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. 2021 Nov 1;18(11):e1003829.
doi: 10.1371/journal.pmed.1003829. eCollection 2021 Nov.

Opioid prescribing among new users for non-cancer pain in the USA, Canada, UK, and Taiwan: A population-based cohort study

Meghna Jani  1   2 , Nadyne Girard  3   4 , David W Bates  5   6   7 , David L Buckeridge  3   4 , Therese Sheppard  1 , Jack Li  8   9 , Usman Iqbal  8   9 , Shelly Vik  10   11 , Colin Weaver  10   11 , Judy Seidel  10   11 , William G Dixon  1   2 , Robyn Tamblyn  3   4
Affiliations

Opioid prescribing among new users for non-cancer pain in the USA, Canada, UK, and Taiwan: A population-based cohort study

Meghna Jani et al. PLoS Med. .

Abstract

Background: The opioid epidemic in North America has been driven by an increase in the use and potency of prescription opioids, with ensuing excessive opioid-related deaths. Internationally, there are lower rates of opioid-related mortality, possibly because of differences in prescribing and health system policies. Our aim was to compare opioid prescribing rates in patients without cancer, across 5 centers in 4 countries. In addition, we evaluated differences in the type, strength, and starting dose of medication and whether these characteristics changed over time.

Methods and findings: We conducted a retrospective multicenter cohort study of adults who are new users of opioids without prior cancer. Electronic health records and administrative health records from Boston (United States), Quebec and Alberta (Canada), United Kingdom, and Taiwan were used to identify patients between 2006 and 2015. Standard dosages in morphine milligram equivalents (MMEs) were calculated according to The Centers for Disease Control and Prevention. Age- and sex-standardized opioid prescribing rates were calculated for each jurisdiction. Of the 2,542,890 patients included, 44,690 were from Boston (US), 1,420,136 Alberta, 26,871 Quebec (Canada), 1,012,939 UK, and 38,254 Taiwan. The highest standardized opioid prescribing rates in 2014 were observed in Alberta at 66/1,000 persons compared to 52, 51, and 18/1,000 in the UK, US, and Quebec, respectively. The median MME/day (IQR) at initiation was highest in Boston at 38 (20 to 45); followed by Quebec, 27 (18 to 43); Alberta, 23 (9 to 38); UK, 12 (7 to 20); and Taiwan, 8 (4 to 11). Oxycodone was the first prescribed opioid in 65% of patients in the US cohort compared to 14% in Quebec, 4% in Alberta, 0.1% in the UK, and none in Taiwan. One of the limitations was that data were not available from all centers for the entirety of the 10-year period.

Conclusions: In this study, we observed substantial differences in opioid prescribing practices for non-cancer pain between jurisdictions. The preference to start patients on higher MME/day and more potent opioids in North America may be a contributing cause to the opioid epidemic.

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Conflict of interest statement

I have read the journal’s policy and the authors of this manuscript have the following competing interests: MJ is a member of the MHRA Opioids Expert Working Group. DB outlines the following disclosures, none directly relevant to this publication. He consults for EarlySense, which makes patient safety monitoring systems. He receives cash compensation from CDI (Negev), Ltd, which is a not-for-profit incubator for health IT startups. He receives equity from ValeraHealth which makes software to help patients with chronic diseases. He receives equity from Clew which makes software to support clinical decision-making in intensive care. He receives equity from MDClone which takes clinical data and produces deidentified versions of it. He receives equity from AESOP which makes software to reduce medication error rates. He receives research funding from IBM Watson Health. WGD has received consultancy fees from Google and Bayer, unrelated to this work. The other others report no conflicts of interests.

Figures

Fig 1
Fig 1. Age- and sex-standardized rates of opioid use per 1,000 population.
Fig 2
Fig 2. Daily dose of first opioid prescription in MMEs.
The lower limit of the box plot represents the lowest standardized dose, the lower and upper ends of the colored box the interquartile range, the line in the box represents the median, and the circle the mean standardized dose. For this box plot, the upper limit of the box plot is set to the 95th percentile. CDC, Centers for Disease Control and Prevention; MME, morphine milligram equivalent.
Fig 3
Fig 3. Type of opioid on initiation.
Fig 4
Fig 4. Opioid trends over time by drug.
See this image and copyright information in PMC

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