Only 4 per cent of opioid overdose patients were prescribed drugs to manage addiction in week after hospital visit: Ontario study

Prescription pills containing oxycodone and acetaminophen are shown in Toronto, Dec. 23, 2017. THE CANADIAN PRESS/Graeme Roy

A new study has found that only one in 18 people who ended up in hospital in Ontario after an opioid overdose were prescribed drugs known to help manage opioid use disorders in the following week —despite this mitigation strategy being recommended in Canada for years.

Long-acting opioids like methadone or Suboxone, when taken under medical supervision, can soothe withdrawal symptoms and help patients curb the urge to seek out more dangerous opioids they may have developed a dependence on, such as heroin, oxycodone or fentanyl.

Called opioid agonist therapy (OAT), it's been around for decades and has been widely recommended for clinical practice in Canada since 2018.

However, a new study published December in the Canadian Medical Association Journal (CMAJ) suggests that, at least in Ontario, only a fraction of patients are gaining access to this treatment.

"We now know that only about four per cent of hospital encounters for opioid overdose led to OAT initiation. These low rates show that we need to improve care and access to treatment," Tina Hu, an assistant professor at the University of Toronto Temerty Faculty of Medicine's department of family and community medicine and lead author of the study, said in a press release.

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Researchers looked at ICES data on more than 47,000 emergency room visits and hospital admissions for opioid toxicity that took place between January 2013 and March 2020. ICES compiles Ontario health data for use in research.

More than 20,000 events involving around 14,000 patients fit the criteria for the study. Researchers then looked to see if OAT initiation occurred in the week after these hospital visits.

Only 851 visits resulted in OAT initiation within seven days of discharge from a hospital. The rate of OAT initiation did not vary between patients who discharged themselves from hospital or were discharged by medical professionals.

Researchers noted that in around 22 per cent of cases, patients had an outpatient visit within seven days of their hospital visit, suggesting there were often multiple opportunities for the initiation of treatment that were rarely capitalized upon.

It's striking considering the rise in opioid overdoses in Canada in recent years.

Hu told CTV News Toronto in December that there has been an "almost 300 per cent increase over the last few years in just emergency department visits for opioid overdoses and hospitalizations have gone up too."

According to CAMH, opioid agonist therapy is "the most effective treatment option for opioid use disorder," and it is best utilized when combined with social supports and treatment programs.

"This is a treatment that saves lives," Hu said, adding that research on OAT shows it has "a very significant impact on reducing morbidity, mortality."

In general, how OAT works is that a patient visits a pharmacy daily at first to receive treatment under supervision. Once their condition is considered stable, they can take home a few doses at a time.

This can range from a week to two or three months of daily pharmacy visits before stabilization is reached, depending on which drug a patient has been prescribed.

Buprenorphine-naloxone, which is also known as Suboxone, requires only seven to 10 days of daily pharmacy visits before a patient can safely receive take-home doses, whereas methadone requires a longer period of supervised doses.

This is one of the reasons why Suboxone is recommended as a first-line treatment, according to 2018 guidelines – because it causes less disruption to a patient's life and employment. Methadone is recommended in situations where Suboxone is not preferred.

The study highlighted that there was a strong income disparity among those who ended up in hospital for opioid toxicity, with 40 per cent of all patients belonging to the poorest income group.

However, those who initiated OAT were more likely to live in a neighbourhood of the highest income group. It's unclear whether this is because these patients were more likely to have a family doctor, because pharmacy visits were less of a barrier for those who may have been able to take time off work or some other factor, but the disparity suggests more research needs to be done into these gaps.

"Our research shows that there were substantial disparities in OAT initiation rates, with potential barriers to prescribing for older patients, those with mental health diagnoses and those in the lowest neighbourhood income quintile," the study stated.

NOT ENOUGH DOCTORS COMFORTABLE PRESCRIBING, EDUCATION NEEDED

One potential reason behind the low initiation rate, researchers suggested, is that not enough health-care professionals are aware of this therapy or feel knowledgeable enough to prescribe it.

The study identified 379 health-care professionals who prescribed OAT during the seven-year study period, most of whom had been practising medicine for more than a decade and were general practitioners, or family doctors.

The researchers cited a U.S. study which found that many emergency room doctors weren't comfortable prescribing buprenorphine-naloxone due to a lack of formal training.

Hu said health-care systems in Canada need to be "able to provide that education and training for physicians and … health staff and to be able to have these networks where we can prescribe and refer and make sure that the patient has a support network when they do leave a hospital."

The health-care system has experienced a staffing crisis in recent years as more professionals, overburdened in a system still reeling from the pandemic, have considered leaving the field or scaling back.

Family doctors in particular are in high demand. The Ontario College of Family Physicians revealed in an October survey that one in four Ontarians could be without a family doctor in just three years.

CHANGES TO RECOMMENDATIONS NOT ENOUGH

This research suggests that calls from experts have been ineffective in getting this mitigation strategy actually implemented in Ontario hospitals.

While the initiation of OAT has gone up steadily over time, and was at 5.6 per cent in the first quarter of 2020, this increase has remained slight and doesn't appear connected to shifts in recommendation, the study found.

In 2018, the Canadian Research Initiative in Substance Misuse recommended that buprenorphine-naloxone be used as the preferred first-line treatment — but in this new study, researchers didn't see a significant increase in OAT initiation after 2018.

The recommendation, which was published in CMAJ in 2018 as a national clinical practice guide, stated that buprenorphine-naloxone was "strongly" recommended, and that withdrawal management alone is not recommended due to elevated risks of death from overdose and high rates of relapse.

The fact that the 2018 recommendation didn't cause a higher initiation rate of OAT suggests that "additional efforts are needed to improve initiation of OAT in acute care settings," the authors wrote in this new study, acknowledging that the reasons behind the low rate are complex and need more examination in order to address the issue.

"It is possible that the low prevalence of OAT initiation in our study is influenced by both underprescribing and poor access and connection to community-based OAT for patients with OUD (opioid use disorder) who were considering initiating treatment."