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Migraine Treatment Patterns and Opioid Use

Among Chronic and Episodic Migraine

Patients Identified by a Clinician-

Administered Semi-Structured Diagnostic

Interview

2018 CADTH Yu, et al 3

Justin S. Yu;1 Jelena M. Pavlovic;2 Stephen D. Silberstein;3 Michael L. Reed;4 Steve H.

Kawahara;5 Robert P. Cowan;6 Firas Dabbous;7 Karen L. Campbell;1 Riya Pulicharam;5

Hema N. Viswanathan;1 Richard B. Lipton8

1Allergan plc, Irvine, CA, USA2Montefiore Medical Center, Bronx, NY, USA

3Jefferson Headache Center, Philadelphia, PA, USA4Vedanta Research, Chapel Hill, NC, USA

5DaVita Medical Group; El Segundo, CA, USA6Stanford University School of Medicine, Stanford, CA, USA

7Independent Consultant, La Jolla, CA, USA8Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, US

Presentation: Tuesday April 17, 10.30 to 11.45amPresentations must be taken to the SPEAKER READY Room the day before the presentationPresentations will be either 15 minutes including time for questionsComputer will run with 1024 by 768 resolution and 32 bit color, equipped with USB portsAdvise if presentation includes sound and/or video

PRESENTER’S DISCLOSURE

I have the following relevant financial relationships to disclose:

• Employed by Allergan plc

• Holds stock in Allergan plc


DISCLOSURES FOR ALL AUTHORS

This study was sponsored by Allergan plc, Dublin, Ireland. Writing and editorial assistance was provided to the authors by Lee B. Hohaia, PharmD of CHC (West Chester, PA, USA) and funded by Allergan plc, Dublin, Ireland. All authors met the ICMJE authorship criteria. Neither honoraria nor payments were made for authorship.

Financial arrangements of the authors with companies whose products may be related to the present report are listed below, as declared by the authors.

Justin Yu, MS, PharmD, is an employee of Allergan plc and receives stock or stock options. Jelena M. Pavlovic, MD, PhD has received honoraria from Allergan and the American Headache Society. Dr. Stephen Silberstein, as a consultant and/or advisory panel member,receives honoraria from Alder Biopharmaceuticals; Allergan, Inc.; Amgen; Avanir Pharmaceuticals, Inc.; eNeura; ElectroCore Medical, LLC; Labrys Biologics; Medscape, LLC; Medtronic, Inc.; Neuralieve; NINDS; Pfizer, Inc.; and Teva Pharmaceuticals. His employer receives research support from Allergan, Inc.; Amgen; Cumberland Pharmaceuticals, Inc.; ElectroCore Medical, Inc.; Labrys Biologics; Eli Lilly and Company; Merz Pharmaceuticals; and Troy Healthcare. Michael L. Reed, PhD, is Managing Director of Vedanta Research, which has received research funding from Allergan, Amgen, Dr. Reddy’s Laboratories, Eli Lilly GlaxoSmithKline, Merck & Co., Inc., and Novartis, via grants to the National Headache Foundation. Vedanta Research has received funding directly from Allergan for work on the CaMEO Study. Steve Kawahara, PharmD, in the past 12 months, has served as a consultant to Allergan and is a full-time employee of the DaVita Medical Group. Robert P. Cowan, MD and Firas Dabbous, PhD have no financial disclosures to report. Karen Campbell, PharmD, is a full-time employee of Allergan plc and owns stock in the company. Riya Pulicharam, MD, in the past 12 months, has served as a consultant and received consulting fees from DaVita medical Group. Hema Viswanathan B.Pharm, PhD is an employee of Allergan and holds stock, stock options, patent or other intellectual property in Allergan plc. Dr Lipton, MD, serves on the editorial board of Neurology and as senior advisor to Headache. He has received research support from the NIH. He also receives support from the Migraine Research Foundation and the National Headache Foundation. He has reviewed for the NIA and NINDS, serves as consultant, advisory board member, or has received honoraria from: Alder, Allergan, Amgen, Autonomic Technologies, Avanir, Boston Scientific, Dr. Reddy’s, Electrocore, Eli Lilly, eNeura Therapeutics, GlaxoSmithKlein, Merck, Novartis, Teva, Vedanta. He receives royalties from Wolff’s Headache, 8th Edition, Oxford Press University, 2009 and Informa. He holds stock options in eNeura Therapeutics and Biohaven.


INTRODUCTION

• Migraine is a leading cause of disability1 and affects approximately

12% of individuals in the United States2

− Affected individuals report reduced productivity, missed days from

work/school, and decreased health-related quality of life3,4

• Multiple treatment options exist for both acute and preventive

treatment of migraine

− Opioids have been used for acute treatment of migraine in people with

chronic migraine (CM; ≥15 headache days/month) and in people with

episodic migraine (EM; <15 headache day/month)

− Opioids are not recommended for regular use due to the risks of

medication overuse, tolerance, dependence, and opioid hyperalgesia5


1. Vos T et al. Lancet 2016;388(10053):1545-1602.

2. Buse DC et al. Headache 2012;52:1456-1470.

3. Lipton RB et al. Headache. 2001;41(7):646-657.

4. Blumenfeld AM et al. Cephalalgia. 2010;31(3):301-315.

5. Marmura MJ et al. Headache 2015;55:3-20.

OBJECTIVE


To describe migraine treatment patterns and opioid use in chronic migraine and episodic migraine patients using health claims data

STUDY OVERVIEW


SSDI: Semi-structured diagnostic interview, was the gold standard for CM diagnosis in this study

Clinical experts included Drs. Pavlovic, Silberstein, Cowan, and Lipton

CM=chronic migraine; EM=episodic migraine; ID-CM=Identify Chronic Migraine; SSDI=Semi-Structured Diagnostic Interview.Note: The pre-screening period was defined as the 12-month time period from the screening date to 364 days prior. The pre-enrollment period was defined as the 12-month month time period from the enrollment date to 364 days prior.

Methods

Large medical group database

screened for adult migraine patients (≥ 18 years of age)

from October 2015 to November

2016

≥1 medical claim with a migraine

diagnosis (346.xx/G43.xxx) in the 12-month pre-screening period

required for study inclusion(n=536)

Patients with migraine who consented to enroll into the

study were administered the

ID-CM screener (to obtain real-world data on validity)

(n=536)

The SSDI was administered to a

convenience sample of

patients; all patients were

required to have continuous

enrollment in the 12-month pre-

enrollment period(final sample

n=192)

Acute treatment, preventive

treatment, opioid use, and baseline

characteristics were assessed for

CM and EM patients based on claims in the 12-

month pre-enrollment period

51 2 3 4

SEMI-STRUCTURED DIAGNOSTIC INTERVIEW

(SSDI)


20-25 minutes Physician-administered interview

31 Questions Headache symptoms, frequency,

productivity, medication use, others

30 and 90 days Patient recall period

Computer +

Physician diagnosis

Computer: ICHD-3 criteria for migraine1 and

modified Silberstein-Lipton criteria for CM2

Physician: Above criteria + clinical judgment

Headache expert: If disagreementCM=chronic migraine; ICHD-3=International Classification of Headache Disorders, Third Edition

1.Cephalalgia. 2018;38:1-211.

2.Silberstein SD, et al. Neurology. 1996;47:871-875.

ASSESSMENTS

• Assessments for CM and EM patients based on pharmacy and

medical claims data collected in the 12-month period from the

enrollment date to 364 days prior to enrollment (i.e., pre-enrollment

period) included

− Baseline characteristics

− Acute treatments for migraine

− Preventive treatments for migraine

− Opioids (pharmacy claims only)

• All variables were assessed using descriptive analyses


PATIENT DEMOGRAPHICS AND CLINICAL CHARACTERISTICS BY

SSDI STATUS: BASED ON CLAIMS FROM 12-MONTH PRE-

ENROLLMENT PERIOD


Chronic migraine

(SSDI+, n = 129)

Episodic migraine

(SSDI–, n = 63)

Age (mean, SD) 49.4 (12.6) 48.9 (15.4)

Female, n (%)* 121 (93.8) 52 (82.5)

Deyo-Charlson Comorbidity Index score (mean, SD) 0.25 (0.72) 0.19 (0.50)

Pain, n (%) 17 (13.2) 5 (7.9)

Anxiety, n (%) 19 (14.7) 10 (15.9)

Depression, n (%)* 31 (24.0) 7 (11.1)

SSDI=Semi-Structured Diagnostic Interview.* P<0.05.

Of 192 patients: • 129 (67%) had chronic migraine (CM) and 63 (33%) had episodic migraine

(EM)

• Those with CM had a Deyo-Charlson Comorbidity Index mean (SD) score of

0.25 (0.72) and those with EM had a mean (SD) score of 0.19 (0.50)

• 14.7% of those with CM and 15.9% of those with EM had anxiety

• 24.0% of those with CM and 11.1% of those with EM had depression

MIGRAINE TREATMENT PATTERNS: BASED ON

CLAIMS FROM 12-MONTH PRE-ENROLLMENT PERIOD


Chronic migraine

(SSDI+, n = 129)

Episodic migraine

(SSDI–, n = 63)

Acute treatment only, n (%)* 10 (7.8) 13 (20.6)

Preventive treatment only, n (%)* 23 (17.8) 4 (6.4)

Both acute and preventive treatment , n (%) 87 (67.4) 35 (55.6)

No acute or preventive treatment, n (%)* 9 (7.0) 11 (17.5)

Unique preventive classes, n (%)*,†

0 19 (14.7) 24 (38.1)

1 51 (39.5) 25 (39.7)

2+ 59 (45.7) 14 (22.2)

SSDI=Semi-Structured Diagnostic Interview.* P<0.05; †Unique preventive classes defined as antiepileptics, antidepressants, antihypertensives, non-steroidal anti-inflammatory drugs and onabotulinumtoxinA

In the past 12 months:

• 93% of those with CM and 82.5% of those with EM had ≥1 claim for migraine treatments

(acute and/or preventive; P < 0.05)

• 67.4% of those with CM and 55.6% of those with EM had ≥1 claim for both acute and

preventive treatments

• 45.7% of those with CM and 22.2% of those with EM received ≥2 unique preventive

treatment classes (P < 0.05)

OPIOID TREATMENT PATTERNS: BASED ON CLAIMS

FROM 12-MONTH PRE-ENROLLMENT PERIOD


Chronic migraine

(SSDI+, n = 129)

Episodic migraine

(SSDI–, n = 63)

Opioid treatment, n (%)* 69 (53.5) 23 (36.5)

No. of opioid claims, mean (SD)* 4.0 (7.1) 2.8 (8.2)

No. of opioid claims, n (%)**

0 60 (46.5) 40 (63.5)

1 16 (12.4) 9 (14.3)

2 10 (7.8) 4 (6.4)

3+ 43 (33.3) 10 (15.9)

SSDI=Semi-Structured Diagnostic Interview* P<0.05; **P<0.10

In the past 12 months:

• 53.5% of CM patients and 36.5% of EM patients had ≥1 opioid claim (P < 0.05)

• The mean number of opioid claims was

− 4.0 (SD = 7.1) among all CM patients

− 2.8 (SD = 8.2) among all EM patients (P < 0.05)

• 33.3% of CM patients and 15.9% of EM patients had ≥3 opioid claims

LIMITATIONS

• The lists of acute and preventive medications for migraine were

based on Level A and B evidence1-3 from United States clinical

practice guidelines and clinical expert opinion

− Other medications, including over-the-counter mediations used for the

treatment of migraine, were not included

• Only pharmacy claims were evaluated to assess opioid use

• The analysis was limited to patients with a diagnosis of migraine in

the 12-month pre-screening period who were likely seeking medical

care


1. Marmura MJ et al. Headache 2015;55:3-20.

2. Silberstein et al., Neurology 2012;78:1337-1345.

3. Holland S et al., Neurology 2012;78:1346-1353.

CONCLUSIONS

• Approximately two-thirds of patients with chronic migraine (CM) had

prescriptions for both acute treatments for migraine and medications

that can be used for prevention of migraine in the past year

• More than half of patients with CM and about a third of patients with

episodic migraine (EM) also received an opioid prescription in the

same time period

• Given the prevalence of opioid use in migraine patients, especially

those with CM, results suggest that improved management of

treatment is needed to optimize care



QUESTIONS?

The Prescription Side of the Opioid Crisis:-

Supporting NB Prescribers and Clinicians in Appropriate Use, Monitoring and Patient

Management

Dr. Heidi Liston, NB Department of HealthStephanie Smith, CADTH

Dr. Pam Jarrett, Horizon Health Network and NB Department of Health

APRIL 17, 2018 2018 CADTH Symposium, Halifax

PMPs have tended to be “reactive” focusing on

identifying the worst cases at the point of dispensing

Paradigm shift

• Focus on prevention and the

prescriber

• Focus on new patients

• Evidenced-based and guideline

supported prescribing of new

patients

• Appropriate management of

patients on long-term opioids to

avoid individuals being “cut-off”

PMP Part of Provincial EHR

Levesque, Christopher Phoenix Moncton Pharmacy

“While someday computerization of medicine will surely be that long-awaited ‘disruptive innovation,’ today it’s often just plain disruptive: of the doctor-patient relationship, of clinicians professional interactions and work flow, and of the way we measure and try to improve things,” Robert Wachter

CredibilityBuy-in

Reduce BarriersSupport Change

Measure

Advisory

Regional

Educational

Enduring

Accessible

Leaders

Partners

Users

Interdisciplinary

Gradual

Plan OutcomeTools

Stakeholder Engagement

A national campaign to help reduce opioids over-

prescribing

Choosing Wisely New Brunswick

https://choosingwiselycanada.org/campaign/opioid-wisely/

https://choosingwiselycanada.org/campaign/opioid-wisely/

https://choosingwiselycanada.org/campaign/new-brunswick/

https://choosingwiselycanada.org/campaign/new-brunswick/

Information Available on the Electronic Health Record (EHR):

Patient demographicinformation

Medication summary profile and Prescription Monitoring Program

Laboratorytest results

Diagnosticimaging reports

Specific cardiologyreports

Hospitalvisit history

Patient demographicinformation

Medication summary profile and Prescription Monitoring Program

Laboratorytest results

Engagement To Date

• Since 2016– Hosted 15 face to face and virtual meetings with

stakeholders groups across disciplines

– Partnered on 6 panels at professional body AGMs

– Presented directly to Association Boards, Regulatory Councils, Practice Groups

– Additional outreach: Grand Rounds, Harm Reduction events, Pain sessions

Knowledge Mobilization &

Implementation Support

24

Knowledge Mobilization &

Implementation Support

25

• Presentations, Education

• Exhibits / Booths

• Conference abstracts

• News Articles (e.g., InfoNursing)

•

• Moving Forward?

How did this help?

• eHealthNB• Real time access to ALL prescription information

(Opioids and Non-Opioids)

• Intervention is educational and patient focused

• Everyone has a role to play in Opioid crisis

• Educational Sessions • Very good attendance

• Educational opportunity

• Forum for discussion when otherwise difficult to create this forum

What Else Did We Learn?

• Doctors appreciate the information being provided

• Physicians want to be part of the solution

• Lack of community resources to assist the primary care provider to help patient with opioid addiction

• More opportunities to work together to learn better ways to help patients with pain management and thus opioid prescriptions

• Managing patient expectations of pain control is also important

• We are on the RIGHT TRACK!

Where To From Here?

• Broader range of education required to ALL health care professionals (prescribers and non-prescribers)

• Who should lead this educational drive?

• Emphasis on alternatives such as Non-Opioid treatment of pain

• Role of eConsult

Clinical Indications for Initiating

Opioidsfor Pain Management in Ontario, Canada

A population-based retrospective cohort study

Sachin Pasricha, Queen’s University School of MedicineDr. Mina Tadrous, U of T Lesile Dan School of PharmacyWayne Khuu, Institute for Clinical Evaluative SciencesDr. David Juurlink, Sunnybrook Health Sciences CentreDr. Muhammad Mamdani, Li Ka Shing Centre for Healthcare Analytics and TrainingDr. Michael Paterson, Institute for Clinical Evaluative SciencesDr. Tara Gomes, St. Michael’s Hospital

Ontario Drug Policy Research Network

Disclosures

• Studentship Funding from Ontario Drug

Policy Research Network, Ontario Ministry

of Health and Long-term Care

Opioid-related deathsRoad trauma

Addiction Healthcare

costs

Side Effects

Psychosocial

effects

Inequity

Opioids



costs

Side Effects

Psychosocial

effects

Inequity

Opioids

Pain Management



costs

Side Effects

Psychosocial

effects

Inequity

Opioids

Back Pain

Surgery

Opioids

Clinical Indications for

which People Initiate

Opioids for Pain

Management

Opioids



Opioids for Pain

Management

Primary

Care

Private

Insurance

Musculoskeletal

Pain

TOTAL POPULATION?

(Narcotics Monitoring System)

Opioids



Opioids for Pain

Management

TOTAL POPULATION?

(Narcotics Monitoring System)

Methods Results Discussion



Opioids for Pain

Management

Purpose

Appropriateness – Dose, duration,

type, indication

Alternatives

Guidelines by Clinical Indication

Resource Allocation

Purpose Methods Results Discussion

Narcotics Monitoring System (NMS)

1. Data Sources

2. Inclusion/Exclusion

3. Identifying Apparent Clinical Indication

4. Prescription and Patient Characteristics


Narcotics Monitoring System (NMS): Ontarians with an opioid

dispensed (April 1, 2015-March 31, 2016)

Previously dispensed an opioid

Opioid prescribed was for cough or Opioid

Maintenance Therapy

1. Data Sources




People who newly Initiated Opioids for Pain

Management (April 1, 2015-March 31, 2016)


Stepwise

Hierarchical

Approach

1. Data Sources






Cohort A

Palliative

Cancer

Usi

ng

MA

IN diagnosis

fro

m h

ealt

hca

re r

eco

rd t

hat

led

to

in

dex

opio

id p

resc

ripti

on

Physician-prescribed

dental pain

Non-surgical deliveries

Hernia repair surgeries

Dentist

prescription

Evidence of palliative

care in past year

Cohort B

Caesarian section

Usi

ng

IC

D-1

0 procedure

co

des

on

hea

lth

care

reco

rd t

hat

led

to

in

dex

op

ioid

pre

scri

pti

on

Knee, hip, shoulder

surgeries

Common excisions

Other surgeries

Dentist-prescribed dental Pain

Evidence of cancer

diagnosis or treatment

in past year

Cohort C

Unknown

No records

found

Diagnosis not a plausible

indication for opioids

Fractures and major trauma

Dislocations, sprains, strains

Burns, wounds, and

superficial trauma

Other trauma

Back pain

Joint and muscle pain

Nephrolithiasis and

cholecystitis

Headache and migraine

Infection

Eyes, ears, nose, and throat

pain

Abdominal/pelvic pain

Chest pain

Other pain

Legend

Allocation to an apparent clinical indication

Continuation of cohort not yet allocated to

an indication onto next hierarchical step

Cohort that has not yet been assigned to an

apparent clinical indication

Cohort allocated to a specific clinical indication




1. Data Sources




Stepwise

Hierarchical

ApproachProvider of prescription = Dentist

Evidence of Cancer (12 months)

Evidence of Palliative Care (12 months)

Re

ce

nt

He

alth

ca

re

Inte

ractions

(≤5

da

ys) Procedural Codes

Unknown

Diagnosis Codes

Deliveries,

Surgeries, etc.

Back pain,

Gallstone, etc.




1. Data Sources




Stepwise

Hierarchical

ApproachProvider of prescription = Dentist

Evidence of Cancer (12 months)

Evidence of Palliative Care (12 months)

Re

ce

nt

He

alth

ca

re

Inte

ractions

(≤5

da

ys) Procedural Codes

Unknown

Diagnosis Codes

Deliveries,

Surgeries, etc.

Back pain,

Gallstone, etc.

Purpose Discussion

1. Data Sources




Clinical Indications Indication Clusters

Methods Results

Dental pain (dentist prescribed)

Dental pain (physician prescribed)

Hernia repairs

Knee/hip/shoulder surgeries

Back pain

Joint/muscle pain

Cancer

Abdominal/pelvic pain

Kidney and gallstones

Etc.

23 CLINICAL INDICATIONS

Dental

Postsurgical

Musculoskeletal

Trauma-related

Cancer/palliative

Other

6 INDICATION CLUSTERS

Purpose Discussion

1. Data Sources




Indication Clusters

Daily Dose

Duration

Opioid formulation

Patient Characteristics

Methods Results

Relative contribution

Clinical Indications


6.0%

5.3%

4.0%

7.1%

4.2%

22.0%

12.0%

11.7%

1.2%

7.2%

4.9%

13.2%

1.2%

Unknown

Other

Cancer/palliative

Trauma

Musculoskeletal

Postsurgical

Dental

653,993

Dentist, Physician

Common excisions,

knee/hip/shoulder, hernia, C-

section, other Joint/muscle, back

Dislocations/sprains/strains,

fracture/major, burns/wounds/superficial,

otherCancer, palliative care

Abdominal/pelvic, stones, infection,

deliveries, headache/migraine

Relative Contribution Daily Dose Duration Formulation Patient


Median: 34 MME (23-45) ≥50 MME: 23.9%

Dental

Postsurgical

Musculoskeletal

Trauma

Cancer/palliative

Other

30 (23-45)

45 (29-64)

30 (17-45)

34 (19-50)

38 (23-54)

33 (19-45)

13.9%

40.5%

22.4%

25.0%

30.3%

23.5%




Median: 34 MME (23-45) ≥50 MME: 23.9%

38 (25-50)

60 (45-90)

45 (28-56)

50 (33-68)

45 (27-60)

31.0%

64.7%

34.3%

50.3%

37.1%

Common excisions

Knee/hip/shoulder

Hernia

C-section

Other surgeries

Kidney and gallstones 45 (28-57) 38.9%



Median: 4 days (3-6) >7 days: 17.4%

Dental

Postsurgical

Musculoskeletal

Trauma

Cancer/palliative

Other

3 (3-5)

4 (3-5)

5 (3-10)

4 (3-7)

4 (3-7)

4 (3-5)

3.8%

10.9%

34.2%

21.2%

21.8%

16.2%


Relative Contribution Formulation Patient

5 (4-10)

5 (3-10)

37.7%

29.4%

Joint/muscle

Back

Headache/migraine 5 (3-9) 28.1%

Daily Dose Duration

Median: 4 days (3-6) >7 days: 17.4%



98.60%

Long-acting only

Immediate-release only

Both

653,993



Overall (48, 29-63)Dental (31, 20-52) Cancer/palliative (66, 55-77)

MEDIAN AGE

Opioids



Opioids for Pain

Management



Dentist-prescribed Dental Pain = 1/5 of new opioid initiations

Postsurgical pain

(Knee/hip/shoulder, C-section)

Musculoskeletal pain

(back, joint/muscle)

Recommended to be below 90 MME, ideally below 50 MME.Above 50 MME, more incidence of road trauma, side effects, mortality.

Guidelines suggest not 7 days, ideally not above 3.This longer initial prescription duration -> increased risk of long-term use.

Higher daily dosesShorter durations

Lower daily dosesLonger durations


Risks of long-term use?

Who gets refills amongst this group? Intended longer duration or

unintended?

Dentist-prescribed Dental Pain = 1/5 of new opioid initiations

Postsurgical pain

(Knee/hip/shoulder, C-section)

Musculoskeletal pain

(back, joint/muscle)


Limitations

1. Certainty of stepwise hierarchical approach

2. Unknown (78,481, 12.0%)

3. Multiple pain indications

Appropriateness – Dose, duration, length, indication

Alternatives

Guidelines by Clinical Indication



Opioids for Pain

Management

Resource Allocation

Manuscript Coming Soon …

• Accepted to PAIN

References

• https://upload.wikimedia.org/wikipedia/en/c/c8/Trileptal_tablets.jpg

• https://www.canada.ca/en/public-health/services/publications/healthy-living/apparent-opioid-related-deaths-report-2016-2017-december.html

• https://www.publicdomainpictures.net/en/view-image.php?image=174447&picture=&jazyk=DE

• https://www.ncbi.nlm.nih.gov/pubmed/18443635

• https://c1.staticflickr.com/5/4566/24328746088_5f7c130180_b.jpg

• https://vimeo.com/167689608

• https://www.marketwatch.com/story/how-much-the-opioid-epidemic-costs-the-us-2017-10-27

• https://www.cnbc.com/2018/02/12/economic-cost-of-the-opioid-crisis-1-trillion-and-growing-faster.html

• https://www.vox.com/science-and-health/2017/11/20/16679688/white-house-opioid-epidemic-cost

• https://globalnews.ca/news/3743705/canadas-opioid-crisis-is-burdening-the-health-care-system-report-warns/

• https://www.cihi.ca/en/opioid-crisis-having-significant-impact-on-canadas-health-care-system

• https://commons.wikimedia.org/wiki/File:Medicon_cough.svg

• http://www.choosingwisely.org/patient-resources/treating-migraine-headaches/

https://upload.wikimedia.org/wikipedia/en/c/c8/Trileptal_tablets.jpg

https://www.canada.ca/en/public-health/services/publications/healthy-living/apparent-opioid-related-deaths-report-2016-2017-december.html

https://www.publicdomainpictures.net/en/view-image.php?image=174447&picture=&jazyk=DE

https://www.ncbi.nlm.nih.gov/pubmed/18443635

https://c1.staticflickr.com/5/4566/24328746088_5f7c130180_b.jpg

https://vimeo.com/167689608

https://www.marketwatch.com/story/how-much-the-opioid-epidemic-costs-the-us-2017-10-27

https://www.cnbc.com/2018/02/12/economic-cost-of-the-opioid-crisis-1-trillion-and-growing-faster.html

https://www.vox.com/science-and-health/2017/11/20/16679688/white-house-opioid-epidemic-cost

https://globalnews.ca/news/3743705/canadas-opioid-crisis-is-burdening-the-health-care-system-report-warns/

https://www.cihi.ca/en/opioid-crisis-having-significant-impact-on-canadas-health-care-system

https://commons.wikimedia.org/wiki/File:Medicon_cough.svg

http://www.choosingwisely.org/patient-resources/treating-migraine-headaches/

BACK DECK

2016

2017Jan.-June

Opioid-related deaths

Opioid-related deaths

2681

1460

Purpose Discussion

Narcotics Monitoring System (NMS):

Ontarians with an opioid (not OMT)

dispensed (April 1, 2015-March 31, 2016)

Missing IKN

Previously dispensed an opioid (not OMT)

Previously dispensed an opioid (OMT)

Previously opioid toxicity incident

Missing data

Opioid prescribed was an antitussive



Methods Results

Who was included/excluded?

n = 1,957,552

1 (<0.01%)

1,153,619 (59.5%)

3,871 (0.2%)

96 (<0.01%)

2,138 (0.1%)

124,810 (16.0%)

653,993 (33.4%)


Type of Opioid

IR Codeine Combination

653,993

IR Oxycodone Combination 20.0%

Cancer and palliative IR Hydromorphone (23.5%)

53.2%


Other Limitations

1. July 2012 onwards

2. Inter-province travel (lag period for health system access)

For more information

Acknowledgements• For the SALOME and NAOMI trials

– The participants– Frontline workers at the Crosstown clinic– Research team– Partners, past and present:

• Providence Health Care, Providence Health Care Research Institute, St. Paul’s Hospital Foundation

• Vancouver Coastal Health• Canadian Institutes of Health Research• InnerChange foundation• Michael Smith Foundation for Health Research• University of British Columbia• Center for Health Evaluation and Outcomes Science• Canada Research Chairs Program• BC Ministry of Health

• For the economic analysis

– Dr. Bohdan Nosyk for his work developing the initial model and protocol for the study.• Email: [email protected]

School of Population and Public Health

mailto:[email protected]

Documents

Title Slide - cadth.ca · Pharmaceuticals; and Troy Healthcare. Michael L. Reed, PhD, is Managing Director of Vedanta Research, ... patent or other intellectual property in Allergan