NON-ILLICIT, NON-METHADONE,

PRESCRIPTION OPIOID OVERDOSE

DEATHS IN BC'S INTERIOR:
Findings from a retrospective case series, 2006-2011.
T Corneil MD MHSc FCFP FRCPC
Medical Health Officer, September 13 2014
Methadone Workshop CPSBC

Background
22% of BC residents suffer from chronic pain (IASP
pain that persists beyond the normal tissue healing
time ~ 3 months)
One third seek medical (physician) care
Of those who see a physician 50-60% are provided
with an opioid for pain management
Based on these results, est. ~25,000 IH residents are
on opioids for CP
Rate of accidental overdose ~ MVI EtOH
deaths in BC!
2014-09-13

Background
n=22

n=74

2014-09-13

Comparison
!

Average$rate$per$100,000$py$2005A2009$$
(annual$mean$number$of$deaths)$
2.7$

3!
2.5!
2!

1.9$

1.7$

1.5!

1.2$

1.3$

VCH*$
(18.0)$

FH*$$$
(20.2)$

2.1$

1!
0.5!
0!

BC*$$$$
(73.2)$

IH$$$$$$
(19.4)$

VI$$$$$$
(14.2)$

NH$$$$$$$
(6.0)$

Figure'1a.'Non.illicit,'non.methadone,'prescription'opioid'overdose'annual'mean'and'
average'rate'of'deaths'in'BC'and'constituent'health'regions'from'2005.2009.'(*p<0.05,'
ANOVA'with'post.hoc'tukey'analysis)'
2014-09-13

Purpose
To explore what associations and risk factors are
contributing to the increased rate of non-illicit, nonmethadone, prescription opioid overdose deaths in
the interior region.

2014-09-13

Questions
1. Who: what are common characteristics of those
who overdose accidentally from Rx opioids?
2. How: what contributes to the rate of Rx opioid
overdose deaths in IH?
3. Why IH: is the rate of Rx opioid overdose
deaths in IH higher than VCH, FH, and BC?
4. What can we do: early preventative public health
measures can we implement locally?

2014-09-13

Methods
Retrospective case series of coroner files from the
deaths of IH residents extracting information
from:
a) Standardized BC vital statistics certificates/reports
(Jan 2006-May 2011, n=110)
b) Contextual coroner documents/notes (Jan 2008May 2011, n=55)
c) Medication profiles (Jan 2010-May 2011, n=26)

2014-09-13

Case Definition
A death within the IH region of an IH resident coded
by the BC Coroners service as a non- illicit, nonmethadone, prescription opioid overdose
death, and involving one or more opioid
medications on post-mortem serum toxicology

2014-09-13

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new age and gender data

May-Hadford, Jennifer
female
= male, median age 50 yo
87.3% between 20 and 60 yo

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Age"group
20@29
30@39
40@49
50@59

Number"of"deaths
7
18
28
43

2014-09-13

Results - geography

2014-09-13

Results IH rate comparison

2014-09-13

Results risk factors

2014-09-13

Results toxicology

2014-09-13

Results toxicology

2014-09-13

Results Rx profiles

2014-09-13

Conclusions drawn
1) High dose opioid (>200mg morphine equivalent)
prescription is not necessary for an overdose
death.
2) The use of adjuvant non-opioid pain medications
with neuro-toxic potential may be contributing to
overdose deaths in persons with chronic pain.

2014-09-13

Actions taken to date

Inform PHO, BC Cornoner, CPSBC, CPBC, HOC
Share this information with GPs, psychiatrists, and
pharmacists
Provide patient education tools to distribute to
those seeking care for chronic pain
Broaden the IH-BCCDC Naloxone opioid overdose
prevention pilot (www.towardtheheart.com) to
include those with chronic pain

2014-09-13

Further actions
a. Continue to collect grey literature, and extract case
data to increase strength of associations
b. Support a review of all non-illicit, non-methadone,
prescription opioid overdose deaths in the province
by the BC Coroners Office
c. Implement a sentinel emergency room overdose
surveillance program to gather contextual premortem information
d. Actively monitoring new cases to evaluate and
measure changes in risk factor and rate

2014-09-13

Limitations
Prescription drug profiles are very dependent access to BC
Pharmanet history (available in about 20% of the files
reviewed)
Extracting comparative data from other regions in the
province is not possible due to restrictions on data
sharing between government agencies and health authorities.
More robust analyses of risk ratios require case-control
cohorts comparing our cases with a) opioid cases involving a
different cause of death, or b) persons living with chronic pain;
privacy laws limit access to both datasets

2014-09-13

Summary
1. Who:
Consistent with the literature:
lower age (median 50)
chronic pain (82%)
co-morbid mental
health disorders (45%)
Different from the literature:
higher proportion of
accidental versus
suicide deaths (85%)

far fewer cases involving a

high dose opioid (25%)
low unemployment/
disability (16%)
low Status Aboriginal (5%)
limited contributory
alcohol (16%)
negligible multi-doctor Rx
(3%)

2014-09-13

Summary
2. How:
Large number of cases (93%) with adjuvant pharmaceutical
classes, or poly-pharmacy, found on post-mortem serum
toxicology testing and validated with Rx profiles with
potential neurological side-effects.
3. Why IH:
At this time we are unable to identify any risk factor that is
causally associated with the region (no comparison data, no
plausible explanation). Speculations

2014-09-13

Summary
4. What can we do:
Educate patients and providers regarding the conclusions we
have drawn about accidental overdose deaths so far

deaths can occur at any opioid dose

deaths usually involve polypharmacy

2014-09-13

Questions

2014-09-13