The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie2023, Vol. 68(11) 876‐879© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/07067437231156000TheCJP.ca | LaRCP.ca
Keywordsalcohol, addictions, substance use disorders, health disparities, COVID-19, SARS-CoV-2, mortality, opioids
Rates of alcohol- and opioid-related harms, including emergency department (ED) visits, hospitalizations, and deaths caused by alcohol or opioids, have increased since the beginning of the pandemic.1, 2 It has been hypothesized that these increases in harms were driven by increased substance use by individuals with a prepandemic alcohol-use disorder (AUD) or opioid-use disorder (OUD) rather than by greater substance use during the pandemic in the general population.3,4 Despite the face validity of these concerns, there is limited data on changes in mortality for individuals with prepandemic substance use disorders (SUDs). This study compared excess mortality during the COVID-19 pandemic between the general population and individuals who received acute care (ED visit or hospitalization) for alcohol or opioids prepandemic.
This was a population-based repeated cross-sectional study that examined all-cause mortality for individuals aged 10+ years in Ontario, Canada using linked health administrative data at ICES, Ontario’s largest health data repository. To evaluate changes in mortality during the COVID-19 pandemic, we compared the age and sex standardized mortality rate (SMR) during the first 15 months of the pandemic (11 March 2020–31 May 2021) to the same period prior to the pandemic (11 March 2018–31 May 2019) and reported risk ratio and rate differences between the 2 periods. We stratified the Ontario population into 3 groups, those with a prior history of acute care for alcohol, for opioids, and the general population, and compared changes in mortality between them. Prior history was defined as 1 or more acute care events in the 2 years before the start of each crosssectional cohort (Appendix in the Online Supplemental Material). We also examined subgroup differences by age and sex and identified deaths associated with COVID-19 infection, defined as death within 30 days of a positive polymerase chain reaction test for COVID-19. The specific databases used for this study are outlined in the Appendix in the Online Supplemental Material. Data were analysed using SAS version 9.4 (SAS Institute).
Our study examined 13,992,324 individuals of which 1.09% (n = 152,834) had prior alcohol acute care and 0.32% (n = 44,942) had prior opioid acute care and 0.08% (n = 10,958) had both prior alcohol and opioid acute care. There were 128,400 all-cause deaths during the prepandemic period and 140,559 all-cause deaths during the pandemic period. During the pandemic, 7.19% (n = 9,725) of deaths in the general population, 2.97% (n = 118) of deaths in the prior alcohol acute care group and 2.34% (n = 39) of deaths in the prior opioid acute care group were associated with COVID-19 infection.
Prior to the pandemic, the SMR per 10,000 population was higher among individuals with prior alcohol acute care (SMR: 434.89) and opioid acute care (SMR: 660.19) than in the general population (SMR: 93.80, Table 1). There were proportionately more individuals with prior alcohol acute care versus opioid acute care such that the former group incurred more deaths (n = 3,482) than the latter (n = 1,283, Table 1).
During the pandemic, there were larger increases in mortality among individuals with prior alcohol or opioid acute care than in the general population. The SMR increased by 10.92% in individuals with prior alcohol acute care, 10.20% in individuals with prior opioid acute care, and 4.50% in the general population (Table 1). Among individuals with prior alcohol or opioid acute care, increases in rates of death were greater in younger versus older adults and men versus women (Table 1).
Following the onset of the COVID-19 pandemic—when compared to the general population—we observed larger increases in all-cause mortality among individuals with evidence of prepandemic acute care for alcohol or opioids. These increases in mortality were particularly pronounced for younger adults and men and did not appear to be directly related to COVID-19 infection.
A combination of drug-specific factors (e.g. an increasingly toxic unregulated opioid supply) and more generalizable factors (e.g. pandemic-related stressors and disruptions in treatment access and supportive services, particularly at the start of the pandemic) may have contributed to these trends.2 Furthermore, individuals with SUDs are a marginalized population that may have been more vulnerable to the social and economic pressures associated with the COVID-19 pandemic than the general population.4
While individuals with prior opioid acute care had a higher baseline mortality rate than individuals with prior alcohol acute care, acute care for alcohol was 3 times more common in Ontario than for opioids. Consequently, individuals with prior alcohol acute care incurred a higher total number and absolute increase in deaths during the pandemic. While alcohol- and opioid-related mortality are unique concerns that require drug-specific solutions, these findings highlight the urgency of greater attention toward addressing alcohol-related mortality in Canada.
This study was limited by a lack of data on substance use in the cause of death. Furthermore, using health administrative data to identify individuals with “AUD” or “OUD” will have biased our sample to be more representative of individuals whose SUD was severe enough to require acute care. Nonetheless, this study indicates that individuals with prior acute alcohol or opioid care experienced much larger increases in mortality during COVID-19 than the general population. Increases in treatment access and evidence-based policies (e.g. screening brief interventions and referral, greater harm reduction services2, 5) aimed at reducing both individual and population-level substance use and mitigating associated negative health impacts are urgently indicated.
This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). Primary outcome data, including hospitalizations and emergency department visits with their respective diagnostic codes, were captured in the Discharge Abstract Database (DAD) and National Ambulatory Reporting System (NACRS). Cause of death data was obtained from vital statistics records (ORGD). Demographic data was obtained from the Registered Persons Database (RPDB). OHIP billings and the Ontario Mental Health Reporting System (OMHRS) were used to capture previous substance use disorders and mental healthcare system interactions. Parts of this material are based on data and information compiled and provided by Ontario Ministry of Health (MOH). The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.
Parts of this material are based on data and/or information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed in the material are those of the author(s), and not necessarily those of CIHI.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Daniel Thomas Myran https://orcid.org/0000-0002-8038-300X
Erik Loewen Friesen https://orcid.org/0000-0003-4261-2534
Supplemental material for this article is available online.
1 Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
2 Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
3 ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
4 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
5 Department of Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
Corresponding author:Daniel T. Myran, MD, MPH, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Ave, PO Box 693, Ottawa, ON K1Y4E9, Canada.Email: dmyran@ohri.ca
