Report December 2018 Opioid-Related Harms in Canada Canadian Institute for Health Information Institut canadien d?information sur la sante 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 cihi.ca copyright@cihi.ca ISBN 978-1-77109-767-3 (PDF) © 2018 Canadian Institute for Health Information How to cite this document: Canadian Institute for Health Information. Opioid-Related Harms in Canada, December 2018. Ottawa, ON: CIHI; 2018. Cette publication est aussi disponible en français sous le titre Préjudices liés aux opioïdes au Canada, décembre 2018. ISBN 978-1-77109-768-0 (PDF) Table of contents About this report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Key findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Opioid-related harms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Hospitalizations Hospitalizations due to opioid poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Community rates of opioid poisoning hospitalizations . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Other opioid-related harms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 ED visits ED visits due to opioid poisonings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Ontario ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Alberta ED visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Yukon ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Appendix A: Opioid poisonings by CMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Appendix B: Definitions of opioid-related harms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Appendix C: Text alternative data tables for figures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Opioid-Related Harms in Canada, December 2018 About this report This report presents data on opioid-related hospitalizations and emergency department (ED) visits. For the first time, the Canadian Institute for Health Information (CIHI) is reporting information on 4 types of opioid harm: opioid poisonings, opioid use disorders, adverse drug reactions and neonatal withdrawal symptoms. Together, these categories provide a comprehensive picture of opioid-related harm in Canada. The hospitalization analysis includes 2013 to 2018 data from all provinces and territories (except Quebec, where the most recent data available at the time of release was from 2016). The ED analysis is based on available, comparable data. At the time of release, this included 2013 to 2018 data from Ontario, Alberta and Yukon. Supplementary data tables accompany this report and are available online. The data tables provide more detailed breakdowns and trending information for opioid-related hospitalizations and ED visits. CIHI will continue to update these analyses as more data becomes available. 4 Opioid-Related Harms in Canada, December 2018 Key findings • Rates of harm due to opioid poisoning continue to rise across Canada — hospitalizations increased by 27% over the past 5 years. • Between 2016 and 2017, –– The rate of hospitalizations due to opioid poisoning increased by 8% in Canada, resulting in an average of 17 hospitalizations each day. • Despite continued national growth in the rate of hospitalizations due to opioid poisoning, several jurisdictions reported slight decreases in 2017. –– In Ontario and Alberta, rates of ED visits due to opioid poisoning increased by 73% and 23%, respectively. –– The fastest-growing rates of hospitalizations and ED visits due to opioid poisoning were seen among males age 25 to 44. • Opioid poisonings affect small and suburban communities across Canada as well as large urban centres. –– Rates of hospitalizations due to opioid poisoning are highest in communities with a population between 50,000 and 99,999. 5 Opioid-Related Harms in Canada, December 2018 Key findings • Poisonings are the most serious and visible harms of opioid misuse. Other opioid-related harms that often require medical attention include opioid use disorders, adverse drug reactions and neonatal withdrawal symptoms. –– Hospitalizations and ED visits due to poisonings and opioid use disorders are increasing, while those due to adverse drug reactions are declining slightly. –– Hospitalizations due to neonatal withdrawal symptoms are also increasing. 6 Opioid-Related Harms in Canada, December 2018 Opioids are effective drugs that play an important role in pain management for many Canadians. But opioids, either prescribed or obtained from illicit sources, can cause a variety of harms. Opioid-related harms Hospitalizations due to opioid poisonings have been an important focus of public health programs; however, hospitalizations also occur due to opioid use disorders, adverse drug reactions and neonatal withdrawal symptoms. With the exception of adverse drug reactions, opioid-related harms can be caused by either prescription or illicit opioids. 7 Opioid-Related Harms in Canada, December 2018 Types of opioid-related harm Opioid poisoning occurs when an opioid is taken incorrectly and results in harm. Opioid use disorders include a wide variety of mental health and behavioural disorders that are attributable to the use of opioids. Adverse drug reaction occurs when an opioid is taken as prescribed and results in harm. Neonatal withdrawal symptoms occur when an infant experiences withdrawal symptoms from the mother’s use of drugs of addiction. These include neonatal abstinence syndrome and drug withdrawal syndrome. Notes With the exception of adverse drug reactions, opioid-related harms can be caused by either prescription or illicit opioids. Full definitions of these harms can be found in Appendix B. 8 Opioid-Related Harms in Canada, December 2018 Hospitalizations due to opioid poisoning Opioid-Related Harms in Canada, December 2018 What is an opioid poisoning? Incorrect use of opioids can include An opioid poisoning occurs when an opioid is taken incorrectly and results in harm. • Wrong dosage taken; • Self-prescribed opioids taken in combination with another prescribed drug or alcohol; and • Opioid not taken as recommended (whether the opioid was prescribed or illegally obtained). 10 Opioid-Related Harms in Canada, December 2018 Figure 1: Opioid poisoning hospitalizations, Canada, 2013 to 2017 Number of hospitalizations 14 4,000 12 10 3,000 8 2,000 6 4 1,000 2 2013 2014 2015 2016 2017 Calendar year Number of hospitalizations Crude rate per 100,000 population Note Quebec data is from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. 11 0 Crude rate per 100,000 population 16 5,000 0 From 2016 to 2017 18 6,000 Number of opioid poisoning hospitalizations per 100,000 population 8 % Opioid-Related Harms in Canada, December 2018 Figure 2: Opioid poisoning hospitalizations by province/territory and Canada, 2017 Age-adjusted hospitalizations per 100,000 population Canada Absolute difference in age-adjusted hospitalizations per 100,000 population, 2016 to 2017 16.4 N.L. 16.6 Y.T. 31.8 N.W.T. 6.0 Nun.† 33.7 P.E.I. 9.5 4.8 B.C. 29.3 5.1 Alta. Man. 22.7 0.2 12.3 Sask. 21.6 2.1 2.5 Que.* Ont. 9.8 N.S. 8.4 14.8 1.8 1.6 N.B. 13.1 4.1 Notes * Quebec data is from 2016 (the most recent year of data available). † CIHI did not receive Nunavut records for hospitalizations between September 1, 2016, and March 31, 2017. Absolute rate differences are not reported for Yukon, the Northwest Territories and Nunavut due to variability resulting from low volumes. Source Hospital Morbidity Database, Canadian Institute for Health Information. 12 The Northern and Western regions of Canada continue to have the highest rates of hospitalizations due to opioid poisoning. Rates have increased in Newfoundland and Labrador, Ontario, Manitoba and British Columbia, while they’ve decreased in the other provinces. Opioid-Related Harms in Canada, December 2018 In part, these decreases are a result of pan-Canadian, provincial, Despite continued national growth in the rate of hospitalizations due to opioid poisoning, several jurisdictions reported slight decreases in 2017. local and neighbourhood initiatives aimed at reducing the harms associated with opioids. Some of these initiatives include • New pan-Canadian prescribing guidelines (The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain);1 • An increased number of supervised consumption sites and overdose prevention sites; • Provincial prescription monitoring programs that assist prescribers and pharmacists; • Increased availability of naloxone without a prescription to people who use drugs, and to their families and friends; • The Good Samaritan Drug Overdose Act; and • Public awareness campaigns about the risks of illegally obtained opioids. 13 Opioid-Related Harms in Canada, December 2018 Figure 3: Opioid poisoning hospitalizations by quarter, Canada, Q1 2016 to Q1 2018 1,800 5.0 1,600 4.5 Number of hospitalizations 3.5 1,200 3.0 1,000 2.5 800 2.0 600 1.5 400 1.0 200 0 0.5 Jan.–Mar. 2016 Apr.–June July–Sept. 2016 2016 Oct.–Dec. 2016 Jan.–Mar. 2017 Apr.–June July–Sept. Oct.–Dec. 2017 2017 2017 Calendar year quarter Number of hospitalizations Crude rate per 100,000 population Note Quebec data is from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. 14 Jan.–Mar. 2018 0 Crude rate per 100,000 population 4.0 1,400 Canada saw a decreasing trend in hospitalizations due to opioid poisonings between Q3 2017 (July to September) and Q1 2018 (January to March). Opioid-Related Harms in Canada, December 2018 Figure 4: Reasons for opioid poisoning hospitalizations, Canada, 2017 Unknown, 12% Intentional, 30% Accidental, 58% Note Quebec data is from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. 15 In 2017, more than half of opioid poisoning hospitalizations were due to accidental causes, while almost one-third were due to intentional causes. Opioid-Related Harms in Canada, December 2018 Figure 5: Opioid poisoning hospitalizations by age, Canada, 2013 to 2017 25 Over the past 5 years, younger adults age 25 to 44 and youth age 15 to 24 had the fastest-growing rates of opioid poisonings, with increases of 62% and 53%, respectively. Crude rate per 100,000 population 20 15 10 5 0 2013 2014 2015 2016 2017 Calendar year <15 15–24 25–44 45–64 65+ Note Quebec data is from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. 16 Opioid-Related Harms in Canada, December 2018 Figure 6: Opioid poisoning hospitalizations by sex, Canada, 2013 to 2017 20 Over the past 5 years, the rate of opioid poisoning hospitalizations increased by 48% among males and 10% among females. Crude rate per 100,000 population 18 16 14 12 10 8 6 4 2 0 2013 2014 2015 2016 2017 Calendar year Female Male Note Quebec data is from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. 17 The decrease seen among females between 2016 and 2017 can primarily be attributed to the 65+ age group. Opioid-Related Harms in Canada, December 2018 Figure 7b: Opioid poisoning hospitalizations by age group, Canada, 2013 to 2017: Females 30 30 25 25 Crude rate per 100,000 population Crude rate per 100,000 population Figure 7a: Opioid poisoning hospitalizations by age group, Canada, 2013 to 2017: Males 20 15 10 5 20 15 10 5 0 0 15–24 <15 25–44 45–64 <15 65+ 15–24 25–44 2014 2015 65+ Age group Age group 2013 45–64 2016 2013 2017 Note Quebec data is from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. 18 2014 2015 2016 2017 Opioid-Related Harms in Canada, December 2018 Community rates of opioid poisoning hospitalizations The following is an expanded local-level analysis that aims to provide a more comprehensive and in-depth view of opioid-related harms across Canada. In this section we examine hospitalizations at the census metropolitan area (CMA) and census subdivision (CSD) levels. 19 Opioid-Related Harms in Canada, December 2018 Figure 8: Rates of hospitalizations due to opioid poisoning by community size, Canada, 2017 35 Rates of hospitalizations due to opioid poisoning are highest for patients who live in communities with a population between 50,000 and 99,999. Age-adjusted rate per 100,000 population 30 25 20 15 10 5 0 <10,000 10,000–49,999 50,000–99,999 100,000–499,999 Community size Note Quebec data and population data are from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. 20 500,000+ Communities with a population greater than 500,000 have the lowest rates of hospitalizations. Opioid-Related Harms in Canada, December 2018 Figure 9: Opioid poisoning hospitalization rates, census metropolitan areas, Canada, 2017 Age-adjusted rate per 100,000 population, 2017 4.6–10.0 10.1–20.0 20.1–30.0 30.1–40.0 40.1–53.0 St. John’s Edmonton Kelowna Vancouver Calgary Winnipeg Victoria Abbotsford– Mission Moncton Saskatoon Regina Thunder Bay Halifax Québec Ottawa–Gatineau (Quebec part) Montréal Ottawa–Gatineau (Ontario part) Greater Sudbury Toronto Brantford St. Catharines–Niagara Hamilton London Saint John Notes Quebec data is from 2016 (the most recent year of data available). To be considered a CMA, the area must have a total population of at least 100,000, of which 50,000 or more live in the urban core. Source Hospital Morbidity Database, Canadian Institute for Health Information. 21 Opioid-Related Harms in Canada, December 2018 Table 1 Highest rates of opioid poisoning hospitalizations by census metropolitan area, Canada, 2017 Number of hospitalizations Age-adjusted rate per 100,000 population Absolute rate difference, 2016 to 2017 CMA Province Kelowna B.C. 101 52.8 22.7 Brantford Ont. 59 41.2 16.9 Thunder Bay Ont. 42 34.7 10.1 St. Catharines–Niagara Ont. 116 27.1 8.5 Abbotsford–Mission B.C. 51 26.7 -3.6 London Ont. 119 22.5 -1.4 Regina Sask. 54 21.4 1.3 St. John’s N.L. 48 21.0 11.9 Vancouver B.C. 536 20.4 5.1 Hamilton Ont. 159 20.2 2.1 Saskatoon Sask. 62 19.7 -0.8 Greater Sudbury Ont. 31 19.1 3.8 Victoria B.C. 73 18.7 -1.5 Edmonton Alta. 253 18.5 -3.0 Calgary Alta. 251 17.8 2.1 Notes To be considered a CMA, the area must have a total population of at least 100,000, of which 50,000 or more live in the urban core. This table shows the 15 CMAs with the highest rates of opioid poisoning hospitalizations. Please see Appendix A for the rates for all CMAs. Source Hospital Morbidity Database, Canadian Institute for Health Information. 22 Opioid-Related Harms in Canada, December 2018 Table 2 Highest rates of opioid poisoning hospitalizations by census subdivision, Canada, 2017 Number of hospitalizations Age-adjusted rate per 100,000 population Absolute rate difference, 2016 to 2017 Census subdivision Province  Nanaimo B.C. 49 57.7 10.9 Prince George B.C. 43 57.7 25.1 City of Kelowna B.C. 69 54.7 18.5 City of Brantford Ont. 52 52.8 23.8 Kamloops B.C. 47 51.6 14.2 Belleville Ont. 23 48.4 10.7 Medicine Hat Alta. 26 43.8 -0.8 Sault Ste. Marie Ont. 30 43.3 6.0 City of Victoria B.C. 36 40.4 14.4 St. Catharines Ont. 54 38.4 15.3 Port Coquitlam B.C. 23 37.4 10.4 City of Thunder Bay Ont. 40 37.1 11.0 Surrey B.C. 178 35.1 16.1 Grande Prairie Alta. 19 32.0 3.1 Red Deer Alta. 33 30.9 2.4 Notes CSD is the general term for municipalities as determined by provincial/territorial legislation. This table shows the 15 CSDs with a population of 50,000 or more with the highest rates of opioid poisoning hospitalizations. Please see the associated data tables for a more comprehensive list of CSDs. Source Hospital Morbidity Database, Canadian Institute for Health Information. 23 Opioid-Related Harms in Canada, December 2018 Other opioid-related harms The following presents hospitalization rates due to opioid use disorders, adverse drug reactions and neonatal withdrawal symptoms. 24 Opioid-Related Harms in Canada, December 2018 Figure 10: Opioid-related hospitalizations, Canada, 2013 to 2017 35 Opioid poisonings have been an important focus of public health programs due to their associated acute harms; however, it is valuable to note that opioid use and misuse can result in other types of harm. Age-adjusted rate per 100,000 population 30 25 20 15 10 5 0 2013 2014 2015 2016 2017 Calendar year Opioid poisoning Opioid use disorders Adverse drug reaction Notes Quebec data is from 2016 (the most recent year of data available). For full definitions of opioid-related harms, refer to Appendix B. Sources Hospital Morbidity Database and Ontario Mental Health Reporting System, Canadian Institute for Health Information. 25 A variety of strategies are necessary to address the different types of harm. Opioid-Related Harms in Canada, December 2018 Figure 11: Hospitalizations for neonatal withdrawal symptoms, Canada, 2013 to 2017 2,500 6 Number of hospitalizations 4 1,500 3 1,000 2 500 0 1 2013 2014 2015 2016 2017 Calendar year Number of hospitalizations Crude rate per 1,000 in-hospital live births Notes Quebec data is from 2016 (the most recent year of data available). For full definitions of opioid-related harms, refer to Appendix B. Source Hospital Morbidity Database, Canadian Institute for Health Information. 26 0 Crude rate per 1,000 in-hospital live births 5 2,000 Across Canada, the rate of hospitalizations for neonatal withdrawal symptoms increased by 21% between 2013 and 2017. Neonatal abstinence syndrome occurs in 55% to 94% of infants exposed to opioids in utero.2 It is rarely fatal but can be associated with significant health care costs, as the diagnosis often results in prolonged hospital stays.3 Opioid-Related Harms in Canada, December 2018 ED visits due to opioid poisonings The analysis of ED visits is currently limited to Ontario, Alberta and Yukon. Although CIHI collects ED data from other jurisdictions, these submissions do not yet include the level of detail or coverage required for this analysis. 27 Opioid-Related Harms in Canada, December 2018 Figure 12: Opioid poisoning ED visits, Ontario, Alberta and Yukon,* 2013 to 2017 120 Over the past 5 years, the rates of opioid poisoning ED visits have increased significantly. Age-adjusted rate per 100,000 population 100 80 60 Between 2016 and 2017, the rates of opioid poisoning ED visits in Ontario and Alberta increased by 73% and 23%, respectively. 40 20 0 2013 2014 2015 2016 2017 Calendar year Ontario Alberta Yukon Note * Due to the low number of ED visits in Yukon, trends must be interpreted with caution. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 28 Opioid-Related Harms in Canada, December 2018 Figure 13: Opioid poisoning ED visits by census metropolitan area, Ontario and Alberta, 2017 Age-adjusted rate per 100,000 population 160 Opioid poisoning ED visits are not restricted to urban areas in Canada — smaller cities across the country are also experiencing them. 140 120 100 80 60 40 20 Ontario Edmonton Calgary Toronto Ottawa–Gatineau (Ontario part) Greater Sudbury Windsor Kitchener– Cambridge–Waterloo Guelph London Hamilton Thunder Bay Oshawa Kingston Barrie Peterborough St. Catharines– Niagara Brantford 0 Alberta Note To be considered a CMA, the area must have a total population of at least 100,000, of which 50,000 or more live in the urban core. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 29 Opioid-Related Harms in Canada, December 2018 Figure 14: Highest rates of opioid poisoning ED visits by census subdivision, Ontario and Alberta, 2017 200 Rates of opioid poisoning ED visits varied by census subdivision. Age-adjusted rate per 100,000 population 180 160 140 120 100 80 60 40 20 Ontario Alberta Notes CSD is the general term for municipalities as determined by provincial/territorial legislation. This figure shows the 15 CSDs in Ontario and Alberta with a population of 50,000 or more with the highest rates of opioid poisoning ED visits. Please see the associated data tables for a more comprehensive list of CSDs. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 30 Grande Prairie Wood Buffalo Medicine Hat Red Deer Lethbridge Kingston Kawartha Lakes Barrie Oshawa St. Catharines Peterborough Welland Niagara Falls City of Brantford Sault Ste. Marie 0 Opioid-Related Harms in Canada, December 2018 Ontario ED visits Between 2016 and 2017, the rate of ED visits due to opioid poisoning increased by 73%, to 55.3 per 100,000. The increase was mostly due to male younger adults age 25 to 44. 31 Opioid-Related Harms in Canada, December 2018 Figure 15: Opioid poisoning ED visits by quarter, Ontario, Q1 2016 to Q1 2018 20 3,000 18 16 14 2,000 12 10 1,500 8 1,000 6 4 500 2 0 0 Jan.–Mar. 2016 Apr.–June July–Sept. 2016 2016 Oct.–Dec. 2016 Jan.–Mar. 2017 Apr.–June 2017 July–Sept. 2017 Oct.–Dec. 2017 Calendar year quarter Number of ED visits Crude rate per 100,000 population Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 32 Jan.–Mar. 2018 Crude rate per 100,000 population Number of ED visits 2,500 As of April 2017, as part of a comprehensive strategy to prevent opioid addiction and overdose, the Ontario Ministry of Health and Long-Term Care requires all Ontario facilities to provide weekly submissions of ED opioid overdose cases to CIHI. Opioid-Related Harms in Canada, December 2018 Figure 16: Opioid poisoning ED visits by age group, Ontario, 2013 to 2017 120 The rate of opioid poisoning ED visits for younger adults age 25 to 44 doubled between 2016 and 2017, increasing more than the rate for any other age group. Crude rate per 100,000 population 100 80 60 40 20 0 2013 2014 2015 2016 2017 Calendar year <15 15–24 25–44 45–64 65+ Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 33 Opioid-Related Harms in Canada, December 2018 Figure 17: Opioid poisoning ED visits by sex, Ontario, 2013 to 2017 80 The rate of ED visits for opioid poisonings increased by 90% among males and 50% among females between 2016 and 2017. Crude rate per 100,000 population 70 60 50 40 30 20 10 0 2013 2014 2015 2016 2017 Calendar year Female Male Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 34 Opioid-Related Harms in Canada, December 2018 Figure 18b: Opioid poisoning ED visits by age group, Ontario, 2013 to 2017: Females 3,000 3,000 2,500 2,500 2,000 2,000 Number of ED visits Number of ED visits Figure 18a: Opioid poisoning ED visits by age group, Ontario, 2013 to 2017: Males 1,500 1,000 500 1,500 1,000 500 0 0 <15 15–24 25–44 45–64 65+ <15 15–24 25–44 Age group 2013 2014 2015 45–64 65+ Age group 2016 2013 2017 Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 35 2014 2015 2016 2017 Opioid-Related Harms in Canada, December 2018 Figure 19: ED visits for opioid-related harms, Ontario, 2013 to 2017 70 Over the past 5 years, rates of ED visits due to opioid poisoning increased by 144%, while rates due to opioid use disorders increased by 42%. Age-adjusted rate per 100,000 population 60 50 40 30 20 10 0 2013 2014 2015 2016 2017 Calendar year Opioid poisoning Opioid use disorders Adverse drug reaction Note For full definitions of opioid-related harms, refer to Appendix B. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 36 Opioid-Related Harms in Canada, December 2018 Alberta ED visits Between 2016 and 2017, the rate of ED visits for opioid poisonings increased by 23%. This increase was mostly due to youth and younger adults age 15 to 44. 37 Opioid-Related Harms in Canada, December 2018 1,400 35 1,200 30 1,000 25 800 20 600 15 400 10 200 5 0 Jan.–Mar. 2016 Apr.–June July–Sept. 2016 2016 Oct.–Dec. 2016 Jan.–Mar. 2017 Apr.–June July–Sept. Oct.–Dec. 2017 2017 2017 Calendar year quarter Number of ED visits Crude rate per 100,000 population Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 38 Jan.–Mar. 2018 0 Crude rate per 100,000 population Number of ED visits Figure 20: Opioid poisoning ED visits by quarter, Alberta, Q1 2016 to Q1 2018 The rate of ED visits increased by 20% from Q1 2017 (January to March) to Q1 2018. Opioid-Related Harms in Canada, December 2018 Figure 21: Opioid poisoning ED visits by age group, Alberta, 2013 to 2017 200 In Alberta, youth age 15 to 24 and younger adults age 25 to 44 continued to have the highest rates of ED visits. 180 Crude rate per 100,000 population 160 140 120 100 80 60 40 20 0 2013 2014 2015 2016 2017 Calendar year <15 15–24 25–44 45–64 65+ Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 39 Opioid-Related Harms in Canada, December 2018 Figure 22: Opioid poisoning ED visits by sex, Alberta, 2013 to 2017 140 The rate of ED visits for opioid poisoning increased by 31% among males and 14% among females between 2016 and 2017. Crude rate per 100,000 population 120 100 80 60 40 20 0 2013 2014 2015 2016 2017 Calendar year Female Male Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 40 Opioid-Related Harms in Canada, December 2018 Figure 23b: Opioid poisoning ED visits by age group, Alberta, 2013 to 2017: Females 2,000 2,000 1,800 1,800 1,600 1,600 1,400 1,400 Number of ED visits Number of ED visits Figure 23a: Opioid poisoning ED visits by age group, Alberta, 2013 to 2017: Males 1,200 1,000 800 1,200 1,000 800 600 600 400 400 200 200 0 <15 15–24 25–44 45–64 0 65+ <15 15–24 Age group 2013 2014 2015 25–44 45–64 65+ Age group 2016 2013 2017 Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 41 2014 2015 2016 2017 Opioid-Related Harms in Canada, December 2018 Figure 24: ED visits for opioid-related harms, Alberta, 2013 to 2017 120 Over the past 5 years, rates of ED visits due to opioid poisoning increased by 165%, while rates due to opioid use disorders increased by 71%. Age-adjusted rate per 100,000 population 100 80 60 40 20 0 2013 2014 2015 2016 2017 Calendar year Opioid poisoning Opioid use disorders Adverse drug reaction Note For full definitions of opioid-related harms, refer to Appendix B. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 42 Opioid-Related Harms in Canada, December 2018 Yukon ED visits Only high-level results are presented for Yukon, as the data represents low volumes and trends must be interpreted with caution. 43 Opioid-Related Harms in Canada, December 2018 Figure 25: ED visits for opioid-related harms, Yukon, 2013 to 2017 350 Over the past 5 years, rates of ED visits due to opioid poisoning increased more than four-fold and rates due to opioid use disorders increased more than three-fold. Age-adjusted rate per 100,000 population 300 250 200 150 100 50 0 2013 2014 2015 2016 2017 Calendar year Opioid poisoning Opioid use disorders Adverse drug reaction Note For full definitions of opioid-related harms, refer to Appendix B. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 44 Opioid-Related Harms in Canada, December 2018 CIHI will continue to play a role in the monitoring and surveillance of opioid use and misuse to support public policy and decision-making. We will publicly report on opioid-related harms as more data becomes available. 45 Opioid-Related Harms in Canada, December 2018 Methodology 46 Opioid-Related Harms in Canada, December 2018 Data sources Hospital Morbidity Database The Hospital Morbidity Database (HMDB) captures administrative, clinical and demographic information on inpatient separations (referred to here as “hospitalizations”) from acute care hospitals. Hospitals in all provinces and territories (except Quebec) submit data directly to CIHI. Quebec data is submitted by the ministère de la Santé et des Services sociaux du Québec. National Ambulatory Care Reporting System The National Ambulatory Care Reporting System (NACRS) contains data on hospital-based and community-based ambulatory care — including day surgery, outpatient and community-based clinics, and EDs — for 64% of the country: all of Ontario, Alberta and Yukon, and some facilities in Prince Edward Island, Nova Scotia, Manitoba, Saskatchewan and British Columbia. CIHI receives data directly from participating facilities or from regional health authorities and ministries of health. 47 Opioid-Related Harms in Canada, December 2018 Ontario Mental Health Reporting System The Ontario Mental Health Reporting System (OMHRS) captures information on all individuals receiving adult mental health services in Ontario, as well as on some individuals receiving services in youth inpatient beds and selected facilities in other provinces. All facilities in Ontario with designated inpatient mental health beds report to OMHRS; this includes all general and specialty psychiatric facilities in the province, numbering approximately 5,000 inpatient mental health beds. OMHRS includes information about mental and physical health, social supports, service use, care planning, outcome measurement, quality improvement and case-mix funding applications. Opioid poisoning: ICD-10-CA coding The following ICD-10-CA version 2015 codes were used to identify opioid poisonings that resulted in hospitalizations and ED visits: ICD-10-CA code Description Example of opioid(s) included T40.0 Poisoning by opium Opium alkaloids T40.1 Poisoning by heroin Heroin, diacetylmorphine T40.2 Poisoning by other opioids Codeine, oxycodone, hydromorphone T40.3 Poisoning by methadone Methadone T40.4 Poisoning by other synthetic narcotics Fentanyl, tramadol T40.6 Poisoning by unspecified and other narcotics Opiates not elsewhere classified Codes with a prefix of Q (indicating a suspected diagnosis) were excluded from this analysis. 48 Opioid-Related Harms in Canada, December 2018 Reasons for opioid poisoning: ICD-10-CA coding Opioid poisoning hospitalizations were categorized based on the following ICD-10-CA categories: • Accidental (X42): The poisoning was considered to be non-intentional in nature. Includes accidental poisoning of drug, wrong drug given or taken in error, and drug taken inadvertently. • Intentional (X62): The poisoning occurred as a result of purposely self-inflicted harm. • Unknown (Y12): Categorization of the poisoning is due to physician documentation of undetermined/ unknown intent. Notes It is mandatory to assign an additional (external cause) code to denote the intent whenever a code for opioid poisoning is assigned. There is a pan-Canadian coding standard specifying that, in cases where there is no documentation of intent, a default code of accidental poisoning should be recorded. Where poisoning is documented as intentional or where intent of poisoning is documented as undetermined, it is coded as such. Physician documentation is not always available to identify the intent behind opioid poisoning. Cases with no associated intent code were excluded from this section of the analysis. 49 Opioid-Related Harms in Canada, December 2018 Opioid use disorders: ICD-10-CA coding The following ICD-10-CA version 2015 codes were used to identify opioid use disorders that resulted in hospitalizations and ED visits: ICD-10-CA code Description 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 Codes with a prefix of Q (indicating a suspected diagnosis) were excluded from this analysis. 50 Opioid-Related Harms in Canada, December 2018 Opioid use disorders: DSM-5 coding Unlike the HMDB and NACRS, OMHRS uses Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) coding to record psychiatric diagnoses in discharge assessments. The following DSM-5 codes were used to identify hospitalizations for opioid-related harms in the Psychiatric Diagnosis fields (Q2a–Q2f): DSM-5 code Description Notes 304.00 Opioid use disorder moderate, and opioid use disorder severe Before April 1, 2016, this code was referred to as “opioid dependence.” 305.50 Opioid use disorder mild Before April 1, 2016, this code was referred to as “opioid abuse.” Adverse drug reaction: ICD-10-CA coding The following ICD-10-CA version 2015 code was used to identify opioid-related adverse drug reactions that resulted in hospitalizations and ED visits: ICD-10-CA code Description Y45.0 Drugs, medicaments and biological substances causing adverse effects in therapeutic use: Opioids and related analgesics Codes with a prefix of Q (indicating a suspected diagnosis) were excluded from this analysis. 51 Opioid-Related Harms in Canada, December 2018 Neonatal withdrawal symptoms: ICD-10-CA coding The following ICD-10-CA version 2015 code was used to identify neonatal withdrawal symptoms that resulted in hospitalizations and ED visits: ICD-10-CA code Description P96.1 Neonatal withdrawal symptoms from maternal use of drugs of addiction Codes with a prefix of Q (indicating a suspected diagnosis) were excluded from this analysis. Opioid poisoning: Hospitalizations HMDB data was included for calendar years 2013 to 2017 and for the first quarter of calendar year 2018 across all provinces and territories. However, the most recent data for Quebec was from 2016, and CIHI did not receive Nunavut data for discharges between September 1, 2016, and March 31, 2017. The analysis was limited to significant diagnoses, that is, cases in which opioid poisoning was considered influential to the time spent in hospital and treatment received by the patient while there. To determine significant opioid poisoning and opioid use disorders hospitalizations, the following diagnosis types were selected: (M) = Most responsible diagnosis (MRDx) (1) = Pre-admit comorbidity (2) = Post-admit comorbidity (W), (X), (Y) = Service transfer diagnosis (C) = CIHI-assigned value for Quebec 52 Opioid-Related Harms in Canada, December 2018 Opioid use disorders: Hospitalizations HMDB data was included for calendar years 2013 to 2017 across all provinces and territories. However, the most recent data for Quebec was from 2016, and CIHI did not receive Nunavut data for discharges between September 1, 2016, and March 31, 2017. The analysis was limited to significant diagnoses, that is, cases in which opioid use disorders were considered influential to the time spent in hospital and treatment received by the patient while there. OMHRS data was also included. The analysis was limited to Ontario facilities with assigned mental health beds and records indicating either a full discharge assessment or a short stay assessment. Opioid-related harm codes found in data element Q2a — Psychiatric Diagnosis were categorized as significant diagnoses, while those found in data elements Q2b to Q2f were categorized as any diagnoses, to align with findings from the HMDB and NACRS. It should be noted that OMHRS classifies these as primary diagnoses and remaining disorders, respectively. In the first quarter of 2018, 1 facility missed the reporting deadline and was consequently omitted from the data set; 2018 numbers may therefore be under-reported. To determine significant opioid use disorders hospitalizations, the following diagnosis types were selected: HMDB OMHRS (M) = Most responsible diagnosis (MRDx) (1) = Pre-admit comorbidity (2) = Post-admit comorbidity (W), (X), (Y) = Service transfer diagnosis (C) = CIHI-assigned value for Quebec Primary diagnosis 53 Opioid-Related Harms in Canada, December 2018 Adverse drug reaction: Hospitalizations HMDB data was included for calendar years 2013 to 2017 across all provinces and territories. However, the most recent data for Quebec was from 2016, and CIHI did not receive Nunavut data for discharges between September 1, 2016, and March 31, 2017. Adverse drug reactions (per external cause code Y45.0 Drugs, medicaments and biological substances causing adverse effects in therapeutic use: Opioids and related analgesics) are based on any diagnosis. Neonatal withdrawal symptoms: Hospitalizations HMDB data was included for calendar years 2013 to 2017 across all provinces and territories. However, the most recent data for Quebec was from 2016, and CIHI did not receive Nunavut data for discharges between September 1, 2016, and March 31, 2017. The analysis for neonatal withdrawal symptoms was limited to significant diagnoses. To determine significant neonatal withdrawal symptoms hospitalizations, the following diagnosis types were selected: (M) = Most responsible diagnosis (MRDx) (1) = Pre-admit comorbidity (2) = Post-admit comorbidity (W), (X), (Y) = Service transfer diagnosis (C) = CIHI-assigned value for Quebec In addition, the analysis included only neonates, defined as persons less than 29 days old at the time of admission to the reporting facility. 54 Opioid-Related Harms in Canada, December 2018 ED visits NACRS data from Ontario, Alberta and Yukon was included for calendar years 2013 to 2017 and for the first quarter of calendar year 2018. The analysis includes Level 3 ED abstracts where an opioid harms diagnosis was noted as either a main or other problem. Limitations The coding of diagnoses using ICD-10-CA is based on documentation on the patient’s chart by the physician or primary care provider. Deficiencies in chart documentation and/or failure to provide coders with appropriate documents can affect data quality and lead to under-reporting. The data in this analysis includes only opioid harms for which an individual was admitted to hospital (or to the ED in Ontario, Alberta and Yukon) and does not capture cases that received treatment in other environments. Therefore, these figures represent an underestimate of the extent of opioid harms in Canada; the magnitude of this underestimation is unknown. Coding and reporting practices may change over time due to factors such as education and policy changes. This should be taken into consideration when interpreting time trends. 55 Opioid-Related Harms in Canada, December 2018 Other methodology notes For analysis by age, the following age groups were used: younger than 15 (children), 15 to 24 (youth), 25 to 44 (younger adults), 45 to 64 (older adults) and 65 and older (seniors). To calculate standardized rates, the direct standardization process was used with the 2011 Canadian population as the reference year. 2017 population numbers (the most recent year of data available) were used to calculate crude rates for 2018. Facility postal codes were used for the provincial/territorial analysis, and patient postal codes were used for the local-level analysis (CMA and CSD). 56 Opioid-Related Harms in Canada, December 2018 Appendix A: Opioid poisonings by CMA Table A1 Opioid poisoning hospitalizations by census metropolitan area, 2017 Number of Age-adjusted rate per hospitalizations 100,000 population Absolute rate difference, 2016 to 2017 2017 rank Province CMA N.L. St. John’s 48 21.0 11.9 8 N.S. Halifax 20 4.6 -6.0 34 N.B. Moncton 25 16.0 -3.1 20 N.B. Saint John 20 15.5 -4.3 23 Que. Montréal 286 6.9 n/a 33 Que. Ottawa–Gatineau (Quebec part) 40 12.6 n/a 27 Que. Québec 84 9.8 n/a 31 Que. Saguenay 22 11.6 n/a 28 Que. Sherbrooke 38 17.5 n/a 16 Que. Trois-Rivières 24 13.6 n/a 25 Ont. Barrie 35 16.6 -2.9 18 Ont. Brantford 59 41.2 16.9 2 Ont. Greater Sudbury 31 19.1 3.8 12 Ont. Guelph 27 16.9 5.6 17 Ont. Hamilton 159 20.2 2.1 10 Ont. Kingston 29 15.8 7.9 21 57 Opioid-Related Harms in Canada, December 2018 Province CMA Ont. Kitchener–Cambridge–Waterloo Ont. Number of Age-adjusted rate per hospitalizations 100,000 population Absolute rate difference, 2016 to 2017 2017 rank 66 12.4 -0.8 26 London 119 22.5 -1.4 6 Ont. Oshawa 58 14.3 0.1 24 Ont. Ottawa–Gatineau (Ontario part) 107 10.3 0.4 30 Ont. Peterborough 22 16.1 -8.8 19 Ont. St. Catharines–Niagara 116 27.1 8.5 4 Ont. Thunder Bay 42 34.7 10.1 3 Ont. Toronto 510 7.9 0.9 32 Ont. Windsor 54 15.6 1.0 22 Man. Winnipeg 94 11.3 3.9 29 Sask. Regina 54 21.4 1.3 7 Sask. Saskatoon 62 19.7 -0.8 11 Alta. Calgary 251 17.8 2.1 15 Alta. Edmonton 253 18.5 -3.0 14 B.C. Abbotsford–Mission 51 26.7 -3.6 5 B.C. Kelowna 101 52.8 22.7 1 B.C. Vancouver 536 20.4 5.1 9 B.C. Victoria 73 18.7 -1.5 13 Notes To be considered a CMA, the area must have a total population of at least 100,000, of which 50,000 or more live in the urban core. Quebec data is from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. 58 Opioid-Related Harms in Canada, December 2018 Appendix B: Definitions of opioid-related harms Opioid poisoning occurs when an opioid is taken incorrectly and results in harm. Incorrect use includes wrong dosage of an opioid, self-prescribed opioids taken in combination with another prescribed drug or alcohol, and self-prescribed opioid not taken as recommended. Opioid use disorders include a wide variety of mental health and behavioural disorders that differ in severity and clinical form (e.g., withdrawal, intoxication) but that are all attributable to the use of opioids, which may or may not have been medically prescribed. Adverse drug reaction is defined as an opioid taken or administered correctly as prescribed that results in an effect or harm. Neonatal withdrawal symptoms from the mother’s use of drugs of addiction include neonatal abstinence syndrome and drug withdrawal syndrome in an infant of a dependent mother. 59 Opioid-Related Harms in Canada, December 2018 Appendix C: Text alternative data tables for figures Figure 1 Opioid poisoning hospitalizations, Canada, 2013 to 2017 Number of hospitalizations Crude rate per 100,000 population 2013 4,554 13.0 2014 4,776 13.4 2015 5,088 14.2 2016 5,554 15.3 2017 6,072 16.5 Calendar year Note Quebec data is from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. 60 Opioid-Related Harms in Canada, December 2018 Figure 2 Opioid poisoning hospitalizations by province/territory and Canada, 2017 Age-adjusted hospitalizations per 100,000 population Absolute difference in age-adjusted hospitalizations per 100,000 population, 2016 to 2017 N.L. 16.6 6.0 P.E.I. 9.5 -4.8 N.S. 8.4 -1.8 N.B. 13.1 -4.1 9.8 n/a Ont. 14.8 1.6 Man. 12.3 2.5 Sask. 21.6 -2.1 Alta. 22.7 -0.2 B.C. 29.3 5.1 Y.T. 31.8 n/r 33.7 n/r n/r n/r 16.4 n/r Province/territory Que.* N.W.T. Nun. † Canada Notes * Quebec data is from 2016 (the most recent year of data available). † CIHI did not receive Nunavut records for hospitalizations between September 1, 2016, and March 31, 2017. n/a: Not applicable. n/r: Not reported. Absolute rate differences are not reported for Yukon, the Northwest Territories and Nunavut due to variability resulting from low volumes. Source Hospital Morbidity Database, Canadian Institute for Health Information. 61 Opioid-Related Harms in Canada, December 2018 Figure 3 Opioid poisoning hospitalizations by quarter, Canada, Q1 2016 to Q1 2018 Crude rate per 100,000 population Calendar year quarter Number of hospitalizations January to March 2016 1,301 3.6 April to June 2016 1,399 3.9 July to September 2016 1,409 3.9 October to December 2016 1,445 4.0 January to March 2017 1,456 4.0 April to June 2017 1,549 4.2 July to September 2017 1,593 4.3 October to December 2017 1,474 4.0 January to March 2018 1,341 3.7 Note Quebec data is from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. 62 Opioid-Related Harms in Canada, December 2018 Figure 4 Reasons for opioid poisoning hospitalizations, Canada, 2017 Year Accidental 2017 Intentional 58% Unknown 30% 12% Note Quebec data is from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. Figure 5 Opioid poisoning hospitalizations by age, Canada, 2013 to 2017 Age group 2013 2014 2015 2016 2017 <15 1.8 1.5 1.9 1.7 1.8 15–24 9.7 10.4 12.2 12.7 14.8 25–44 12.4 13.1 14.8 17.1 20.1 45–64 18.2 18.3 18.8 20.0 21.2 65+ 18.8 19.8 18.9 19.8 18.5 Notes Quebec data is from 2016 (the most recent year of data available). Crude rate per 100,000 population. Source Hospital Morbidity Database, Canadian Institute for Health Information. 63 Opioid-Related Harms in Canada, December 2018 Figure 6 Opioid poisoning hospitalizations by sex, Canada, 2013 to 2017 Sex 2013 2014 2015 2016 2017 Female 13.9 14.0 14.6 15.5 15.3 Male 12.0 12.9 13.8 15.1 17.8 Notes Quebec data is from 2016 (the most recent year of data available). Crude rate per 100,000 population. Source Hospital Morbidity Database, Canadian Institute for Health Information. Figure 7a Opioid poisoning hospitalizations by age group, Canada, 2013 to 2017: Males Age group 2013 2014 2015 2016 2017 <15 1.4 0.8 1.3 1.3 1.2 15–24 9.6 11.1 12.6 12.8 15.3 25–44 12.6 14.0 16.2 20.0 25.9 45–64 16.7 17.9 17.8 19.0 21.3 65+ 16.1 16.4 16.9 16.4 17.3 Notes Quebec data is from 2016 (the most recent year of data available). Crude rate per 100,000 population. Source Hospital Morbidity Database, Canadian Institute for Health Information. 64 Opioid-Related Harms in Canada, December 2018 Figure 7b Opioid poisoning hospitalizations by age group, Canada, 2013 to 2017: Females Age group 2013 2014 2015 2016 2017 <15 2.1 2.3 2.5 2.1 2.5 15–24 9.8 9.7 11.9 12.5 14.2 25–44 12.1 12.3 13.4 14.2 14.3 45–64 19.7 18.7 19.9 20.9 21.1 65+ 21.0 22.6 20.5 22.6 19.4 Notes Quebec data is from 2016 (the most recent year of data available). Crude rate per 100,000 population. Source Hospital Morbidity Database, Canadian Institute for Health Information. 65 Opioid-Related Harms in Canada, December 2018 Figure 8 Rates of hospitalizations due to opioid poisoning by community size, Canada, 2017 Community size Age-adjusted rate per 100,000 <10,000 18.1 10,000–49,999 22.3 50,000–99,999 30.5 100,000–499,999 19.4 500,000+ 12.2 Note Quebec data and population data are from 2016 (the most recent year of data available). Source Hospital Morbidity Database, Canadian Institute for Health Information. 66 Opioid-Related Harms in Canada, December 2018 Figure 9 Opioid poisoning hospitalization rates, census metropolitan areas, Canada, 2017 Age-adjusted rate per 100,000 population, 2017 CMA Province Abbotsford–Mission B.C. 26.7 Brantford Ont. 41.2 Calgary Alta. 17.8 Edmonton Alta. 18.5 Greater Sudbury Ont. 19.1 Hamilton Ont. 20.2 Kelowna B.C. 52.8 London Ont. 22.5 Regina Sask. 21.4 Saskatoon Sask. 19.7 St. Catharines–Niagara Ont. 27.1 St. John’s N.L. 21.0 Thunder Bay Ont. 34.7 Vancouver B.C. 20.4 Victoria B.C. 18.7 Halifax N.S. 4.6 Moncton N.B. 16.0 Saint John N.B. 15.5 Montréal Que. 6.9 Ottawa–Gatineau (Quebec part) Que. 12.6 67 Opioid-Related Harms in Canada, December 2018 Age-adjusted rate per 100,000 population, 2017 CMA Province Québec Que. 9.8 Ottawa–Gatineau (Ontario part) Ont. 10.3 Toronto Ont. 7.9 Winnipeg Man. 11.3 Notes Quebec data is from 2016 (the most recent year of data available). To be considered a CMA, the area must have a total population of at least 100,000, of which 50,000 or more live in the urban core. Source Hospital Morbidity Database, Canadian Institute for Health Information. Figure 10 Opioid-related hospitalizations, Canada, 2013 to 2017 Calendar year Opioid poisoning Opioid use disorders Adverse drug reaction 2013 12.9 19.5 28.5 2014 13.3 22.9 28.4 2015 14.0 26.4 27.9 2016 15.2 30.1 28.1 2017 16.4 32.1 26.8 Notes Quebec data is from 2016 (the most recent year of data available). For full definitions of opioid-related harms, refer to Appendix B. Age-adjusted rate per 100,000 population. Sources Hospital Morbidity Database and Ontario Mental Health Reporting System, Canadian Institute for Health Information. 68 Opioid-Related Harms in Canada, December 2018 Figure 11 Hospitalizations for neonatal withdrawal symptoms, Canada, 2013 to 2017 Calendar year Crude rate per 1,000 in-hospital live births Number of hospitalizations 2013 2014 2015 2016 2017 4.3 4.6 4.7 4.9 5.2 1,592 1,710 1,736 1,832 1,908 Notes Quebec data is from 2016 (the most recent year of data available). For full definitions of opioid-related harms, refer to Appendix B. Source Hospital Morbidity Database, Canadian Institute for Health Information. Figure 12 Opioid poisoning ED visits, Ontario, Alberta and Yukon,* 2013 to 2017 Province/territory 2013 2014 2015 2016 2017 Ontario 22.7 24.7 26.5 32.0 55.3 Alberta 38.8 43.1 60.7 83.5 102.8 Yukon 23.2 51.6 28.7 40.5 103.4 Notes * Due to the low number of ED visits in Yukon, trends must be interpreted with caution. Age-adjusted rate per 100,000 population. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 69 Opioid-Related Harms in Canada, December 2018 Figure 13 Opioid poisoning ED visits by census metropolitan area, Ontario and Alberta, 2017 Age-adjusted rate per 100,000 population CMA Province Brantford Ont. 144.5 St. Catharines–Niagara Ont. 126.4 Peterborough Ont. 108.9 Barrie Ont. 92.5 Kingston Ont. 80.8 Oshawa Ont. 71.0 Thunder Bay Ont. 70.8 Hamilton Ont. 63.7 London Ont. 62.2 Guelph Ont. 61.5 Kitchener–Cambridge–Waterloo Ont. 59.9 Windsor Ont. 51.7 Greater Sudbury Ont. 43.1 Ottawa–Gatineau (Ontario part) Ont. 33.8 Toronto Ont. 32.0 Calgary Alta. 82.3 Edmonton Alta. 67.8 Note To be considered a CMA, the area must have a total population of at least 100,000, of which 50,000 or more live in the urban core. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 70 Opioid-Related Harms in Canada, December 2018 Figure 14 Highest rates of opioid poisoning ED visits by census subdivision, Ontario and Alberta, 2017 Age-adjusted rate per 100,000 population CSD Province Sault Ste. Marie Ont. 176.6 City of Brantford Ont. 172.5 Niagara Falls Ont. 158.5 Welland Ont. 154.0 Peterborough Ont. 140.7 St. Catharines Ont. 124.1 Oshawa Ont. 119.9 Barrie Ont. 105.9 Kawartha Lakes Ont. 93.9 Kingston Ont. 93.0 Lethbridge Alta. 172.3 Red Deer Alta. 169.4 Medicine Hat Alta. 135.1 Wood Buffalo Alta. 109.7 Grande Prairie Alta. 109.1 Notes CSD is the general term for municipalities as determined by provincial/territorial legislation. This table shows the 15 CSDs in Ontario and Alberta with a population of 50,000 or more with the highest rates of opioid poisoning ED visits. Please see the associated data tables for a more comprehensive list of CSDs. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 71 Opioid-Related Harms in Canada, December 2018 Figure 15 Opioid poisoning ED visits by quarter, Ontario, Q1 2016 to Q1 2018 Calendar year quarter January to March 2016 Crude rate per 100,000 population Number of ED visits 990 7.1 April to June 2016 1,076 7.7 July to September 2016 1,137 8.1 October to December 2016 1,257 9.0 January to March 2017 1,361 9.6 April to June 2017 1,902 13.4 July to September 2017 2,685 18.9 October to December 2017 1,873 13.2 January to March 2018 1,855 13.1 Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 72 Opioid-Related Harms in Canada, December 2018 Figure 16 Opioid poisoning ED visits by age group, Ontario, 2013 to 2017 Age group 2013 2014 2015 2016 2017 2.9 3.5 3.9 4.0 3.5 15–24 29.8 31.8 31.5 38.8 64.8 25–44 30.0 32.5 37.4 51.2 106.4 45–64 26.4 27.8 29.1 32.5 49.1 65+ 17.7 21.1 22.1 20.8 22.2 <15 Note Crude rate per 100,000 population. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. Figure 17 Opioid poisoning ED visits by sex, Ontario, 2013 to 2017 Sex 2013 2014 2015 2016 2017 Female 22.3 22.1 25.9 27.7 41.5 Male 23.1 27.4 27.1 36.2 68.7 Note Crude rate per 100,000 population. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 73 Opioid-Related Harms in Canada, December 2018 Figure 18a Opioid poisoning ED visits by age group, Ontario, 2013 to 2017: Males Age group 2013 2014 2015 2016 2017 28 32 25 42 30 15–24 247 308 279 365 640 25–44 632 734 790 1,201 2,749 45–64 486 578 548 690 1,161 65+ 144 186 193 191 219 <15 Note Number of ED visits. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. Figure 18b Opioid poisoning ED visits by age group, Ontario, 2013 to 2017: Females Age group 2013 2014 2015 2016 2017 36 45 60 47 49 15–24 301 277 295 343 557 25–44 458 455 585 712 1,310 45–64 524 493 582 582 770 65+ 221 265 296 286 308 <15 Note Number of ED visits. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 74 Opioid-Related Harms in Canada, December 2018 Figure 19 ED visits for opioid-related harms, Ontario, 2013 to 2017 Opioid-related harm 2013 2014 2015 2016 2017 Opioid poisoning 22.7 24.7 26.5 32.0 55.3 Opioid use disorders 44.2 42.2 47.7 56.3 62.7 Adverse drug reaction 16.2 16.0 16.2 15.5 13.8 Notes For full definitions of opioid-related harms, refer to Appendix B. Age-adjusted rate per 100,000 population. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. Figure 20 Opioid poisoning ED visits by quarter, Alberta, Q1 2016 to Q1 2018 Calendar year quarter Number of ED visits Crude rate per 100,000 population January to March 2016 757 17.9 April to June 2016 917 21.6 July to September 2016 948 22.4 October to December 2016 1,002 23.7 January to March 2017 1,027 24.0 April to June 2017 1,148 26.8 July to September 2017 1,245 29.0 October to December 2017 1,132 26.4 January to March 2017 1,239 28.9 Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 75 Opioid-Related Harms in Canada, December 2018 Figure 21 Opioid poisoning ED visits by age group, Alberta, 2013 to 2017 Age group 2013 2014 2015 2016 2017 9.6 6.6 6.2 5.3 5.7 15–24 56.2 61.8 114.0 149.1 177.5 25–44 50.2 62.6 91.2 136.1 189.5 45–64 40.1 43.0 55.5 71.7 78.4 65+ 31.7 32.1 29.8 39.2 31.9 <15 Note Crude rate per 100,000 population. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. Figure 22 Opioid poisoning ED visits by sex, Alberta, 2013 to 2017 Sex 2013 2014 2015 2016 2017 Female 42.6 42.5 55.9 69.7 79.3 Male 35.4 45.0 68.4 100.9 132.3 Note Crude rate per 100,000 population. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 76 Opioid-Related Harms in Canada, December 2018 Figure 23a Opioid poisoning ED visits by age group, Alberta, 2013 to 2017: Males Age group 2013 2014 2015 2016 2017 26 13 24 18 16 15–24 146 181 355 453 503 25–44 312 472 718 1,179 1,747 45–64 178 220 296 437 527 56 54 59 80 77 <15 65+ Note Number of ED visits. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. Figure 23b Opioid poisoning ED visits by age group, Alberta, 2013 to 2017: Females Age group 2013 2014 2015 2016 2017 44 36 23 23 29 15–24 155 153 255 335 423 25–44 313 338 485 638 805 45–64 239 235 299 340 330 86 96 86 119 92 <15 65+ Note Number of ED visits. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 77 Opioid-Related Harms in Canada, December 2018 Figure 24 ED visits for opioid-related harms, Alberta, 2013 to 2017 Opioid-related harm 2013 2014 2015 2016 2017 Opioid poisoning 38.8 43.1 60.7 83.5 102.8 Opioid use disorders 57.4 62.3 77.8 86.9 98.0 Adverse drug reaction 28.9 26.0 28.1 27.3 25.2 Notes For full definitions of opioid-related harms, refer to Appendix B. Age-adjusted rate per 100,000 population. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. Figure 25 ED visits for opioid-related harms, Yukon, 2013 to 2017 Opioid-related harm 2013 2014 2015 2016 2017 Opioid poisoning 23.2 51.6 28.7 40.5 103.4 Opioid use disorders 97.8 96.2 138.4 214.1 311.6 Adverse drug reaction 55.5 42.1 44.1 40.4 62.2 Notes For full definitions of opioid-related harms, refer to Appendix B. Age-adjusted rate per 100,000 population. Source National Ambulatory Care Reporting System, Canadian Institute for Health Information. 78 Opioid-Related Harms in Canada, December 2018 References 1. Busse J, ed. The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. 2017. 2. Hudak ML, Tan RC; Committee on Drugs; Committee on Fetus and Newborn. Neonatal drug withdrawal. Pediatrics. 2012. 3. Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014. 79 media@cihi.ca CIHI Ottawa CIHI Toronto CIHI Victoria CIHI Montréal 495 Richmond Road 4110 Yonge Street 880 Douglas Street 1010 Sherbrooke Street West Suite 600 Suite 300 Suite 600 Suite 602 Ottawa, Ont. Toronto, Ont. Victoria, B.C. Montréal, Que. K2A 4H6 M2P 2B7 V8W 2B7 H3A 2R7 613-241-7860 416-481-2002 250-220-4100 514-842-2226 cihi.ca 8582-1018