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Cid A, Mahajan N, Wong WWL, Beazely M, Grindrod KA. An economic evaluation of community pharmacy-dispensed naloxone in Canada. Can Pharm J (Ott) 2024; 157:84-94. [PMID: 38463179 PMCID: PMC10924576 DOI: 10.1177/17151635241228241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 03/12/2024]
Abstract
Aims To determine the cost-effectiveness of pharmacy-based intranasal (IN) and intramuscular (IM) naloxone distribution in Canada. Methods We developed a state-transition model for pharmacy-based naloxone distribution, every 3 years, to illicit, prescription, opioid-agonist therapy and nonopioid use populations compared to no naloxone distribution. We used a monthly cycle length, lifetime horizon and a Canadian provincial Ministry of Health perspective. Transition probabilities, cost and utility data were retrieved from the literature. Costs (2020) and quality-adjusted life years (QALY) were discounted 1.5% annually. Microsimulation, 1-way and probabilistic sensitivity analyses were conducted. Results Distribution of naloxone to all Canadians compared to no distribution prevented 151 additional overdose deaths per 10,000 persons, with an incremental cost-effectiveness ratio (ICER) of $50,984 per QALY for IM naloxone and an ICER of $126,060 per QALY for IN naloxone. Distribution of any naloxone to only illicit opioid users was the most cost-effective. One-way sensitivity analysis showed that survival rates for illicit opioid users were most influenced by the availability of either emergency medical services or naloxone. Conclusion Distribution of IM and IN naloxone to all Canadians every 3 years is likely cost-effective at a willingness-to-pay threshold of $140,000 Canadian dollars/QALY (~3 × gross domestic product from the World Health Organization). Distribution to people who use illicit opioids was most cost-effective and prevented the most deaths. This is important, as more overdose deaths could be prevented through nationwide public funding of IN naloxone kits through pharmacies, since individuals report a preference for IN naloxone and these formulations are easier to use, save lives and are cost-effective. Can Pharm J (Ott) 2024;157:xx-xx.
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Affiliation(s)
- Ashley Cid
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - Nikita Mahajan
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - William W L Wong
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - Michael Beazely
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - Kelly A Grindrod
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
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Booth RG, Shariff SZ, Carter B, Hwang SW, Orkin AM, Forchuk C, Gomes T. Opioid-related overdose deaths among people experiencing homelessness, 2017 to 2021: A population-based analysis using coroner and health administrative data from Ontario, Canada. Addiction 2024; 119:334-344. [PMID: 37845790 DOI: 10.1111/add.16357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/28/2023] [Indexed: 10/18/2023]
Abstract
AIMS To measure the change in proportion of opioid-related overdose deaths attributed to people experiencing homelessness and to compare the opioid-related fatalities between individuals experiencing homelessness and not experiencing homelessness at time of death. DESIGN, SETTING AND PARTICIPANTS Population-based, time-trend analysis using coroner and health administrative databases from Ontario, Canada from 1 July 2017 and 30 June 2021. MEASUREMENTS Quarterly proportion of opioid-related overdose deaths attributed to people experiencing homelessness. We also obtained socio-demographic and health characteristics of decedents, health-care encounters preceding death, substances directly contributing to death and circumstances surrounding deaths. FINDINGS A total of 6644 individuals (median age = 40 years, interquartile range = 31-51; 74.1% male) experienced an accidental opioid-related overdose death, among whom 884 (13.3%) were identified as experiencing homelessness at the time of death. The quarterly proportion of opioid-related overdose deaths attributed to people experiencing homelessness increased from 7.2% (26/359) in July-September 2017 to 16.8% (97/578) by April-June 2021 (trend test P < 0.01). Compared with housed decedents, those experiencing homelessness were younger (61.3 versus 53.1% aged 25-44), had higher prevalence of mental health or substance use disorders (77.1 versus 67.1%) and more often visited hospitals (32.1 versus 24.5%) and emergency departments (82.6 versus 68.5%) in the year prior to death. Fentanyl and its analogues more often directly contributed to death among people experiencing homelessness (94.0 versus 81.4%), as did stimulants (67.4 versus 51.6%); in contrast, methadone was less often present (7.8 versus 12.4%). Individuals experiencing homelessness were more often in the presence of a bystander during the acute toxicity event that led to death (55.8 versus 49.7%); and where another individual was present, more often had a resuscitation attempted (61.7 versus 55.1%) or naloxone administered (41.2 versus 28.9%). CONCLUSIONS People experiencing homelessness account for an increasing proportion of fatal opioid-related overdoses in Ontario, Canada, reaching nearly one in six such deaths in 2021.
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Affiliation(s)
- Richard G Booth
- Arthur Labatt Family School of Nursing, Western University, London, Canada
- ICES (formerly the Institute for Clinical Evaluative Sciences), Ontario, Canada
- London Health Sciences Centre, Lawson Health Research Institute, London, Canada
| | - Salimah Z Shariff
- Arthur Labatt Family School of Nursing, Western University, London, Canada
- ICES (formerly the Institute for Clinical Evaluative Sciences), Ontario, Canada
- London Health Sciences Centre, Lawson Health Research Institute, London, Canada
| | - Brooke Carter
- ICES (formerly the Institute for Clinical Evaluative Sciences), Ontario, Canada
- London Health Sciences Centre, Lawson Health Research Institute, London, Canada
| | - Stephen W Hwang
- ICES (formerly the Institute for Clinical Evaluative Sciences), Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
| | - Aaron M Orkin
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Emergency Medicine, St Joseph's Health Centre, Toronto, Canada
| | - Cheryl Forchuk
- Arthur Labatt Family School of Nursing, Western University, London, Canada
- London Health Sciences Centre, Lawson Health Research Institute, London, Canada
| | - Tara Gomes
- ICES (formerly the Institute for Clinical Evaluative Sciences), Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Schmidt RA, Kaminski N, Kryszajtys DT, Rudzinski K, Perri M, Guta A, Benoit AC, Bayoumi AM, Challacombe L, Hales J, Kenny K, Kolla G, O'Reilly E, Sereda A, Rai N, Strike C. 'I don't chase drugs as much anymore, and I'm not dead': Client reported outcomes associated with safer opioid supply programs in Ontario, Canada. Drug Alcohol Rev 2023; 42:1825-1837. [PMID: 37718646 DOI: 10.1111/dar.13745] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/26/2023] [Accepted: 08/22/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION The ongoing opioid overdose crisis, which has killed over 30,000 people in Canada since 2016, is driven by the volatility of an unregulated opioid drug supply comprised primarily of fentanyl. The Canadian government has recently funded safer opioid supply (SOS) programs, which include off-label prescriptions of pharmaceutical-grade opioids to high risk individuals with the goal of reducing overdose deaths. METHODS In 2021, we examined the implementation and adaption of four SOS programs in Ontario. These programs use a primary care model and serve communities experiencing marginalisation. We conducted semi-structured interviews with program clients. We present the results of a thematic analysis with the aim of describing clients' self-reported impact of these programs on their health and well-being. RESULTS We interviewed 52 clients between June and October 2021 (mean age 47 years, 56% men, 17% self-identified Indigenous, 14% living with HIV). Our results indicate multifaceted pathways to improved self-reported health and well-being among clients including changes to drug use practices, fewer overdoses, reduced criminalised activity, improved trust and engagement in health care, and increased social stability (e.g., housing). DISCUSSION AND CONCLUSION Most clients reported that the intervention saved their life because of the reduced frequency of overdoses. Findings suggest that SOS programs improved clients' health outcomes and increase opportunities for engagement in health services. Our results provide insight into the mechanisms behind some of the emergent evidence on the impact of safer supply prescribing.
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Affiliation(s)
- Rose A Schmidt
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
| | - Nat Kaminski
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - David T Kryszajtys
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Katherine Rudzinski
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- School of Social Work, University of Windsor, Windsor, Canada
| | - Melissa Perri
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Adrian Guta
- School of Social Work, University of Windsor, Windsor, Canada
| | - Anita C Benoit
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Health and Society, University of Toronto Scarborough, Scarborough, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Ahmed M Bayoumi
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, Canada
| | | | - Jessica Hales
- Regent Park Community Health Centre, Toronto, Canada
| | - Kathleen Kenny
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | - Emmet O'Reilly
- South Riverdale Community Health Centre, Toronto, Canada
| | | | - Nanky Rai
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Parkdale Queen West Community Health Centre, Toronto, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Clemens KK, Ouédraogo AM, Le B, Voogt J, MacDonald M, Stranberg R, Yan JW, Krayenhoff ES, Gilliland J, Forchuk C, Van Uum R, Shariff SZ. Impact of Ontario's Harmonized Heat Warning and Information System on emergency department visits for heat-related illness in Ontario, Canada: a population-based time series analysis. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2022; 113:686-697. [PMID: 35982292 PMCID: PMC9481795 DOI: 10.17269/s41997-022-00665-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 06/20/2022] [Indexed: 06/15/2023]
Abstract
INTERVENTION Ontario's Harmonized Heat Warning and Information System (HWIS) brings harmonized, regional heat warnings and standard heat-health messaging to provincial public health units prior to periods of extreme heat. RESEARCH QUESTION Was implementation of the harmonized HWIS in May 2016 associated with a reduction in emergency department (ED) visits for heat-related illness in urban locations across Ontario, Canada? METHODS We conducted a population-based interrupted time series analysis from April 30 to September 30, 2012-2018, using administrative health and outdoor temperature data. We used autoregressive integrated moving average models to examine whether ED rates changed following implementation of the harmonized HWIS, adjusted for maximum daily temperature. We also examined whether effects differed in heat-vulnerable groups (≥65 years or <18 years, those with comorbidities, those with a recent history of homelessness), and by heat warning region. RESULTS Over the study period, heat alerts became more frequent in urban areas (6 events triggered between 2013 and 2015 and 14 events between 2016 and 2018 in Toronto, for example). The mean rate of ED visits was 47.5 per 100,000 Ontarians (range 39.7-60.1) per 2-week study interval, with peaks from June to July each year. ED rates were particularly high in those with a recent history of homelessness (mean rate 337.0 per 100,000). Although rates appeared to decline following implementation of HWIS in some subpopulations, the change was not statistically significant at a population level (rate 0.04, 95% CI: -0.03 to 0.1, p=0.278). CONCLUSION In urban areas across Ontario, ED encounters for heat-related illness may have declined in some subpopulations following HWIS, but the change was not statistically significant. Efforts to continually improve HWIS processes are important given our changing Canadian climate.
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Affiliation(s)
- Kristin K Clemens
- Department of Medicine, Western University, London, Ontario, Canada.
- ICES, Toronto, Ontario, Canada.
- St. Joseph's Health Care London, 268 Grosvenor Street, London, Ontario, N6A 4V2, Canada.
| | | | | | - James Voogt
- Department of Geography and Environment, Western University, London, Ontario, Canada
| | - Melissa MacDonald
- Environment and Climate Change Canada, Dartmouth, Nova Scotia, Canada
| | - Rebecca Stranberg
- Consumer and Hazardous Products Safety Directorate, Healthy Environments and Consumer Safety Branch, Health Canada, Ottawa, Ontario, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - E Scott Krayenhoff
- School of Environmental Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Jason Gilliland
- Department of Geography and Environment, Western University, London, Ontario, Canada
- Department of Pediatrics, Western University, London, Ontario, Canada
| | - Cheryl Forchuk
- School of Health Studies, Western University, London, Ontario, Canada
| | - Rafique Van Uum
- Department of Science, University of Toronto, Toronto, Ontario, Canada
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Spring C, Croxford S, Ward Z, Ayres R, Lord C, Desai M, Vickerman P, Artenie A. Perceived availability and carriage of take-home naloxone and factors associated with carriage among people who inject drugs in England, Wales and Northern Ireland. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 102:103615. [DOI: 10.1016/j.drugpo.2022.103615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/27/2022] [Accepted: 02/05/2022] [Indexed: 11/15/2022]
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Antoniou T, Martins D, Campbell T, Tadrous M, Munro C, Leece P, Mamdani M, Juurlink DN, Gomes T. Impact of policy changes on the provision of naloxone by pharmacies in Ontario, Canada: a population-based time-series analysis. Addiction 2021; 116:1514-1520. [PMID: 33207025 PMCID: PMC8247272 DOI: 10.1111/add.15324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 08/03/2020] [Accepted: 11/02/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS In June 2016, the Ontario, Canada government implemented the Ontario Naloxone Program for Pharmacies (ONPP), authorizing pharmacists to provide injectable naloxone kits at no charge to all Ontario residents. In March 2018, the program was amended to include intranasal naloxone and remove the requirement to present a government health card to the dispensing pharmacist. We examined whether these changes increased naloxone dispensing through the ONPP. DESIGN Population-based time-series analysis using interventional autoregressive integrated moving average models. SETTING Ontario, Canada. PARTICIPANTS All Ontario residents between 1 July 2016 and 31 March 2020. MEASUREMENTS Monthly rates of pharmacy naloxone dispensing. FINDINGS Overall, 199 484 individuals were dispensed a naloxone kit during the study period. In the main analysis, the rate of pharmacy naloxone dispensing increased by 65.1% following program changes (55.6-91.8 kits per 100 000 population between February 2018 and May 2018; P = 0.01). In subgroup analyses, naloxone dispensing increased among individuals receiving opioid agonist therapy (OAT) (3374.9-7264.2 kits per 100 000 OAT recipients; P = 0.04) among individuals receiving other prescription opioids (192.8-381.8 kits per 100 000 population prescribed opioids; P < 0.01), among individuals with past opioid exposure (134.7-205.6 kits per 100 000 population with past opioid exposure; P < 0.01) and in urban centers (56.2-91.4 kits per 100 000 population; P < 0.01). We did not observe a clear impact on pharmacy-dispensed naloxone to individuals with no or unknown opioid exposure (34.4-39.3 kits per 100 000 population with no/unknown opioid exposure; P = 0.42) and in rural regions (50.4-97.2 kits per 100 000 population; P = 0.09). CONCLUSIONS Changes to the Ontario Naloxone Program for Pharmacies to add intranasal naloxone and remove the requirement to present a government health card appeared to increase pharmacy-based naloxone dispensing uptake in Ontario, Canada, particularly among individuals at high risk of inadvertent opioid overdose.
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Affiliation(s)
- Tony Antoniou
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoOntarioCanada,ICESTorontoOntarioCanada,Department of Family and Community Medicine, Unity HealthTorontoOntarioCanada,Department of PediatricsUniversity of TorontoTorontoOntarioCanada
| | - Diana Martins
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoOntarioCanada
| | | | - Mina Tadrous
- ICESTorontoOntarioCanada,Women's College HospitalTorontoOntarioCanada,Family and Community MedicineUniversity of TorontoTorontoOntarioCanada
| | - Charlotte Munro
- Ontario Drug Policy Research Network Lived Experience Advisory GroupTorontoOntarioCanada
| | | | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoOntarioCanada,ICESTorontoOntarioCanada,Family and Community MedicineUniversity of TorontoTorontoOntarioCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoTorontoOntarioCanada,Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - David N. Juurlink
- ICESTorontoOntarioCanada,Department of PediatricsUniversity of TorontoTorontoOntarioCanada,Family and Community MedicineUniversity of TorontoTorontoOntarioCanada,Department of MedicineUniversity of TorontoTorontoOntarioCanada,The Sunnybrook Research InstituteTorontoCanada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoOntarioCanada,ICESTorontoOntarioCanada,Family and Community MedicineUniversity of TorontoTorontoOntarioCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoTorontoOntarioCanada
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