People with an opioid-use disorder who were prescribed at least one day’s supply of opioids as part of the Province of British Columbia’s Risk Mitigation Guidance were 61-per-cent less likely to die in the following week when compared to a similar group of people who did not receive a prescription.
The new research, published this week in the British Medical Journal (BMJ), evaluates the effectiveness of Risk Mitigation Guidance*. This is the first known instance of a North American province or state providing clinical guidance to physicians and nurse practitioners for prescribing pharmaceutical alternatives to patients at risk of death from the toxic drug supply.
“This is the first study to evaluate prescribing pharmaceutical alternatives at a population level. We demonstrated that providing pharmaceutical alternatives to the toxic and unpredictable street drug supply is associated with a reduction in deaths in the days immediately following,” says Dr. Amanda Slaunwhite, senior scientist with the BC Centre for Disease Control, assistant professor at the University of British Columbia’s School of Population and Public Health, and scientist at the Centre for Advancing Health Outcomes, housed in St. Paul’s Hospital.
Critical need for interventions to keep people alive
“With more than 13,300 lives lost in B.C. since 2016 and one of the highest death rates in the country, we need to identify and evaluate interventions that keep people alive.”
The study was a collaboration between scientists, people with lived and living experience of substance use, and public health professionals from the First Nations Health Authority, BC Centre for Disease Control, Centre for Advancing Health Outcomes, BC Centre on Substance Use at St. Paul’s Hospital, University of Victoria’s Canadian Institute for Substance Use Research, Simon Fraser University and University of British Columbia.
Those getting Rx opioids had 61-per-cent lower risk of death
The research looked at anonymized data about acute health-care use, overdose events and deaths among the 5,882 people with opioid or stimulant use disorder who filled a prescription under Risk Mitigation Guidance between March 2020 and August 2021. This cohort was compared to a very similar cohort that did not receive Risk Mitigation Guidance medication.
In addition to finding that the cohort of people who were prescribed pharmaceutical-grade opioids had a 61-per-cent lower risk of death from any cause the following week, this group was also 55 per cent less likely to die of a drug poisoning event (overdose) the following week.
Prescribing regulated drugs a beneficial harm-reduction treatment
“Deaths from the toxic drug supply are preventable and pharmaceutical alternatives can reduce risk of death by making people less reliant on the unpredictable and toxic drug supply,” says Dr. Bohdan Nosyk, a professor in the Faculty of Health Sciences at Simon Fraser University and scientist at the Centre for Advancing Health Outcomes.
“Like naloxone and needle distribution programs, prescription of regulated drugs is a harm reduction intervention and provides benefits only while prescriptions are being used.”
While the study only reports on the immediate benefit associated with receiving pharmaceutical alternatives to the toxic drug supply in the week following a prescription being filled, it showed that the protective effect increased with the number of days opioid medications were dispensed. People who received four or more days of prescription opioids were 91 per cent less likely to die from any cause, and 89 per cent less likely to die from overdose in the following week.
The number of people accessing stimulant prescriptions was relatively small in this analysis. As a result, findings on the reduction in mortality for the approximately 500 people who were prescribed only stimulants were less certain but in line with the effects of opioid prescription, and they show a decrease in the likelihood of acute care visits.
In addition, this study was not able to assess whether someone used their prescription and whether the medications were used as prescribed.
Further research is needed to assess the effectiveness of the Prescribed Safer Supply policy direction introduced in July 2021 which supports clinicians in prescribing pharmaceutical alternatives to the toxic drug supply beyond the context of the COVID-19 pandemic.
BACKGROUND
- Risk Mitigation Guidance was introduced in British Columbia in March 2020, to support healthcare providers in prescribing select medications, including opioids and stimulants, to people at risk of overdose and withdrawal during the dual public health emergencies of unregulated toxic drugs and the COVID-19 pandemic, when physical distancing and self-isolation were encouraged.
- The Risk Mitigation Guidance tool for clinicians enabled people at high risk of drug poisoning from the toxic, unregulated market to access pharmaceutical-grade drugs of known composition and potency such as:
o Opioids like hydromorphone and M-Eslon (morphine)
o Stimulants like methylphenidate
o Benzodiazepines
o Alcohol withdrawal management medications - The goal of Risk Mitigation Guidance was to reduce the harm caused by exposure to the toxic drug supply and to enable physical distancing, self-isolation, and quarantine measures, where possible, to reduce and prevent the spread of COVID-19.
- Drug poisoning (or overdose) deaths are caused by the increasingly toxic, unregulated drug supply contaminated with fentanyl, benzodiazepines, and other substances.
- According to the latest data from the BC Coroners Service, the province is expected to report an unprecedented number of unregulated drug-related deaths in 2023, with about seven people dying each day.
- Those who are accessing this harm reduction intervention are more likely to live in urban areas, according to previous analyses.
