An Overview of Non-Medical Use of Prescription Drugs and Criminal Justice Issues in Canada

3. Who is using prescription drugs non-medically (e.g., gender, age, and socioeconomic differences)?

3.1. Who is using prescription opioids non-medically?

3.1.1. General Populations

As indicated above, the first nationally representative survey to look into the question of NMUPO was the CADUMS survey with field work conducted in 2008 (Health Canada, 2009). So far, only results on the question of ‘use to get high’ were released, which are methodologically restricted and do not provide a full picture on the NMUPO phenomenon. In this category, there was no difference between men and women, but young adults (ages 19-24) were much overrepresented (4.9% of all young adult users of PO use them to get high, compared to 1.0% of all others).

In the Ontario CAMH Monitor of 2008, similar results were reported, albeit we can compare the results for NMUPO in general in addition to those who responded that they use PO to ‘get high’. Any NMUPO was reported by 2.3% (1.3%-3.1%) of Ontario adults. No significant differences were found between men (2.3%, 95%CI: 0.9%-5.8%) and women (2.3%, 95%CI: 1.1%-4.5%). The only significant difference was found for psychological distress. Use of any pain relievers was significantly higher among those reporting elevated psychological distress (8.2%, 95%CI: 27.5%-48.2%, versus 1.4%, 95%CI: 0.7%-2.9%) No other significant differences were found for age, binge drinking, income, tobacco use and region (CAMH Monitor 2008, unpublished data).

NMUPO to ‘get high’ was reported by 0.5% (0.1%-2.9%) of Ontario adults, the same proportion as for Canada. NMUPO to ‘get high’ was significantly higher among men (0.9%, 95%CI: 0.1%, 6.2%) than among women (0.1%, 95%CI: 0.0%-0.7%). Bivariate analyses revealed significant differences for psychological distress and tobacco use. Use of any pain relievers to ‘get high’ was significantly higher among those reporting elevated psychological distress (3.5%, 95%CI: 0.5%-20.9%), and among current smokers (2.7%, 95%CI: 0.5%-14.4%). No significant differences were found for age, binge drinking, income, and region (CAMH Monitor 2008, unpublished data).

Much higher rates for NMUPO were reported in the OSDUHS high school students’ survey for 2007. Past year NMUPO (i.e., at least once in the past 12 months) was reported by 20.6% (95%CI: 18.9%-22.3%) of students. Bivariate analysis by sex revealed a significant difference between males (18.0%, 95%CI: 15.8%-20.3%) and females (23.5%, 95%CI: 20.8%-26.3%). Based on the regression analysis, significant predictors were sex, with females more likely than males to report use (OR=1.4, 95%CI: 1.1-1.8); grade, showing a significant increase between 7th grade and 8th grade (OR= 1.9, 95%CI: 1.1-3.4); past year tobacco use (OR=1.8, 95%CI: 1.4-2.3), alcohol use (OR=1.8, 95%CI: 1.2-2.5), and any illicit drug use (OR=1.9, 95%CI: 1.4-2.4) (Adlaf & Paglia-Boak, 2007).

Specifically, past year non-medical OxyContin use was reported by 1.8% (95% CI: 1.3%-2.4%) of students. Bivariate analysis by sex revealed no significant difference between males (1.7%, 95%CI: 1.2%-2.3%) and females (1.9%, 95%CI: 1.3%-2.8%). Results from the regression analysis showed the significant predictors were tobacco use (OR=2.2, 95%CI: 1.4-4.3), any illicit drug use (OR=9.8, 95%CI: 5.4-18.1), and poor self-rated mental health (OR=2.5, 95%CI: 1.1-5.8).

Overall, the age gradient with more NMUPO was also confirmed by Sproule et al. (1999) and by research outside of Canada (US: (Dowling et al., 2006; Zacny et al., 2003)). So overall, youth or young adulthood seem to be the age periods, where NMUPO is most prevalent. However, there may be a second age group in the forties with higher NMUPO (Simoni-Wastila & Strickler, 2004), as well as some higher prevalence in the elderly (Martin, 2008).

With respect to sex, the picture is less clear. NMUPO in Canada was not found more prevalent in women overall, but in high school students. On the other hand, more men than women reported NMUPO to ‘get high’. In the US, studies often report higher prevalence in women (Mitka, 2000; Simoni-Wastila, 2000; Simoni-Wastila et al., 2004b).

Another important risk factor for NMUPO is socio-economic status (SES), although the evidence here stems entirely from the US (Spiller et al., 2009; Huang et al., 2006). Several studies have showed, that lower socio-economic status, with associated variables such as poverty, employment or low income, are risk factors for NMUPO.

So overall, lower age, low SES and use/abuse of other substances seem to be the best predictors of NMUPO in the general population.

3.1.2. Street Drug User Populations

Among street drug users, there are also some indications that predominant PO users, e.g., as compared to heroin or other street drug users, present distinct socio-economic characteristics. An analysis based on follow-up data from the multi-site OPICAN study suggested that NMUPO users, among other characteristics, were more likely to be older and received legal employment income, than heroin-only users (Fischer et al., 2008a). Relevant information comes from several US studies, which also suggest that NMUPO users may feature somewhat distinct socio-economic characteristics. For example, lower levels of illegal income generation and higher levels of income from paid work have been found in primary NMUPO users compared to other drug users (Sigmon, 2006). The age relationship from the general population does not hold true for NMUPO users among street drug users, possibly linked to the fact, that there is a group of NMUPO street drug users which migrated from using heroin intravenously for various reasons (e.g., (Fischer et al., 2008a; Strang & Rashiq, 2005)).

3.1.3. Treatment Populations

Data from the DATIS population indicate, that clients in Ontario treated primarily for PO as the problem substance showed the following characteristics (from (Fischer et al., 2009c), submitted CMAJ): more male (58.7%; lower proportion of men compared to other problem substances); younger compared to other problem substances with almost 60% younger than 35 years of age; about ¼ of the sample fully or part time employed (comparable to people with cocaine as problem substance but less employment than people with alcohol problems); 29.8% with some kind of legal problems (lower compared to other problem substances). Unfortunately, additional socio-demographic details of PO clients within the DATIS population are not available without further specific analysis.

3.2. Who is using benzodiazepines non-medically?

3.2.1. General Populations

There are very few studies on NMUBD for Canada in general population samples. The CADUMS included a category of sedatives which in all likelihood consisted mainly of BDs. In total, sedative use was about 11% in the general population more in women (13.2%) than in men (8.0%), and more in older (11.7%) compared to young adults (defined as 15-24 year olds;5.5%). However, when using sedatives to get high, the young adults have clearly higher rates: 14.4% in this age group agreed to this question. In using sedatives to get high, no differences were found between gender (Health Canada, 2009).

In high school students, past year non-medical sedative use was reported by 1.8% (95%CI: 1.4%-2.3%). Bivariate analysis by sex revealed no significant difference between males (1.7%, 95%CI 1.2%-2.4%) and females (1.9%, 95%CI: 1.5%-2.5%). The only significant predictor from the regression analysis was poor self-rated mental health (OR=2.4, 95%CI: 1.2-4.8) (Adlaf & Paglia-Boak, 2007).

In treatment samples, BD use as problem substance increased with age ((Rush, 2002); based on DATIS), and was higher among women (5.9%) compared to men (2.5%). Clients with BD problems are included in the DATIS population of individuals seeking treatment in Ontario; however, no specific analysis has been conducted to describe this sub-population in any socio-demographic detail.

In the US, there are more and representative large-scale surveys including NMUBD in the general population, but there are no clear and consistent conclusions, not even with respect to sex, ethnicity or age (Goodwin & Hasin, 2002; Huang et al., 2006; Simoni-Wastila, 2000; Simoni-Wastila et al., 2004b; Simoni-Wastila & Strickler, 2004). It may be that there are clearer trends for subclasses of BD.

4. How and under what circumstances are individuals obtaining prescription drugs for non-medical use? Are there links to organized crime or other criminal networks?

4.1. Introduction

Unlike illicit drugs such as heroin and cocaine, prescription drugs such as opioids (POs) and benzodiazepines (BDs) are legitimately generated products, and as such are available and distributed legally, specifically through the medical system. Data from the US and specifically for POs highlights that there are at least five main points in the system where diversion from the medical system can occur, namely at the manufacturing site, in transit, by the distributor or dispenser, at the point of prescribing, or by the consumer (Smith & Woody, 2005). Therefore, there is a diverse heterogeneity of sources or routes that POs can be diverted from the medical system to the non-medical user.

Essential context for the phenomenon of non-medical use of prescription drugs concerns the recent increase in the general availability and legitimate use of prescription substances, since along with increases in medical availability obviously comes an increase in the opportunity for diversion. According to the International Narcotics Control Board (INCB), the total consumption in defined daily doses per million inhabitants per day of all POs in Canada more than doubled in six years from 8,713 in 2000-2002 to 18,914 in 2005-2007. Canada is currently ranked as the third highest consumer in the world after the US and Germany (International Narcotics Control Board, 2004; International Narcotics Control Board, 2005a; International Narcotics Control Board, 2009a). Similar to POs, the total consumption of BD-type anxiolytics in defined daily doses per thousand inhabitants per day in Canada increased from 21.65 in 2000-2002 to 38.66 in 2005-2007 (International Narcotics Control Board, 2005b; International Narcotics Control Board, 2008b; International Narcotics Control Board, 2009c). Although data from the late 1990s reported that diversion represented only a very small percentage of the number of drugs that are dispensed in Canada, with increases in consumption so too increases the quantities available for non-medical use (Darke & Stewart, 1999; Goldman, 2008).

4.2. How are prescription opioids obtained?

4.2.1. Canadian Data  General Populations

There is very little available data from Canada, especially within general populations and specifically for POs. One study which mailed questionnaires to regular users of codeine found that 37% met the criteria for codeine dependence. Amongst the dependent group, in addition to the codeine that they received legitimately from their doctor, 32% also obtained codeine from friends, 11% from family members, 19% from the street and 11% through prescriptions from more than one doctor (double doctoring) (Sproule et al., 1999).  Street Drug Users Populations

Relatively more data is available on sourcing by marginalized populations in Canada. Street drug users appear to use a variety of sources, which commonly includes dealers, providing evidence that street drug markets for POs are functioning. For example, in-depth interviews with IDUs in Toronto discovered that the vast majority of POs used for non-medical purposes were bought from dealers. Furthermore, there appeared to be a general distinction between PO markets and markets for other drugs (Firestone-Cruz & Fischer, 2008).Interviews with regular street users of POs in two cities in Canada found that regular sources (described as involving multiple transactions in past month, having a personal or business rapport and having mutual knowledge of offerings/preferences) were used more frequently in Toronto (79.1%) than Victoria (35.9%). In addition, 46.5% of users in Toronto and 69.2% in Victoria had sold POs, and the majority had exchanged POs for other drugs (76.7% in Toronto and 79.5% in Victoria). Finally, in both sites, again there was a possible demarcation line between sources of POs and sources for other illicit drugs (Fischer et al., 2009a). Among illicit opioid users in the multisite OPICAN cohort, baseline data showed that for several individual POs, about half of respondents reported friends as sources and around 40% used regular dealers. Other less frequent sources included irregular dealers (between 10% and 20%), a doctor (between 8% and 40%, depending on the specific drug), and a small proportion from theft (Haydon et al., 2005). Follow up data from the OPICAN cohort confirmed that a substantial proportion of POs used non-medically were obtained directly or indirectly (e.g. through friends or partners) from sources in the medical system (Fischer et al., 2006b). Finally, a narrative description of the street drug trade specifically in Edmonton, Alberta in 2005 suggested that most POs were procured by robbery, diversion, sale of legally obtained prescription and the use of stolen prescription blanks (Strang & Rashiq, 2005).  Treatment Populations

Another relatively rich data source comes from patients entering treatment for opioid dependence. Among patients admitted to the Methadone Maintenance Treatment (MMT) program at the Centre for Addiction and Mental Health (CAMH) – Canada’s largest addiction treatment hospital – in Toronto between Jan 2000 to Dec 2004, the majority of NMUPO users sourced the drugs using a doctor’s prescription (37%) with other key sources being from the street (21%), a combination of prescription and street (26%), non-prescription purchases (i.e., over-the-counter codeine formulations) (5%) and from family or friends (1%) (Sproule et al., 2009). Interestingly, there was a clear linear trend between age and source, with the likelihood of obtaining from the street decreasing with age, and obtaining from a physician increasing with age (Sproule et al., 2009). An earlier study of patients admitted between January 1997 and December 1999 to MMT at CAMH found similar results with POs obtained from physicians, purchased on streets, obtained from family or friends. However, 61% reported at least some came from physician’s prescription (Brands et al., 2004).

4.2.2. US DATA  General Populations

Similar to Canada, there is very little evidence available from the US regarding the sourcing of POs amongst general populations. Youth and student NMUPO users mainly report peers, friends and family members as their primary sources, as well as their roommates or partners (McCabe & Boyd, 2005). However, a web survey of students at a Midwestern university in 2005 found that almost 40% report that they have more than one source (McCabe et al., 2007). For example, of past year NMUPO users between the ages of 18 and 25 years in the 2005 NSDUH, the majority (53%) obtained their drugs from a friend or relative for free. Other methods of obtaining POs for non-medical use included from one doctor (12.7%) and bought from a friend or relative (10.6%) (SAMHSA, 2006). Furthermore, those who hold a prescription have been shown as sources of POs. In a 2003 random sample of undergraduates, of those with a prescription for POs, 26% had been approached to divert their medication (McCabe et al., 2006). College samples have also shown several sex differences in sourcing. In the NSDUH sample, males were three time more likely than females to have bought from a dealer and were more likely to have bought POs from a friend. Conversely, women are more likely to have obtained their POs from a friend or relative for free (McCabe et al., 2007; SAMHSA, 2006). Additionally, those in the NSDUH sample who met criteria for dependence were less likely to obtain POs for free from a friend or relative (37.5%), but more likely to have bought them from a friend or relative (19.9%). (8.1% F vs 15.9% M) (SAMHSA, 2006).

Amongst high school students in Detroit, the most common sources of POs were family and friends, yet users also commonly obtained POs from a dealer or by way of theft (Boyd et al., 2006). As with college students, high school students that have a legitimate prescription for POs are common sources. Of students in grades 7-12 in a Michigan school district who held prescriptions, 10% reported having traded their drugs, 25% had given them away or had loaned them to other students (boys more frequently to boys, and girls to girls), and 12% had had their medications taken without consent, or stolen (Boyd et al., 2007).

Regarding other specific sources, it has been suggested that the Internet has become an increasingly relevant source for illegitimately obtaining prescription drugs (Compton & Volkow, 2006). However, there is some debate regarding the quantity of prescription drugs that are procured on the Internet, and the fact that the role may have been overstated (Zacny et al., 2003; Dekker, 2007; Mitka, 2000; Forman, 2006). On websites that did sell prescription drugs without a prescription, the most frequently offered prescription drugs in 2006 were BDs (84%), followed by POs (68%). Although the total number of sites increased between 2004 and 2006, the percentage of sites offering these drugs reportedly decreased overall (Beau Dietl & Associates, 2006). In addition, possibly related to increased awareness, regulation and law enforcement there are indications that there have been some decreases in Internet availability in recent years (Boyer & Wines, 2008).

Finally there is some evidence to suggest that healthcare workers themselves may act as a means of diverting prescription medications. For example, data from drug diversion cases involving healthcare workers investigated in Cincinnati between 1992 and 2002 showed that opioids were the most commonly diverted drugs (67.4%). Nurses, nursing assistants and medical assistants were responsible in ¾ cases, with hospitals being the most common sources, followed by pharmacies (Inciardi et al., 2006).  Street Drug User Populations

Similar to general populations, evidence suggests that street drug users often obtain POs for non-medical use from friends, acquaintances or family members, as well as personal prescriptions. However, it appears that they use a variety of other sources, which include script doctors, doctor shopping, residential burglaries and thefts from pharmacies, as well as active street markets (Inciardi et al., 2007; Joranson & Gilson, 2007). A study of sourcing in a sample of heroin involved IDUs in New York City found that nearly 2/5 had sold at least one PO at least once in their lifetime and those who had sold heroin or cocaine in their lifetime were twice as likely to sell POs (Davis & Johnson, 2008). Interestingly in this sample, the main source for OxyContin in particular differed according to the primary motivation for use. For example, those who use OxyContin for euphoria or withdrawal were twice as likely to use a dealer than those whose primary motivation was for pain relief (83% of whom reported a doctor or pharmacy as a source) (Davis & Johnson, 2008).  Treatment Populations

A relatively rich source of data on sourcing comes from people who are entering treatment for drug dependence. A number of these studies have found that, as with general populations, a primary source of POs is from friends or family, with ~50% - 70% reporting this source (Anonymous, 2005; Cicero et al., 2008b; Levy, 2007; Rosenblum et al., 2007). In addition, there is evidence to suggest that those who present with substance use disorders use a greater variety of sources, with one study reporting that more than 60% regularly use more than one source (Cicero et al., 2008a). In some studies, use of dealer is the most common, reported by up to 82% of enrollees, and more frequently by males and those who report motivations other than pain as their primary motivation for use (Anonymous, 2005; Rosenblum et al., 2007; Cicero et al., 2008a; Cicero et al., 2008b). Between 17% and 37% report direct or indirect sourcing from a physician, with one study reporting that 84% had a legitimate prescription at some point (Anonymous, 2005; Levy, 2007; Passik et al., 2006). Less frequent sources include thefts and prescription forgeries, with the least frequently acknowledged source, perhaps not surprisingly being the Internet (Cicero et al., 2008a; Cicero et al., 2008b; Anonymous, 2005; Rosenblum et al., 2007; Passik et al., 2006).

4.3. How are benzodiazepines obtained?

4.3.1. Canadian data  Street Drug User Populations

Yet again, there is very little data on the sources of BDs for non-medical use amongst marginalized populations. Among street drug users in the OPICAN cohort, baseline data showed that the most common sources for BDs for non medical use were friends (46%) and doctors (27.6%). Less frequently reported sources were irregular dealers (16.5%), regular dealers (8.8%), a partner (3.5%) and, as with POs, only a very small number from thefts (0.4%) (Haydon et al., 2005). A more local study found that specifically in Edmonton, Alberta , according to inner city key informants, 55% sourced BDs on the street, 33.3% from physicians and 11.1% from both (Wild et al., 2008).

4.3.2. US data  General populations

From the very limited available evidence on how BDs are obtained for non-medical use in the general population, it appears that as with POs, youth or student NMUBD users mainly report peers, friends and family members as their primary sources, as well as their roommates or partners. In the 2003 Student Life Survey, a web-based survey of a random sample of college students at a Midwestern university, of those who reported non-medical use of sedatives or anxiety meds (e.g., Ativan, Xanax, Valium, Klonopin), 58.2% reported obtaining their drugs from friends and 9.6% family (McCabe & Boyd, 2005). Again as with POs, youth with a legitimate prescription also report diversion of their own medication. For example, in a 2005 study of 7-12 graders, of those with a prescription for sedative or anxiety medication (e.g., Ativan, Xanax, Valium, Klonopin, etc), 10% reported trading their medication, with many fewer reporting having sold them. In addition, 15% had given them away or loaned them, and 14% had them taken against their will (Boyd et al., 2007). As with POs, there is some evidence to suggest that healthcare workers may act as a means of diverting BDs. Data from drug diversion cases involving healthcare workers investigated in Cincinnati between 1992 and 2002 showed that POs were the most commonly diverted drugs (67.4%), followed by BDs (14.5%) (Inciardi et al., 2006).  Street Drug User Populations

Evidence regarding obtaining BDs among street drug users comes mainly from anecdotal or local reports. For example, local clinicians and outreach workers in Denver, Colorado describe the easy availability of BDs (e.g., Valium, Xanax, Ativan), on the street. Similarly, BDs and other prescription depressants are seen to be a growing threat in Georgia with the drugs widely available on the street or via the Internet. Dealers and abusers themselves use a variety of methods for obtaining the drugs, including stolen prescription pads, robbing pharmacies, and attempts to convince doctors to prescribe the desired pills (Community Epidemiology Work Group, 2008). One available study which involved interviews with IDUs in US cities between 2004 and 2006, reported three main sources for all prescription drugs, including tranquilizers (such as Xanax, Valium and Klonopin). The main sources reported were self, friends or relatives with legitimate prescriptions, public or streets settings and finding the prescription drugs on the street or elsewhere (Lankenau et al., 2007).

5. What are the health implications for those who use prescription drugs non-medically (e.g., dependence, other illicit drug use, co-morbidity, treatment utilization)?

5.1. NMUPO Health Risks

5.1.1. Introduction

The health risks of POs can roughly be divided into two categories:

Four major forms of health risks exist:

  1. dependence and other forms of drug use disorders;
  2. overdose;
  3. disease risks such as association with mental and behavioural disorders, infectious diseases such hepatitis C (HCV), and B (HBV), human immunodeficiency virus infection (HIV), and other somatic conditions;
  4. injuries, both unintentional injury (other forms of poisoning than overdosing) and intentional injury (suicide, violence).

The forms of relationship between NMUPO and health outcomes can be associations or causal relations. For the most part, the underlying literature reports associations only, even though many authors have the tendency to misinterpret these as causal. In the following, we will only use causal language if such a relationship was firmly established.

5.1.2. Dependence

POs are highly addictive, but by no means would all of the NMUPO users develop dependence or other drug use disorders. Sproule et al. (1999) found that roughly 1/3 of codeine users in a convenience sample in Ontario met the criteria for dependence (Sproule et al., 1999). This proportion seems high in relation to the addictive potential found in recent US surveys, or historically for other drugs given extramedical use. For instance, in the US, among respondents 18 years and older (n=91,823) of the nationally representative 2002-2004 National Surveys on Drug Use and Health, the prevalence of past-year NMUPO amounted to 4.5%. Of those with non-medical use, 12.9% met criteria for abuse/dependence (Becker et al., 2008). In an earlier study representative for the US, Anthony et al. found that roughly ¼ of extramedical heroin users were at risk of developing dependence over the life course (Anthony et al., 1994). While more representative data from Canada are missing, it is safe to estimate that between 10% and 33% of NMUPO users may develop dependence or other drug use disorders. We have no indication that this rate is different from illegal opioid users.

5.1.3. Overdose

NMUPO has been linked to overdosing and to overdose deaths. While data for Canada are scarce, there are reports on fentanyl-related deaths in Ontario (Martin et al., 2006), and a report that the oxycodone in 2002 was involved in 27 drug related deaths in Toronto alone (Research Group on Drug Use, 2004). However, the exact quantification of overdose deaths related to NMUPO for Canada has not been established.

In the US, NMUPO-related deaths have increased since the mid 1990s and prescription drugs have replaced heroin and cocaine as the leading drugs involved in fatal drug overdoses in all urban-rural categories (Paulozzi & Yongli, 2008). More details on overdose death can be found in section 7 below.

Given the overall epidemiological profile (see other chapters), we expect quite a large number of NMUPO-related mortality for Canada as well (Popova et al., 2009). However, while NMUPO is related to overdose and mortality in Canada, the question should be raised, if NMUPO is not relatively safer than illegal street opioids, i.e. heroin for Canada. Overall, NMUPO appears to be less associated with injection, as well as is less likely to be contaminated with other substances, therefore likely resulting in lessened risk for infectious disease (e.g., HCV or HIV) transmission and/or overdose. Thus, overall, there may be a public health benefit associated with the recent shifts to NMUPO in the street drug use scene (Fischer et al., 2009b).

5.1.4. Disease Risks

In general, for street drug users, low standards of general hygiene due to personal neglect of general health, unsafe injection practices and multiple daily injections, poverty as well as nutritional deficiency and direct suppression effect of immune system by opioids (Govitrapong et al., 1998) may adversely affect the immune system and lead to a variety of bacterial infections, such as bacterial endocarditis, septicaemia, pneumonia, bacterial infections of bones and joints, and oral diseases.

Moreover, in most studies to date and irrespective of the sample, NMUPO has been associated with higher levels of psychiatric symptoms and disorders, and pain, compared to the general population (see descriptions of CAMH Monitor 2008 and OSDUHS above; (Brands et al., 2004; Monga et al., 2007; Sproule et al., 1999; Sproule et al., 2009). Also, other substance use and substance use disorders are over-proportionally present among NMUPO users (Adlaf et al., 2006; Brands et al., 2004; Firestone-Cruz & Fischer, 2008; Fischer et al., 2008a; Leri et al., 2005; Monga et al., 2007; Patra et al., 2009; Sproule et al., 1999; Strang & Rashiq, 2005). Overall, there is ample evidence for Canada, that NMUPO is associated with elevated use of other substances and with higher levels of mental problems.

With respect to somatic disease, we expect higher levels of all categories associated with a weakened immune system, pain, irrespective of the sample examines (i.e, in the general population, treatment samples and marginalized samples, in comparison with similar people without NMUPO) and for those who inject POs non-medically, higher levels of the related infections.

The most clear links within somatic disease seem to be between NMUPO and pain. Clearly, high levels of pain were found as a problem indicated by many NMUPO users from the general population (Banta-Green et al., 2009) as well as from marginalized populations (Monga et al., 2007) or in treatment samples (Brands et al., 2004; Sproule et al., 2009)

5.1.5. Injuries

There are few studies on the associations between NMUPO and injury for Canada. In an early study in Saskatchewan, Shorr et al. (1992) found that compared to non-users, the relative risk (95% CI) of hip fracture among people 65 years or older in current users of codeine or propoxyphene was 1.6 (1.4-1.9) (Shorr et al., 1992). Overall, based on the general literature outside of Canada, we expect that both intentional and unintentional injuries are linked to NMUPO ((Maurer, 2009), but see (Kelly et al., 2004), but we need specific studies to test this hypothesis.

5.1.6. Treatment and health services utilization

There are no Canada wide data on treatment enrolment for PO. The most systematic data we found refer to Ontario, where a clear upward trend for admission related to NMUPO can be seen (see more detailed data below in section 7).

Table 1: POs used in past 12 month/ reporting POs as presenting problem substance of substance abuse clients with open admissions (without family members) recorded in the DATIS system (Drug and Alcohol Treatment Information System (DATIS), 2008)
Fiscal Year 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
  N % N % N % N % N %
Past 12 months 10,977 13.6 14,288 15.3 16,507 16.7 18,404 18.0 20,756 20.1
Problem substance 6,192 7.6 8,860 9.5 10,568 10.7 12,046 11.8 14,049 13.6

Source: DATIS Statistical tables

As treatment admission for NMUPO -disorders tend to correlate quite highly with overall usage, we can expect further increases here, as long as the overall per capita use of POs increase.

In a survey of paramedics in Brockville and the District Leeds Grenville (Ontario), 15% reported OxyContin amongst the most common problem substances, with the estimated percentage of emergency medical calls caused by or related to OxyContin at 2% (more than cocaine/crack, heroin and hallucinogens) (Garvin, 2004).

5.2. NMUBD Health Risks

5.2.1. Dependence

For Canada, data on NMUBD are scarce (see above), and data on health consequences of NMUBD are even scarcer. BDs are a drug class which clearly has reinforcing properties and thus a potential for dependence and abuse (Busto & Sellers, 1991; Busto et al., 1989). However, there are no prevalence or incidence data for BD dependence or BD-use disorders for Canada.

For the US, such data exist: Among the general population, based on the 2002–2004 National Survey on Drug Use and Health (NSDUH), for respondents for 18 years and older (n = 92,020), the prevalence of past-year non-medical use of sedatives or tranquilizers, mostly from the class of BDs, was 2.3%. Of those with non-medical use, 9.8% met criteria for abuse/dependence (Becker et al., 2007). Among adolescent respondents in the 2005 NSDUH, prevalence rates were notably higher with 8.2% reporting past year non-medical use of tranquilizers (including BDs and other minor tranquilizers. Of all non-medical prescription drug users, 17.4% met criteria for dependence, 6.5% of whom were solely for non-medical use of tranquilizers (Schepis & Krishnan-Sarin, 2008).

5.2.2. Overdose

BD use has been part of the mix in street drug users (see above). BDs were found in Canadian overdose deaths as well, but no study has systematically explored possible associations. Drug poisoning deaths in England showed BDs caused 3.8% of all deaths caused by poisoning from a single drug (Charlson et al., 2009). Overviews as well as a number of studies from Australia corroborated these results and found relatively high involvement of BD in overdose deaths also involving heroin and opioids or methamphetamines (Darke et al., 2007; Darke & Zador, 1996; Kaye et al., 2008; Paulozzi et al., 2009). Not many studies were done in Canada on this theme, but Fischer et al. (2004) corroborated the international findings and found a significant bivariate association between BD use and risk of overdose (OR = 1.70; 95% CI: 1.13 – 2.57) (Fischer et al., 2004). So overall, BDs consistently had been associated with overdosing and overdose deaths in marginalized populations.

For the general population, the results on NMUBD and mortality were inconclusive. On the basis of existing research there is limited data examining independent effects of NMUBD upon mortality. Future research is needed to carefully examine risks of use in accordance with doctors' prescriptions and extra-medical use (Charlson et al., 2009).

5.2.3. BD and abuse/dependence of other substances

For Canada, we lack data on associations with NMUBD in the general populations. In the relatively small subgroup of street users, there are clear indications of NMUBD as part of the most common poly-substance use patterns, as several studies on IDUs or opioid users in Canada show (e.g., (Health Canada, 2006; Haydon et al., 2005; Fischer et al., 2005; Wild et al., 2008). In these populations, intravenous applications of BDs can also be found. In treatment sample for substance use disorders, there were also clear indications for parallel use of BD, especially in MMT treatment (Brands et al., 2004).

5.2.4. Injuries

BD use was found to be associated with traffic injury (Kelly et al., 2004) and suicide (Fanton et al., 2007). The latter relationship may just show the confounding based on the primary disorder where BD were prescribed. There are some indications that falls in the elderly are associated with BD use, but the data are not conclusive (Hegeman et al., 2009). The relationships between NMUBD and injury are not clear.

5.2.5. Treatment and health services utilization

There are no Canada-wide data on treatment enrolment for BD. The most systematic data we found refer to Ontario, where no trends related to BD use can be seen (Drug and Alcohol Treatment Information System (DATIS), 2008):

Table 2: Reporting BDs as presenting problem substance of substance abuse clients with open admissions (without family members) recorded in the DATIS system (Drug and Alcohol Treatment Information System (DATIS), 2008)
2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
N  % N  % N  % N  % N  %
3 186 3,9 3 777 4,0 3 647 3,7 3 503 3,4 3 548 3,4

In the survey of paramedics in Brockville and the District Leeds Grenville (Ontario), 38% of respondents identified sedatives/hypnotics (including BDs and barbiturates) as the most common problem substances related to emergency calls, compared to 15% for OxyContin(Garvin, 2004).