Understanding a broader range of opioid-related hospitalizations in Canada

The Public Health Agency of Canada, in collaboration with the provincial and territorial (PT) offices of Chief Coroners and Chief Medical Examiners, PT public health and health partners, and Emergency Medical Services data providers releases quarterly reports on apparent opioid-related deaths and Emergency Medical Services responses for suspected opioid-related overdoses. The Public Health Agency of Canada also collaborates with Health Canada to report on hospitalizations for opioid-related poisonings (overdoses) using hospital administrative data from the Canadian Institute for Health Information (CIHI).

However, harms related to opioids extend beyond overdoses and, in some cases, death. Administrative data from CIHI on hospitalizations can also be used to examine other types of opioid-related harms, including adverse drug reactions from prescribed opioids, and mental and behavioural disorders related to the use of opioids.

This brief report summarizes national data (excluding Quebec) for these three categories of hospitalizations for opioid-related harms, between April 1, 2018 to March 31, 2019. Each type of opioid-related harm is presented by sex and age group. Additionally, total length of stay (LOS) in hospital and what happened after being hospitalized (discharge disposition) is described for each type of harm.

Definitions of opioid-related harms included in this report

Opioid-related poisonings: Opioid poisoning harms (overdose) resulting from incorrect use of opioids in an intentional, accidental or unknown manner. Opioid poisonings may involve non-pharmaceutical opioids, pharmaceutical opioids, or both pharmaceutical and non-pharmaceutical opioids.

Pharmaceutical opioids refer to opioids that were manufactured by a pharmaceutical company and approved for medical purposes in humans. Pharmaceutical opioids can be obtained by a prescription, but sometimes may also be obtained through other means.

Adverse drug reactions from prescribed opioids: occurs when an opioid is taken as prescribed and results in harm, for example, delirium, confusion, and respiratory depression.

Opioid use disorders: includes mental health and behavioural disorders that are related to the use of opioids.

Overall rates by sex

Across Canada (excluding Quebec), overall rates of hospitalization for opioid-related harms were highest for opioid use disorders, followed by adverse drug reactions from prescribed opioids, and opioid-related poisonings. Hospitalizations for opioid-related poisonings (overdoses) and opioid use disorders were higher among males than females, while hospitalizations for adverse drug reactions from prescribed opioids were higher among females.

Figure 1. Crude rates for opioid-related hospitalizations by sex, Canada excluding Quebec, April 2018 to March 2019
Text equivalent (Figure 1)
Opioid-related harm hospitalization Crude rate per 100,000 population for both sexes Crude rate per 100,000 population for males Crude rate per 100,000 population for females
Opioid-related poisonings 17.7 19.9 15.5
Adverse drug reactions from prescribed opioids 21.6 17.9 25.2
Opioid use disorders Footnote * 35.1 38.9 31.5
Footnote fig1

Hospitalizations for opioid use disorders are under-represented as the data source used (Discharge Abstract Database) does not include full coverage for hospitalizations due to mental illness and substance use disorders. Additional opioid use disorder hospitalizations may be captured in the Ontario Mental Health Reporting System (OMHRS) and therefore these results should be interpreted with caution.

Return to footnote * referrer

Footnote 2

'Other sex' are not reported as counts were less than 5.

Source: Discharge Abstract Database, Canadian Institute for Health Information

Rates by age and sex

Age and sex specific crude rates also varied by type of opioid-related harm. Similar to the pattern observed for apparent opioid-related deaths, younger adults had the highest rates of hospitalization for opioid-related poisonings. Younger males (ages 20 to 29 years, and 30 to 39 years) had the highest rates of hospitalizations for this category of harms. In contrast, rates for hospitalization for adverse drug reactions from prescribed opioids were concentrated among both males and females who were 60 years of age and older, with rates of 61 per 100,000 population and 75 per 100,000 population, respectively. In comparison, rates for all other age groups for adverse drug reactions from prescribed opioids by sex were 20 per 100,000 population or less. The distribution of rates for hospitalizations for opioid-use disorder were more similar to those for opioid-related poisonings; however, there was a more even pattern across the sexes - males and females had similar rates in each age group.

Figure 2. Crude rates for opioid-related poisoning hospitalizations by age group and sex, Canada excluding Quebec, April 2018 to March 2019
Text equivalent (Figure 2)
Age group Crude rate per 100,000 population for males Crude rate per 100,000 population for females
0 to 9 years 2.2 1.7
10 to 19 years 6.1 10.5
20 to 29 years 27.9 17.4
30 to 39 years 34.0 15.9
40 to 49 years 23.8 18.3
50 to 59 years 22.6 20.8
60 years and older 18.0 17.7
All ages 19.9 15.5

'Other sex' are not reported as counts were less than 5.

Source: Discharge Abstract Database, Canadian Institute for Health Information

Figure 3. Crude rates for hospitalizations for adverse drug reactions to prescribed opioids by age group and sex, Canada excluding Quebec, April 2018 to March 2019
Text equivalent (Figure 3)
Age group Crude rate per 100,000 population for males Crude rate per 100,000 population for females
0 to 9 years 3.5 3.2
10 to19 years 2.5 3.8
20 to 29 years 2.7 4.8
30 to 39 years 3.2 8.2
40 to 49 years 6.7 11.7
50 to 59 years 16.0 20.4
60 years and more 60.7 74.6
All ages 17.9 25.2

'Other sex' are not reported as counts were less than 5.

Source: Discharge Abstract Database, Canadian Institute for Health Information

Figure 4. Crude rates for opioid use disorder hospitalizationsFootnote * by age group and sex, Canada excluding Quebec, April 2018 to March 2019
Text equivalent (Figure 4)
Age group Crude rate per 100,000 population for males Crude rate per 100,000 population for females
0 to 9 years 0.6 2.1
10 to19 years 5.7 8.4
20 to 29 years 54.8 57.2
30 to 39 years 71.2 61.3
40 to 49 years 58.6 41.5
50 to 59 years 47.0 27.8
60 years and more 28.1 20.4
All ages 38.9 31.5
Footnote 4-1

Hospitalizations for opioid use disorders are under-represented as the data source used (Discharge Abstract Database) does not include full coverage for hospitalizations due to mental illness and substance use disorders. Additional opioid use disorder hospitalizations may be captured in the Ontario Mental Health Reporting System (OMHRS) and therefore these results should be interpreted with caution.

Return to footnote * referrer

Footnote 4-2

'Other sex' are not reported as counts were less than 5.

Source: Discharge Abstract Database, Canadian Institute for Health Information

Length of stay

Length of stay in hospital varied by type of opioid-related harm. Median length of stay was longest for adverse drug reactions from prescribed opioids, at eight days, and shortest for opioid-related poisonings, at three days. Length of stay was similar for males and females across each of the harms included.

Figure 5. Median total length of stay (LOS) in days by opioid-related harm and sex, Canada excluding Quebec, April 2018 to March 2019
Text equivalent (Figure 5)
Opioid-related harm hospitalization Median total length of stay in days for males Median total length of stay in days for females
Opioid-related poisonings 3 3
Adverse drug reactions from prescribed opioids 8 8
Opioid use disorders Footnote * 5 6
Footnote fig5-1

Hospitalizations for opioid use disorders are under-represented as the data source used (Discharge Abstract Database) does not include full coverage for hospitalizations due to mental illness and substance use disorders. Additional opioid use disorder hospitalizations may be captured in the Ontario Mental Health Reporting System (OMHRS) and therefore these results should be interpreted with caution.

Return to footnote * referrer

Footnote fig5-2

'Other sex' are not reported as counts were less than 5.

Source: Discharge Abstract Database, Canadian Institute for Health Information

Discharge disposition

Similarly, the distribution of discharge disposition varied by type of harm. For all types of opioid-related hospitalizations, most patients were discharged home, ranging from 60% to 65% for males, and 64% to 67% for females. Similar proportions of hospitalizations for opioid-related poisonings and patients hospitalized for adverse drug reactions from prescribed opioids indicated that the patient died (8% and 9% for males, and 5% each for females). The proportion of hospitalizations that indicated the patient died was almost twice as high for males compared to females, across all types of opioid-related harms. This is consistent with the disproportionate burden of apparent opioid-related deaths among males as compared to females. The proportion of patients leaving against medical advice demonstrated considerable variability: while 13% of males and 9% of females hospitalized for an opioid-related poisoning left against medical advice, as did 16% of males and 17% of females hospitalized for an opioid use disorder, only 2% of males and 1% of females hospitalized for an adverse drug reaction from prescribed opioids did so. Patients who leave against medical advice may not have received all of the medical care or supports available.

Figure 6. Discharge disposition by opioid-related harm and sex, Canada excluding Quebec, April 2018 to March 2019
Text equivalent (Figure 6)
Discharge disposition from hospital Percent of opioid-related poisonings for males Percent of opioid-related poisonings for females Percent of adverse reactions to prescribed opioid for males Percent of adverse reactions to prescribed opioid for females Percent of opioid use disorders for malesFootnote * Percent of opioid use disorders for femalesFootnote *
Transfer 19% 19% 24% 27% 20% 18%
Home 60% 67% 65% 66% 63% 64%
Leave 13% 9% 2% 1% 16% 17%
Died 8% 5% 9% 5% 2% 1%
Footnote fig6

Hospitalizations for opioid use disorders are under-represented as the data source used (Discharge Abstract Database) does not include full coverage for hospitalizations due to mental illness and substance use disorders. Additional opioid use disorder hospitalizations may be captured in the Ontario Mental Health Reporting System (OMHRS) and therefore these results should be interpreted with caution.

Return to footnote * referrer

Footnote 2

'Other sex' are not reported as counts were less than 5.

Source: Discharge Abstract Database, Canadian Institute for Health Information

In summary

Understanding patterns of a range of opioid-related harms can help inform clinical and public health actions to address the opioid overdose crisis. These data demonstrate that not only are opioid-related poisonings (overdoses) a source of considerable morbidity for Canadians, there are a notable number of hospitalizations for adverse drug reactions to prescribed opioids, and for opioid use disorders. While younger adults are disproportionately represented among hospitalizations for opioid-related poisonings (overdoses) and opioid-use disorder, older adults are disproportionately affected by adverse drug reactions related to prescribed opioids. In addition, while most people hospitalized for any opioid-related harm are discharged home, a notable proportion of those hospitalized for opioid-related poisoning or opioid use disorders leave before being formally discharged. This may indicate a need to better understand the acceptability of health care for these conditions. Continuing to understand patterns of opioid-related harms through hospitalization and other data sources will help Canada address the continuing opioid overdose crisis.

Acknowledgements

We would like to acknowledge the Canadian Institute for Health Information (CIHI) for collecting and providing the data used for reporting opioid-related hospitalizations.

Disclaimer

Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions and statements expressed herein are those of the authors, and not necessarily those of the Canadian Institute for Health Information (CIHI).

Technical Notes

Definitions (Refer to Appendix A for full definition)

Length of stay: Represents the total length of stay in hospital (including the amount of time the patient received acute care and alternative level of care, if applicable).

Discharge disposition: Identifies the location where the patient was discharged to or the status of the patient on discharge from hospital.

Methodology

Data from CIHI's Discharge Abstract Database (DAD) for the fiscal year April 1, 2018 to March 31, 2019 was analysed for this report. This analysis was limited to acute inpatient hospitalizations, which are nationally representative across Canada, with the exception of Quebec. This analysis presents the number of acute inpatient hospitalizations for opioid-related harms, it does not reflect the number of patients who were hospitalized in the study year. It is possible some patients may have been hospitalized more than once for an opioid-related harm. Only crude rates are presented.

The International Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA) is used in the DAD to capture diagnoses from the patient's hospitalization. It is the national standard for reporting morbidity statistics. Refer to Appendix A for a complete listing of all ICD-10-CA diagnosis codes used to identify opioid-related harms presented in this report. More information on the DAD and ICD-10-CA coding can be found on CIHI's website.

For opioid-related poisoning and opioid use disorders, analyses were restricted to significant diagnosis types; hospitalizations in which the opioid-related harm was considered influential to the time spent in hospital and treatment received by the patient while there. For hospitalizations associated with an opioid-related poisoning and/or an opioid use disorder, the following types of diagnoses were retained for analysis:

Adverse drug reactions from prescribed opioids are considered external cause of injury codes. In line with CIHI coding standards, a diagnosis type of "9" was used for identifying these records.

A diagnosis prefix of "Q", indicating unconfirmed diagnoses or query diagnoses recorded by the physician, were excluded from these analyses. Records indicating the patient was admitted to the facility as a cadaveric donor and still births were also excluded.

The field for discharge disposition was recoded as follows:
Original Discharge Disposition field values Recoded Discharge Disposition field values
Inpatient Care ('10')
ED and Ambulatory Care ('20')
Residential Care ('30')
Group/Supportive Living ('40')
Correctional Facility ('90')
Transfer
Home with Support/Referral ('04')
Private Home ('05')
Home
Absent Without Leave (AWOL) ('61')
Left Against Medical Advice (LAMA) ('62')
Did not Return from Pass/Leave ('65')
Leave
Died While on Pass/Leave ('66')
Suicide out of Facility ('67')
Died in Facility ('72')
Medical Assistance in Dying (MAID) ('73')
Suicide in Facility ('74')
Died

Crude rates for hospitalization for each opioid-related harm were calculated using census data for July 1, 2018 from Statistics Canada.

Limitations

General notes

Data on sex

Data suppression

Counts less than 5 are suppressed according to CIHI's privacy guidelines.

Appendix A

List of ICD-10-CA diagnostic codes use to identify opioid-related hospitalizations
Type of Opioid-Related Harm ICD-10-CA Code Description
Opioid-related poisonings T40.0 Poisoning by opium
T40.1 Poisoning by heroin
T40.2 Poisoning by other opioids
T40.20 Poisoning by codeine and derivatives
T40.21 Poisoning by morphine
T40.22 Poisoning by hydromorphone
T40.23 Poisoning by oxycodone
T40.28 Poisoning by other opioids not elsewhere classified
T40.3 Poisoning by methadone
T40.4 Poisoning by other synthetic narcotics
T40.40 Poisoning by fentanyl and derivatives
T40.41 Poisoning by tramadol
T40.48 Poisoning by other synthetic narcotics not elsewhere classified
T40.6 Poisoning by other and unspecified narcotics
Adverse drug reactions from prescribed opioids Y45.0 Opioids and related analgesics
Y45.01 Codeine and derivatives
Y45.02 Morphine
Y45.03 Hydromorphone
Y45.04 Oxycodone
Y45.05 Fentanyl and derivatives
Y45.06 Tramadol
Y45.09 Other and unspecified opioids and related analgesics
Opioid use disorders F11.0 Mental and behavioural disorders due to use of opioids, acute intoxication
F11.1 Mental and behavioural disorders due to use of opioids, harmful use
F11.2 Mental and behavioural disorders due to use of opioids, dependence syndrome
F11.3 Mental and behavioural disorders due to use of opioids, withdrawal state
F11.4 Mental and behavioural disorders due to use of opioids, withdrawal state with delirium
F11.5 Mental and behavioural disorders due to use of opioids, psychotic disorder
F11.6 Mental and behavioural disorders due to use of opioids, amnesic syndrome
F11.7 Mental and behavioural disorders due to use of opioids, residual and late- onset psychotic disorder
F11.8 Mental and behavioural disorders due to use of opioids, other mental and behavioural disorders
F11.9 Mental and behavioural disorders due to use of opioids, unspecified mental and behavioural disorder
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