hospitals: Comparing Canada and Australia Production of this document is made possible by financial contributions from Health Canada and provincial and territorial governments. The views expressed herein do not necessarily represent the views of Health Canada or any provincial or territorial government. Unless otherwise indicated, this product uses data provided by Canada’s provinces and territories. All rights reserved. The contents of this publication may be reproduced unaltered, in whole or in part and by any means, solely for non-commercial purposes, provided that the Canadian Institute for Health Information is properly and fully acknowledged as the copyright owner. Any reproduction or use of this publication or its contents for any commercial purpose requires the prior written authorization of the Canadian Institute for Health Information. Reproduction or use that suggests endorsement by, or affiliation with, the Canadian Institute for Health Information is prohibited. For permission or information, please contact CIHI: Canadian Institute for Health Information 495 Richmond Road, Suite 600 Ottawa, Ontario K2A 4H6 Phone: 613-241-7860 Fax: 613-241-8120 www.cihi.ca [email protected] ISBN 978-1-77109-743-7 (PDF) © 2018 Canadian Institute for Health Information How to cite this document: Canadian Institute for Health Information. Types of Opioid Harms in Canadian Hospitals: Comparing Canada and Australia. Ottawa, ON: CIHI; 2018. Cette publication est aussi disponible en français sous le titre Types de préjudices liés aux opioïdes dans les hôpitaux canadiens : comparaisons entre le Canada et l’Australie. ISBN 978-1-77109-744-4 (PDF) Table of contents Acknowledgements .........................................................4 Executive summary .........................................................4 About this report ...........................................................6 Why are we comparing Canada and Australia? .................................6 Opioid harm in Canada .....................................................10 Use of opioids .........................................................11 Types of opioid harm ....................................................13 Patient characteristics ......................................................20 ED visits and hospital stays ...............................................20 Age and gender ........................................................22 Location. .25 Income. 26 System perspectives .......................................................29 ED visits for opioid harms .................................................29 Hospital stays for opioid harms ............................................39 Opioid harms in Canada and Australia ......................................46 Conclusion ...............................................................50 Appendix A: Technical notes .................................................52 Appendix B: Canadian and Australian data ......................................53 Appendix C: Coding for opioid harm groups .....................................54 Appendix D: Coding for specialized care ........................................57 Appendix E: Coding for other and unspecified opioids ..............................58 Appendix F: Summary statistics for opioid harm groups ............................60 Appendix G: Text alternatives for figures ........................................62 References ..............................................................75 Types of Opioid Harms in Canadian Hospitals: Comparing Canada and Australia Acknowledgements The Canadian Institute for Health Information (CIHI) wishes to acknowledge and thank the following individuals and organizations for their contribution to this report: • The Australian Institute of Health and Welfare (AIHW) collaborated closely on this report. We would like to acknowledge AIHW’s partnership and valuable contributions. • We would also like to thank Dr. Michael Otterstatter at the BC Centre for Disease Control (BCCDC) for graciously sharing BCCDC’s findings and allowing the use of this data in our report. This report represents a collaborative effort across much of CIHI. We would like to thank the many individuals and teams who contributed their expertise and time in various capacities. Please note that the analyses and conclusions in the present document do not necessarily reflect those of the individuals or organizations mentioned above. Executive summary Canada is in the midst of an opioid crisis. Opioid use can lead to addiction, as well as other to harms such as accidental overdose or poisoning, suicide, motor vehicle accidents, infections from injection use, and many other social and emotional problems.1 The opioid-related death rate in Canada in 2017 was estimated at 10.9 per 100,000 population.2 Representatives from the Canadian Institute for Health Information (CIHI) and the Australian Institute of Health and Welfare (AIHW) worked together to produce comparable estimates of opioid use and harms in each country. The goals of the collaboration were to explore the usefulness of international comparisons, to understand the comparability of different data holdings and to learn about the differences and similarities between the 2 countries. In addition, this work will expand our understanding of Canada’s opioid crisis and the impact of opioid harms beyond poisonings on hospital care.3 4 Types of Opioid Harms in Canadian Hospitals: Comparing Canada and Australia Hospital stays and emergency department (ED) visits for those suffering from 5 types of opioid harm are profiled in this report: • Accidental poisoning (including poisoning of unknown intent); • Intentional poisoning; • Opioid dependence; • Adverse drug reaction; and • Other harm. Key findings in this report include the following: • Canada and Australia are seeing different opioid challenges (fentanyl versus heroin) and have different processes in their hospitals, which makes direct comparisons difficult. • While poisoning is the most severe opioid harm, it is the tip of the iceberg, representing about a third of all opioid harms seen in hospitals and EDs. • There are 5 distinct opioid harm profiles, indicating that different strategies may be required to tackle the challenges of opioids. These profiles present differently across care settings, including the community, the ED and the hospital. A cross-setting perspective is required. – Fentanyl is the leading cause of opioid-related deaths outside of hospitals in Canada, but most patients who come to hospitals with opioid harms are seen for more commonly prescribed opioids such as codeine, morphine and oxycodone. – Individuals who use opioids typically use the health care system more frequently than the general population, and they are also more likely to leave care against medical advice. – Poisoning is more common among younger people, but a larger proportion of resources is spent on older people whose care has been complicated by opioid use. 5 Types of Opioid Harms in Canadian Hospitals: Comparing Canada and Australia About this report Representatives from CIHI and AIHW worked together to produce comparable estimates of opioid use and harms in each country.4 This topic was selected because opioids are a class of drug causing concern in both Canada and Australia and impacting most of the developed world. The goals of the collaboration were to explore the value of international comparisons for opioids, to understand the comparability of different data holdings and to learn about the differences and similarities between the 2 countries. Why are we comparing Canada and Australia? It is natural to compare Canada and Australia because they have similar demographic profiles, similar health care systems (mostly public), single-source data stewards for hospital and ED data (CIHI and AIHW, respectively) and a common data coding system (ICD-10 i). Table 1 Canadian and Australian demographic measures Demographics Canada Australia Sex (percentage female) 50% 50% Life expectancy at birth 81.9 82.3 Median age 42.2 38.7 Population age 25 to 54 (workforce) 40% 41% Population living in urban areas 82% 90% Health expenditure (percentage of GDP) 10% 10% Privately funded health care 33% 30% Note GDP: Gross domestic product. Sources Canada Statistics Canada. Report on the demographic situation in Canada. Accessed July 24, 2018. Canadian Institute for Health Information. National health expenditure trends. Accessed July 24, 2018. Australia Australian Bureau of Statistics. 3101.0 — Australian demographic statistics, Dec 2017. Accessed July 24, 2018. Australian Institute of Health and Welfare. Australia’s Health 2018. 2018. IndexMundi. Australia demographics profile 2018. Accessed July 24, 2018. i. International Statistical Classification of Diseases and Related Health Problems, 10th Revision. 6 Types of Opioid Harms in Canadian Hospitals: Comparing Canada and Australia Availability and use of opioids in Canada and Australia Although Canada and Australia have opioid use problems stemming from both licit (prescribed medications) and illicit use, the specific types of opioids involved are not always the same. Understanding these differences is an important step in understanding differences in opioid harms and where care is sought. In recent years, Canada and Australia have targeted campaigns at physicians to encourage responsible opioid prescribing. Overall, there was a downward trend in prescribed opioid use in both countries in the