- Risk mitigation guidance in B.C. allows opioid and stimulant prescriptions for people at risk of overdose
- A study examined the effect of these prescriptions on deaths and hospital visits
- Prescribing opioids significantly reduced the risk of death from overdose and all causes
In March 2020, at the beginning of the COVID-19 pandemic, risk mitigation guidance (RMG) was issued in B.C. This provided certain healthcare providers with guidance about prescribing medications, including opioids and stimulants, as an alternative to the unregulated drug supply for people who were at risk of COVID-19 and overdose. This practice is commonly referred to as prescribed safer supply. The RMG was informed by evidence and clinical guidance on the treatment of substance use disorder. It was the first clinical guidance provided by a provincial government to support healthcare providers to prescribe alternatives to the unregulated drug supply.
Providing pharmaceutical alternatives to the toxic drug supply (referred to here as RMG medications) is a new practice that has developed in response to the public health crisis of unregulated drug toxicity (overdose) deaths. The aim of this study was to examine population-level evidence about the effects of RMG medications on the risk of death and hospital visits due to overdose and all causes.
Study details
This study examined linked data from a number of population-level administrative databases, including data from public health insurance plans, community pharmacies, hospitals, corrections and coroners’ records. The study population was residents of B.C. who had an indication of opioid or stimulant use disorder (i.e., people whose records showed a likely diagnosis of opioid or stimulant use disorder or who had been provided with opioid agonist treatment medication).
Participant records were followed starting from the week of March 27, 2020, or the first week in which records indicated a person had an opioid or stimulant use disorder, whichever was most recent. Follow-up ended when a person died or was incarcerated or when the study period ended on August 31, 2021.
Pharmaceutical alternatives included in the RMG (e.g., tablet hydromorphone or oral morphine for opioids; methylphenidate or dextroamphetamine for stimulants) can also be prescribed for other purposes (e.g., pain management, treatment of ADHD). For this reason, the study used algorithms to identify prescriptions for RMG medications in pharmacy dispensing records.
To create a comparison group, the researchers individually matched people who received RMG medications to people who did not receive them. Over 50 demographic, socio-economic and other factors were included in the matching process. Receipt of opioid agonist treatment (OAT) was included as a control.
Data were analyzed in weekly intervals. People were most often provided RMG medications on-and-off for multiple weeks throughout the study period. Some people received pharmaceutical alternatives for only one week or received them continuously for multiple weeks. In analyzing the data by week, the researchers were able to examine the immediate effects of receiving RMG medications.
Study results
The study identified 70,360 people with an opioid use disorder, 5,356 (7.6%) of whom were provided opioid RMG medications. Among the 41,890 people identified with a stimulant use disorder, 1,061 (2.5%) were provided stimulant RMG medications. A total of 535 people received both opioid and stimulant RMG medications.
Characteristics of people who received opioid RMG medications include:
- female – 36.4%
- median age – 38 years
- live in a rural region – 9.9%
- received income assistance in the past year – 83.0%
- had unstable housing in the past year – 38.1%
- had ever been diagnosed with HIV – 7.3%
- had ever been diagnosed with hepatitis C – 22.1%
Characteristics of people who received stimulant RMG medications include:
- female – 38.5%
- median age – 39 years
- live in a rural region – 15.3%
- received income assistance in the past year – 79.2%
- had unstable housing in the past year – 39.3%
- had ever been diagnosed with HIV – 8.5%
- had ever been diagnosed with hepatitis C – 21.8%
The matched comparison groups had very similar characteristics.
Effects of opioid RMG medications
People who received one or more days of opioid RMG medications were 61% less likely to die from all causes and 55% less likely to die from overdose in the week following provision of pharmaceutical opioids. The protective effect increased with the number of days they received RMG medications during the week. When people received opioid RMG medications on four or more days, they had a 91% reduced risk of death from all causes and an 89% reduced risk of dying from overdose in the following week.
Receiving opioid RMG medications was not associated with significant changes in the risk of hospital visits for all causes or for overdose.
Effects of stimulant RMG medications
The number of people who were provided only stimulant RMG medications was small, making it challenging to draw conclusions about the effects. Receiving one or more days of stimulant RMG medications was associated with a lower risk of death from all causes and from overdose in the week following provision of stimulant medications, but these results were not statistically significant. Similar results were found for people who received stimulant RMG medications on four or more days.
People receiving stimulant RMG medications were significantly less likely to access the hospital for any cause.
Need for increased access to RMG medications and ongoing evaluation
This study found that access to RMG medications was very limited among people with an opioid or stimulant use disorder in B.C. Fewer than one in 10 people with an opioid use disorder and fewer than one in 40 people with a stimulant use disorder received RMG medications during the study period.
Among people who had an opioid use disorder, receiving opioid RMG medications significantly lowered the risk of death from all causes and overdoses. When people received opioid RMG medications on four or more days in a week, the risk of death from all causes and overdoses was reduced even further. These effects may be related to findings from other research showing that RMG medications reduce people’s reliance on the unregulated drug supply.
Among people who had a stimulant use disorder, receiving stimulant RMG medications significantly reduced the risk of hospital visits for all causes. Because there are very few treatment or care options for people with stimulant use disorder, this effect may be related to the benefits of increased engagement in care.
This study provides population-level evidence that opioid pharmaceutical alternatives are a promising intervention that can dramatically reduce death among people with an opioid use disorder. Further research and evaluation are needed to reduce harms and to better understand the impact of pharmaceutical alternatives. Research is also needed to determine the role of different aspects of pharmaceutical alternatives on health outcomes (e.g., understanding the effects of receiving the medications themselves and the effects of supports from healthcare providers).
REFERENCES:
- Slaunwhite A, Min J, Palis H et al. Effect of Risk Mitigation Guidance for opioid and stimulant dispensations on mortality and acute care visits during dual public health emergencies: retrospective cohort study. BMJ. 2024;384:e076336.
- McNeil R, Fleming T, Mayer S et al. Implementation of safe supply alternatives during intersecting COVID-19 and overdose health emergencies in British Columbia, Canada, 2021. American Journal of Public Health. 2022;112(S2):S151-8.