Abstract
Objective
To examine the quarterly incidence and prevalence of medications for opioid use disorder (OUD) and alcohol use disorder (AUD) from 2015 to 2021.
Methods
A retrospective population-wide observational study in Manitoba, Canada, was conducted using administrative claims data from the Manitoba Centre for Health Policy to examine the incidence and prevalence of OUD (methadone, buprenorphine-naloxone, buprenorphine) or AUD medications (naltrexone, acamprosate, disulfiram) per 10,000 individuals in each quarter between January 1, 2015, and December 31, 2021.
Results
There were 1179 and 451 individuals who received at least one prescription for OUD and AUD, respectively, in the first quarter of 2020. The prevalence of OUD medications more than doubled from 6.3 to 14.3 per 10,000 from January 1, 2015, to December 31, 2021. Likewise, AUD medication prevalence increased almost 10-fold from 0.68 to 6.5 per 10,000 from January 1, 2015, to December 31, 2021, primarily due to naltrexone. The incidence of AUD prescription use increased 8.6-fold from 0.29 to 2.51 per 10,000 during the study period. In contrast, the incidence of opioid agonist therapy declined from 2.1 per 10,000 in the first quarter of 2015 to 0.53 per 10,000 the first quarter of 2016, primarily due to methadone. Whereas methadone incidence declined, buprenorphine-naloxone incidence increased almost 15-fold during the study period.
Conclusion
An increase in both AUD medication prevalence and incidence in addition to an increase in buprenorphine-naloxone incidence was observed. These findings reflect an increase in the uptake of medications for treating AUD and OUD following changes to improve coverage and access to these medications.
Key Words/Abbreviations: alcohol use disorder; drug utilization study; opioid agonist therapy; opioid use disorder; AUD, alcohol use disorder; DPIN, Drug Program Information Network; MHSAL, Manitoba Health Seniors and Active Living; OAT, opioid agonist therapy; OUD, opioid use disorder; RAAM, Rapid Access to Addiction Medicine
Globally, the rate of substance use disorder (SUD) increased by 22% from 2010 to 2019 and has been associated with an elevated risk of premature death and disability.1-3 Opioids and alcohol are 2 common substances involved in SUDs associated with important life consequences.3-6 Both of these substances have commonly been involved in drug-related health service use and overdose deaths.4-6 Fentanyl and alcohol were among the top 3 most common primary causes of drug-related overdose deaths in Manitoba, a province of Canada, from 2017 to 2020.4 Death due to opioid overdose has increased considerably in Canada by as much as 91% during the first 2 years of the COVID-19 pandemic.6 Accumulating evidence has also linked alcohol use to increased risk of cancer, heart disease, stroke, health care costs, lost productivity, and higher risk of interaction with the justice system.7-10 New guidance on alcohol use highlights that abstinence may offer better health benefits, including better health and sleep.7 One study observed that those with alcohol use disorder (AUD) have higher rates of experiencing an adverse health outcome in the year prior to AUD being diagnosed, which highlights the need for better recognition and treatment of AUD early.9
One component of treating AUD and opioid use disorder (OUD) is medication treatment. Acamprosate and naltrexone are 2 medications with evidence demonstrating efficacy for the treatment of AUD in reducing alcohol consumption and achieving abstinence.11 For the treatment of OUD, buprenorphine/naloxone, buprenorphine, and methadone are medications that have demonstrated efficacy.12 However, few studies have investigated the utilization trends of these medications over time. A previous population-based cohort study conducted in Manitoba found that AUD medications were underutilized from 1996 to 2015, with only 1.3% of individuals with AUD receiving medication treatment.13 A study in Ontario reported similar findings, with less than 1% of the population with an AUD diagnosis being dispensed naltrexone or acamprosate in the year after diagnosis.14 Previous studies have also found opioid agonist therapy (OAT) uptake and retention to be limited. One study in British Columbia found that only half of individuals who initiated OAT in 2005 to 2018 were retained on therapy at 6-month follow-up.15
It is not known how the incidence and prevalence of OAT and AUD medications may have changed in recent years. This is important because many changes have occurred in the last few years due to the pandemic and changes in medication access in Manitoba.16-19 The purpose of this study is to describe the quarterly incidence and prevalence of OAT and AUD medications from 2015 to 2021. We hypothesized that we would observe an increase in the incidence and prevalence of OUD and AUD medications due to the combined effects of formulary changes, dissemination of guidelines, and clinical service developments in addiction medicine in Manitoba.
METHODS
Data Sources
This was a population-based observational study using administrative data from the Manitoba Population Research Data Repository held at the Manitoba Centre for Health Policy. The Drug Program Information Network (DPIN) was used to identify the name, dose, days’ supply, quantity, and date of prescription filled for all Manitoba residents regardless of drug coverage, with the exception of medications received in the hospital and nursing stations, or directly from Rapid Access to Addictions Medicine (RAAM) clinic stock (relevant for buprenorphine/naloxone starts only). Individuals living on reserve and those incarcerated are also not captured. The Manitoba Health Insurance Registry and Statistics Canada census files provided demographic information (age, sex, urban [includes Winnipeg and Brandon]/rural residence, income quintile [based on the average income of the neighborhood of residence]) at the end of each interval. This study was approved by the Human Research Ethics Board of the University of Manitoba and the Manitoba Health Seniors and Active Living (MHSAL) Provincial Health Research Privacy Committee.
Population
All community-dwelling individuals living in Manitoba with MHSAL coverage at least 3 years prior to the first day of the quarter of interest between 2015 and 2021 were included. Manitoba is a central province in Canada that has a population of approximately 1.4 million people. For each quarter or year of interest, the denominator for the general population was the sum of individuals who were listed in the MHSAL registry for at least 3 years prior to the first day of the quarter of interest.
Medication Exposure
Manitoba residents who were dispensed ≥1 medication for OAT or AUD medication within each quarter from January 1, 2015, to December 31, 2021, were identified as the population of OAT user and AUD medication user, respectively. All OAT and AUD medications, identified using their Anatomic Therapeutic Classification code, which are available in Canada were included in the analysis. Medications of interest included medications used in opioid dependence (methadone N07BC02, buprenorphine N07BC01 [includes parenteral and sublingual formulations], N07BC51 [sublingual, includes combination with naloxone]) and medications used in alcohol dependence (naltrexone N07BB04, acamprosate N07BB03, disulfiram N07BB01). Buprenorphine transdermal formulations for pain (N02AE01) was not included.
Statistical Analysis
The primary analysis included calculating the quarterly prevalence and incidence rates of prescription medications for AUD or OUD in the general population who received from January 1, 2015, to December 31, 2021. These medications were categorized based on their class (eg, OAT) and type (eg, methadone). Incidence was defined as those who have not received a prescription for the class of interest in the 3 years prior to receiving their first prescription. The rate of dispensing of each medication class was determined for each quarter by counting the number of individuals dispensed a prescription for that medication class divided by the total number of individuals in that quarter in the general population. The denominator for the general population was the sum of individuals who were listed in the MHSAL registry for at least 3 years prior to the first day of the quarter of interest. Descriptive statistics were used to describe the demographic characteristics of the study population in the first quarter of 2020 (year of the COVID-19 pandemic) stratified by individuals who received an OAT and AUD prescription. Analyses were conducted using SAS, version 9.4 (SAS Institute, Inc, Cary, NC). A 2-tailed t test was performed to test for significant mean differences in the incidence and prevalence before and after formulary changes, stratified by quarter with P < 0.05 indicating significance. This included the following specific medications: (1) buprenorphine-naloxone (introduced in formulary April 20, 2017), (2) buprenorphine (introduced in formulary July 16, 2020), and (3) acamprosate and naltrexone (changed from reimbursed with conditions to open benefit in formulary April 4, 2019).
RESULTS
A total of 1179 and 451 individuals received at least one prescription for OAT and AUD medication, respectively, in the first quarter of 2020. Demographic information of the study population for those who received a prescription for OUD and AUD for the first quarter of 2020 is shown in Table 1, respectively. Forty percent of the population who received an OAT prescription were between the ages of 40 to 65 years, and 55.3% were male. Among those who received an AUD prescription, 53% were between the ages of 40 to 65 years, and 59.4% were male.
TABLE 1.
Population Demographics for those Who Had an Opioid Agonist Therapy or Alcohol Use Disorder Prescription in Quarter 1 of 2020
| Characteristics | Opioid Agonist Therapy Prescription User, n (%) n = 1179 |
Alcohol Use Disorder Prescription User, n(%) n = 451 |
|---|---|---|
| Age | ||
| 19–39 y | 620 (52.6) | 170 (37.7) |
| 40–65 y | 476 (40.4) | 240 (53.2) |
| Other* | 83 (7.0) | 41 (9.1) |
| Sex | ||
| Male | 652 (55.3) | 268 (59.4) |
| Female | 527 (44.7) | 183 (40.6) |
| Residence | ||
| Urban (Brandon/Winnipeg) | 763 (64.7) | 266 (59.0) |
| Rural | 416 (35.3) | 185 (41.0) |
| Income quintile as 1st day of current quarter† | ||
| R1 (lowest) | 119 (10.0) | 34 (7.5) |
| R2 | 89 (7.6) | 64 (14.2) |
| R3 | 78 (6.6) | 30 (6.7) |
| R4 | 54 (4.6) | - |
| R5 (highest) | 75 (6.4) | 31 (6.9) |
| U1 (lowest) | 252 (21.4) | 61 (13.5) |
| U2 | 164 (13.9) | 58 (12.9) |
| U3 | 133 (11.3) | 46 (10.2) |
| U4 | 106 (9.0) | 51 (11.3) |
| U5 (highest) | 102 (8.7) | 46 (10.2) |
*n < 6 (suppressed) for age groups 18 years and younger.
†Income quintiles reflect the average neighborhood income the individual resides in, with “1” reflecting the lowest and “5” the highest average income level for 2 distinct population groups: urban (U, Winnipeg and Brandon) and rural (R, other Manitoba areas).
Overall, the prevalence of both OAT and AUD therapy increased from 2015 to 2021 (Fig. 1). The prevalence of OUD medications more than doubled from 6.3 per 10,000 to 14.3 per 10,000 from January 1, 2015, to December 31, 2021. Among specific OAT prescriptions for OUD, the prevalence of methadone increased slightly from 6.01 per 10,000 in the first quarter of 2015 to 8.27 per 10,000 in the first quarter of 2018 and stabilized at an average rate of 8.24 per 10,000 from the second quarter of 2018 to the fourth quarter of 2019. The prevalence of methadone then peaked in the third quarter of 2020 at 8.59 per 10,000 followed by a decline in prevalence at 7.69 per 10,000 in the last quarter of 2021 (Fig. 2A). In contrast, the prevalence of buprenorphine-naloxone increased more than 20-fold from 0.29 per 10,000 in the first quarter of 2015 to 6.02 per 10,000 in the last quarter of 2021, and the prevalence significantly increased after the introduction of buprenorphine-naloxone in the formulary on April 20, 2017 (P < 0.001). Buprenorphine use increased from 0.07 per 10,000 in the second quarter of 2020 to 1.08 per 10,000 in the last quarter of 2021 (P < 0.001). No use of buprenorphine was observed prior to the second quarter of 2020.
Figure 1.
Prevalence rates per 10,000 people for those receiving OAT and AUD prescription from 2015 to 2021. AUD indicates alcohol use disorder pharmacotherapy; OAT, opioid agonist therapy.
Figure 2.
A, Prevalence rates per 10,000 people for those receiving specific OAT prescription from 2015 to 2021 (n = 1179). B, Prevalence rates per 10,000 people for those receiving specific AUD prescription from 2015 to 2021 (n = 451). AUD indicates alcohol use disorder pharmacotherapy; OAT, opioid agonist therapy.
With respect to the prevalence of medications for AUD, naltrexone prevalence increased 10-fold from 0.55 per 10,000 in the first quarter of 2015 to 5.70 per 10,000 in the last quarter of 2021 (Fig. 2B), and the prevalence increased after the change in reimbursement criteria to open benefit in the formulary on April 4, 2019 (P < 0.001). Acamprosate prevalence had remained low between 0.14 and 0.32 per 10,000 from the first quarter of 2015 to the second quarter of 2019. The prevalence of acamprosate declined to 0 in quarters 1 and 2 of 2020, followed by an increase from 0.27 per 10,000 in quarter 3 of 2020 to 0.90 per 10,000 in the last quarter of 2021 (P < 0.001). No use of disulfiram was observed during the study period.
In terms of new prescriptions, the incidence of medications for AUD increased 8.6-fold from 0.29 per 10,000 to 2.51 per 10,000 during the study period (Fig. 3). In contrast, the incidence of OAT declined markedly from 2.1 per 10,000 in the first quarter of 2015 to 0.53 per 10,000 the first quarter of 2016, primarily due to methadone (Fig. 4A). This was followed by a steady increase in OAT incidence to 1.22 per 10,000 in the last quarter of 2021. The incidence of buprenorphine increased from 0.07 per 10,000 to 0.27 per 10,000 from the second quarter of 2020 to the last quarter of 2021 (P < 0.001). The incidence of buprenorphine-naloxone increased from 0.06 per 10,000 in the first quarter of 2015 to 0.89 per 10,000 in the last quarter of 2021 and significantly increased after its introduction in the formulary (P < 0.001).
Figure 3.
Incidence rates per 10,000 people for those receiving OAT and AUD prescription from 2015 to 2021. AUD indicates alcohol use disorder pharmacotherapy; OAT, opioid agonist therapy.
Figure 4.
A, Incidence rates per 10,000 people for those receiving specific OAT prescription from 2015 to 2021 (n = 1179). B, Incidence rates per 10,000 people for those receiving specific AUD prescription from 2015 to 2021 (n = 451). AUD indicates alcohol use disorder pharmacotherapy; OAT, opioid agonist therapy.
The incidence of naltrexone increased from 0.25 per 10,000 to 2.17 per 10,000 from the first quarter of 2015 to the last quarter of 2021 (Fig. 4B) and significantly increased after being an open benefit in the formulary (P < 0.001). The incidence of acamprosate increased from 0.06 per 10,000 from the first quarter of 2015 to 0.22 per 10,000 in the first quarter of 2019. The incidence declined to 0 in quarter 3 of 2019, and quarters 1 and 2 of 2020, followed by an incline from 0.27 per 10,000 in quarter 3 of 2020 to 0.44 per 10,000 in quarter 4 of 2021 (P < 0.001).
DISCUSSION
This study found an increase in the prevalence of both OAT and AUD medications and an increase in the incidence of AUD medications from 2015 to 2021 in the Canadian province of Manitoba. This increase is likely due to improved access to medications due to changes in medication coverage; however, changes in prescription requirements and the introduction of addiction-specific clinics in Manitoba could also have impacted the increase in use of these agents. For instance, the first RAAM clinic opened in Winnipeg on August 31, 2018.19 The RAAM clinics provide low barrier addiction services, including prescribing medications for addictions, without requiring a doctor referral or appointment. There are currently 7 RAAM clinics in Manitoba, with 3 in Winnipeg and 1 each in Thompson, Brandon, Portage la Prairie, and Selkirk. It is possible that these clinics could increase access to addiction medicine. In addition, education on opioid agonist prescribing and dispensing had been developed and offered to physicians and pharmacists during this period, including a College of Physicians and Surgeons of Manitoba 2014 publication,18 Opioid Agonist Therapy Recommended Practice Manual and Canadian Research Initiative in Substance Misuse 2018 National Guideline for the Treatment of Opioid Use Disorder, which strongly recommends buprenorphine/naloxone as the preferred first-line therapy. Lastly, prescription requirements for OAT have also changed. In 2019, prescribers in Manitoba were permitted to fax OAT prescriptions directly to the patient’s pharmacy of choice instead of submitting a triplicate paper copy of the prescription.18 This change was made to reduce the number of lost, stolen, or altered prescriptions. This has made communication between the pharmacy and prescriber easier and allowed for continuous care during the pandemic.18
With respect to specific OAT medications, the prevalence of methadone remained higher than the other OAT medications during the study period. However, the prevalence of methadone decreased, and the prevalence of buprenorphine and buprenorphine-naloxone steadily increased over the study period. Of note, the incidence of buprenorphine-naloxone had been increasing almost 15-fold from 2015 to 2020, surpassing methadone incidence by the third quarter of 2020. This increase may reflect the advantage of buprenorphine-naloxone relative to methadone for patients with OUD, including their improved convenience and safety profile,20,21 making this medication the preferred first-line therapy in the national OUD guideline published by CRISM in 2018. In addition, reduced store hours and restrictions implemented during the COVID-19 pandemic may have also caused the change in the dispensing of these medications favoring the convenience and simplicity of buprenorphine-naloxone compared with methadone. Buprenorphine-naloxone also allows quicker stabilization compared with methadone, and it is also considered safer and less likely to cause overdose compared with methadone.21 It also contains naloxone, as a deterrent to using it in unintended ways (eg, by injection or snorting).21 Cost coverage for buprenorphine-naloxone also improved on April 20, 2017, in which drug coverage no longer required patients to have a failed trial of methadone first.22 The long-acting injectable buprenorphine was added to the Manitoba provincial drug formulary, with conditions, on July 16, 2020, making treatment for OUD more accessible to rural and remote communities and may explain why its use occurred only in the second quarter of 2020.17 A long-acting injection option for OAT has the potential to improve recovery-oriented care and reduce stigma because this formulation does not require daily to weekly visits to the pharmacy for witnessed dosing and provides more flexibility to engage in daily activities such as work.23 Long-acting buprenorphine injection is delivered as monthly subcutaneous injections by a health care provider, which is initiated only after the patient has been stabilized on an equivalent of 8 to 24 mg per day of sublingual buprenorphine for a minimum of 7 days.17 The long-acting injectable buprenorphine has allowed provision of treatment for people living in remote communities who do not have easy access to a pharmacy, most of whom previously had no treatment options. Future research comparing the long-term adherence and retention of OAT and the impact on outcomes would be of interest.
The prevalence and incidence of AUD therapy have also increased between 2015 and 2021. It is not clear if the rise in prevalence and incidence is due to an increase prevalence of AUD, change in AUD medication coverage, or an increase in the recognition of AUD and access to AUD medications. However, a combination of these factors could contribute to the observed trends. The prevalence of naltrexone is higher than acamprosate and rose steadily during the study period. This is likely due to its ease of use (once daily dosing, relatively smaller pill size) and lower cost compared with acamprosate,23,24 as well as the stronger level of evidence, particularly for reduction in heavy drinking.23 Acamprosate prevalence and incidence in contrast declined to approximately 0 at the end of 2019 and beginning of 2020. This is likely due to the drug shortage of acamprosate, which occurred between January 29, 2019, and July 9, 2020.25 The incidence and prevalence of acamprosate use increased again during the second quarter in 2020, which may be a result of the removal of conditions prior to drug coverage in Manitoba.16 As of April 4, 2019, acamprosate and naltrexone no longer require prior approval to receive coverage, likely making these medications potentially more accessible to individuals who may be prescribed these medications.16 No records of disulfiram use was found in this study because it was removed from the provincial drug formulary in 2001 and is now only dispensed as a compounded product, which could not be identified on DPIN records. From a clinical perspective, it is also rarely used in the treatment of AUD due to limitations in effectiveness and safety implications.
Few studies have examined the trend in OUD and AUD medication use before and during the COVID-19 pandemic. Studying the uptake of OUD and AUD medications during this period is important, given the evidence supporting their efficacy in reducing the risk of relapse, morbidity, and mortality.12 In particular, attention to alcohol consumption and opioid-related deaths have increased in recent years. Alcohol is the most common substance used worldwide, with young adults reporting a 27% increase in alcohol consumption during the pandemic in Canada.26 Although opioid use is not nearly as common, there has been an increase in opioid-related harms, particularly with exposure to high doses and in combination with other sedating medication.4 The early detection and treatment of AUD and OUD may help reduce the risk of morbidity and mortality associated with these conditions. A few studies have recently evaluated the effects of reducing restrictions associated with take-home doses of OAT during the pandemic, and many report improved outcomes associated with this practice.27-29 This speaks to the need for better access to these medications. Previous population-based studies that examined the use of AUD medications have observed an underutilization of these treatments among those with AUD in the prepandemic era.13,14 Our study provided additional insight on the use of OAT and AUD medications during the pandemic and amid changes in how individuals access these medications.
This study has strengths and limitations to acknowledge. The use of administrative data allowed us to examine the receipt of OAT and AUD medications to all eligible community-dwelling Manitoba residents regardless of age or drug coverage. This allowed us to gain insight into a population without being subject to recall bias, selection bias, or response bias, which may occur in survey-based studies related to SUD research. This study also provided us with new information on the use of these medications during the pandemic and after a number of variables have shifted that may have helped improve access to OUD and AUD medications. However, because of the number of factors identified that could have influenced medication trends that occurred very close together, it was not possible to differentiate whether the changes observed were due to one specific factor in particular. Of note, drug coverage through the Manitoba Pharmacare program is available after an income-based deductible is met during each fiscal year, which occurs from April to March. The influence this drug coverage program exerts may not be generalizable to other provinces in Canada and internationally. Moreover, physicians and pharmacists must undergo specific OAT training in order to prescribe or dispense OAT in Manitoba, which may differ from regulations to prescribe or dispense OAT in other jurisdictions. In addition, the study was unable to identify disulfiram use because it is a compounded product, which cannot be differentiated on DPIN records, although we expect this to be of little import based on clinical experience. Furthermore, this study did not include only patients with a diagnosis of OUD or AUD as this population may be underrepresented in claims data,30,31 and as such, we focused specifically on the receipt of OUD and AUD prescriptions in the general population. Lastly, this study collected data on prevalence and incidence but did not obtain data on adherence, nor are we able to measure the actual consumption of medication, only dispensation of medication from a pharmacy. Further research comparing the adherence, retention rates, and discontinuation rates of the specific OAT and AUD medications would be of interest for future research to gain a better understanding of the long-term effectiveness of these medications in treating OUD and AUD, respectively
CONCLUSIONS
An increase in both AUD prevalence and incidence was observed from 2015 to 2020. Although an increase in OAT prevalence was seen, the incidence of methadone has decreased, and the incidence of buprenorphine-naloxone increased during the study period, which aligns with a shift toward preferential use of buprenorphine-naloxone based on its enhanced safety profile. These findings also reflect an increased uptake of medication treatment for AUD and OUD following improved coverage and access to these medications. Further research is warranted to explore how these shifts in OAT and AUD medication use impact outcomes, including retention to therapy and health service use.
ACKNOWLEDGMENTS
The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Manitoba Population Research Data Repository under project HIPC 2020/2021-29. Data used in this study are from the Manitoba Population Research Data Repository housed at the Manitoba Centre for Health Policy, University of Manitoba, and were derived from data provided by Manitoba Health and Vital Statistics and Winnipeg Regional Health Authority/Shared Health.
Footnotes
Thus study was funded by the Work: Research Manitoba COVID-19 Rapid Response Grant.
The authors report no conflicts of interest.
The manuscript has not been posted on a preprint server.
Contributor Information
Kearley Abbott, Email: abbottk@myumanitoba.ca.
Rachel Hyrsak, Email: hyrsakr@myumanitoba.ca.
James M. Bolton, Email: jbolton@hsc.mb.ca.
Jitender Sareen, Email: jsareen@manitoba-physicians.ca.
Murray W. Enns, Email: menns@hsc.mb.ca.
Geoffrey Konrad, Email: gkonrad2@manitoba-physicians.ca.
Erin Knight, Email: eknight@hsc.mb.ca.
Sherif Eltonsy, Email: sherif.eltonsy@umanitoba.ca.
Kaarina Kowalec, Email: kaarina.kowalec@umanitoba.ca.
Jamison Falk, Email: jamison.falk@umanitoba.ca.
Silvia Alessi-Severini, Email: silvia.alessi-severini@umanitoba.ca.
Kun Liu, Email: kun.liu@umanitoba.ca.
Heather Prior, Email: heather.prior@umanitoba.ca.
REFERENCES
- 1.National Institute on Drug Abuse (NIDA) . Drug misuse and addiction. Available at: https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drug-misuse-addiction. Accessed October 13, 2023. [DOI] [PubMed]
- 2.United Nations Office on Drugs and Crime (UNODC) . World Drug Report 2022. United Nations Publication, 2022. Available at: www.unodc.org/unodc/en/data-and-analysis/world-drug-report-2022.html. Accessed October 13, 2023. [Google Scholar]
- 3.Castelpietra G Knudsen AKS Agardh EE, et al. The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990–2019: findings from the Global Burden of Disease Study 2019. Lancet Reg Health Eur. 2022;16:100341. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Government of Manitoba . Epidemiology and Surveillance Unit. Substance Related Harms Surveillance. Last updated October 13, 2023. Available at: https://manitoba.ca/mh/srh-public-report.html. Accessed December 12, 2023.
- 5.Canadian Centre on Substance Use and Addiction . Alcohol (Canadian Drug Summary). 2019. Available at: https://www.ccsa.ca/alcohol-canadian-drug-summary. Accessed December 12, 2023.
- 6.Canadian Centre on Substance Use and Addiction . Opioids (Canadian Drug Summary). 2022. Available at: https://www.ccsa.ca/opioids-canadian-drug-summary. Accessed December 12, 2023.
- 7.Canadian Centre on Substance Use and Addiction . Canada’s Guidance on Alcohol and Health: Final Report. 2023. Available at: https://www.ccsa.ca/canadas-guidance-alcohol-and-health. Accessed December 12, 2023.
- 8.Canadian Substance Use Costs and Harms (CSUCH) . Data Visualization Tool. Available at: https://csuch.ca/explore-the-data/. Accessed November 30, 2023.
- 9.Leong C Bolton JM Ekuma O, et al. Association of alcohol use disorder on alcohol-related cancers, diabetes, ischemic heart disease and death: a population-based matched cohort study. Addiction. 2022;117(2):368–381. [DOI] [PubMed] [Google Scholar]
- 10.Bolton JM Leong C Ekuma O, et al. Health service use among Manitobans with alcohol use disorder: a population-based matched cohort study. CMAJ Open. 2020;8(4):E762–E771. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Jonas DE Amick HR Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings. JAMA. 2014;311(18):1889. [DOI] [PubMed] [Google Scholar]
- 12.Santo T Jr. Clark B Hickman M, et al. Association of opioid agonist treatment with all-cause mortality and specific causes of death among people with opioid dependence: a systematic review and meta-analysis. JAMA Psychiatry. 2021;78(9):979–993. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Konrad G Leong C Bolton JM, et al. Use of pharmacotherapy for alcohol use disorder in Manitoba, Canada: a whole-population cohort study. PLoS One. 2021;16(9):e0257025. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Spithoff S Turner S Gomes T, et al. First-line medications for alcohol use disorders among public drug plan beneficiaries in Ontario. Can Fam Physician. 2017. May;63(5):e277–e283. [PMC free article] [PubMed] [Google Scholar]
- 15.Socias ME Dong H Wood E, et al. Trajectories of retention in opioid agonist therapy in a Canadian setting. Int J Drug Policy. 2020;77:102696. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Province of Manitoba: news release: changes to provincial formulary making it easier to access addictions medications. (2019). Available at: https://news.gov.mb.ca/news/index.html?archive=&item=45176. Accessed October 30, 2023.
- 17.Province of Manitoba: bulletin 108: Manitoba drug benefits and interchangeability formulary amendments. (2020). Available at: https://www.gov.mb.ca/health/mdbif/bulletin108.pdf. Accessed October 30, 2023.
- 18.The College of Physicians and Surgeons of Manitoba . Manitoba Opioid Agonist Therapy Recommended Practice Manual. 1.5 The relationship with pharmacy and prescriptions for opioid agonist therapy. (2023). Available at: https://cpsm.mb.ca/assets/PrescribingPracticesProgram/Relationship%20with%20Pharmacy%20&%20Prescriptions%20for%20OAT.pdf?utm_source=web&utm_medium=direct&utm_campaign=OATmanual. Accessed October 30, 2023.
- 19.Manitoba Government Press Release . First rapid access to addictions medicine clinic opens in Winnipeg. (2018). Available at: https://news.gov.mb.ca/news/index.html?archive=&item=44582. Accessed October 30, 2023.
- 20.eCPS . Methadose™ Product Monograph. Last updated February 25, 2019. Available at: https://www-e-therapeutics-ca.uml.idm.oclc.org/. Accessed December 12, 2023.
- 21.eCPS . Suboxone® Product Monograph. Last updated October 26, 2021. Available at: https://www-e-therapeutics-ca.uml.idm.oclc.org. Accessed December 12, 2023.
- 22.Province of Manitoba: bulletin 91: Manitoba drug benefits and interchangeability formulary amendments. (2017). Available at: http://www.gov.mb.ca/health/mdbif/bulletin91.pdf. Accessed October 30, 2023.
- 23.Lefebvre LG. Alcohol-related disorders. Last updated April 28, 2021. Available at: https://www-e-therapeutics-ca.uml.idm.oclc.org. Accessed December 12, 2023.
- 24.eCPS . Campral® Product Monograph. Last updated January 23, 2019. Available at: https://www-e-therapeutics-ca.uml.idm.oclc.org. Accessed December 12, 2023.
- 25.Drug Shortages Canada . Drug Shortage Report Campral. (2020. Available at: https://www.drugshortagescanada.ca/shortage/72306. Accessed December 12, 2023.
- 26.Samji H et al. , for the British Columbia Centre for Disease Control COVID-19 Young Adult Task Force . Impacts of the COVID-19 Pandemic on the Health and Well-being of Young Adults in British Columbia. British Columbia Centre for Disease Control, 2021. Available at: http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID-Impacts/BCCDC_COVID-19_Young_Adult_Health_Well-being_Report.pdf Accessed October 30, 2023. [Google Scholar]
- 27.McDonald R, Bech AB, Clausen T. Flexible delivery of opioid agonist treatment during COVID-19 in Norway: qualitative and quantitative findings from an online survey of provider experiences. BMC Health Serv Res. 2023;23:965. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Adams A Blawatt S Magel T, et al. The impact of relaxing restrictions on take-home doses during the COVID-19 pandemic on program effectiveness and client experiences in opioid agonist treatment: a mixed methods systematic review. Subst Abuse Treat Prev Policy. 2023;18:56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Kitchen SA Campbell TJ Men S, et al. Impact of the COVID-19 pandemic on the provision of take-home doses of opioid agonist therapy in Ontario, Canada: a population-based time-series analysis. Int J Drug Policy. 2022;103:103644. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Scherrer JF Sullivan MD LaRochelle MR, et al. Validating opioid use disorder diagnoses in administrative data: a commentary on existing evidence and future directions. Addict Sci Clin Pract. 2023;18:49. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Wansrisuthon W Ratta-apha W Thongchot L, et al. Accuracy of diagnosis and International Classification of Diseases; Tenth Revision coding for alcohol dependence, alcohol withdrawal, and alcohol-withdrawal delirium among inpatients at a university hospital. J Addict Med. 2017;11(3):241–242. [DOI] [PubMed] [Google Scholar]