TY - JOUR
KW - Adult
KW - Aged
KW - Analgesics, Opioid/adverse effects/therapeutic use
KW - Attitude of Health Personnel
KW - Chronic Pain/diagnosis/drug therapy/epidemiology
KW - Continuity of Patient Care/trends
KW - Databases, Factual
KW - Female
KW - Health Knowledge, Attitudes, Practice
KW - Health Services Accessibility/trends
KW - Health Services Research
KW - Healthcare Disparities/trends
KW - Humans
KW - Male
KW - Middle Aged
KW - Ontario/epidemiology
KW - Opioid-Related Disorders/diagnosis/epidemiology/therapy
KW - Practice Patterns, Physicians'/trends
KW - Primary Health Care/trends
KW - Retrospective Studies
KW - Time Factors
AU - T. Gomes
AU - T. J. Campbell
AU - D. Martins
AU - J. M. Paterson
AU - L. Robertson
AU - D. N. Juurlink
AU - M. Mamdani
AU - R. H. Glazier
A1 - 
AB - BACKGROUND: Stigma and high-care needs can present barriers to the provision of high-quality primary care for people with opioid use disorder (OUD) and those prescribed opioids for chronic pain. We explored the likelihood of securing a new primary care provider (PCP) among people with varying histories of opioid use who had recently lost access to their PCP. METHODS AND FINDINGS: We conducted a retrospective cohort study using linked administrative data among residents of Ontario, Canada whose enrolment with a physician practicing in a primary care enrolment model (PEM) was terminated between January 2016 and December 2017. We assigned individuals to 3 groups based upon their opioid use on the date enrolment ended: long-term opioid pain therapy (OPT), opioid agonist therapy (OAT), or no opioid. We fit multivariable models assessing the primary outcome of primary care reattachment within 1 year, adjusting for demographic characteristics, clinical comorbidities, and health services utilization. Secondary outcomes included rates of emergency department (ED) visits and opioid toxicity events. Among 154,970 Ontarians who lost their PCP, 1,727 (1.1%) were OAT recipients, 3,644 (2.4%) were receiving long-term OPT, and 149,599 (96.5%) had no recent prescription opioid exposure. In general, OAT recipients were younger (median age 36) than those receiving long-term OPT (59 years) and those with no recent prescription opioid exposure (44 years). In all exposure groups, the majority of individuals had their enrolment terminated by their physician (range 78.1% to 88.8%). In the primary analysis, as compared to those not receiving opioids, OAT recipients were significantly less likely to find a PCP within 1 year (adjusted hazard ratio [aHR] 0.55, 95% confidence interval [CI] 0.50 to 0.61, p < 0.0001). We observed no significant difference between long-term OPT and opioid unexposed individuals (aHR 0.96; 95% CI 0.92 to 1.01, p = 0.12). In our secondary analysis comparing the period of PCP loss to the year prior, we found that rates of ED visits were elevated among people not receiving opioids (adjusted rate ratio (aRR) 1.20, 95% CI 1.18 to 1.22, p < 0.0001) and people receiving long-term OPT (aRR 1.37, 95% CI 1.28 to 1.48, p < 0.0001). We found no such increase among OAT recipients, and no significant increase in opioid toxicity events in the period following provider loss for any exposure group. The main limitation of our findings relates to their generalizability outside of PEMs and in jurisdictions with different financial incentives incorporated into primary care provision. CONCLUSIONS: In this study, we observed gaps in access to primary care among people who receive prescription opioids, particularly among OAT recipients. Ongoing efforts are needed to address the stigma, discrimination, and financial disincentives that may introduce barriers to the healthcare system, and to facilitate access to high-quality, consistent primary care services for chronic pain patients and those with OUD.
AD - Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada.; ICES, Toronto, Canada.; University of Toronto, Toronto, Canada.; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada.; ICES, Toronto, Canada.; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada.; ICES, Toronto, Canada.; University of Toronto, Toronto, Canada.; Department of Family Medicine, McMaster University, Hamilton, Canada.; Chronic Pain Support Services, Ottawa, Canada.; ICES, Toronto, Canada.; University of Toronto, Toronto, Canada.; The Sunnybrook Research Institute, Toronto, Canada.; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada.; ICES, Toronto, Canada.; University of Toronto, Toronto, Canada.; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada.; ICES, Toronto, Canada.; University of Toronto, Toronto, Canada.; Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada.
BT - PLoS medicine
C5 - Education & Workforce; Financing & Sustainability; Healthcare Disparities; Opioids & Substance Use
CP - 6
DO - 10.1371/journal.pmed.1003631
IS - 6
JF - PLoS medicine
LA - eng
M1 - Journal Article
N2 - BACKGROUND: Stigma and high-care needs can present barriers to the provision of high-quality primary care for people with opioid use disorder (OUD) and those prescribed opioids for chronic pain. We explored the likelihood of securing a new primary care provider (PCP) among people with varying histories of opioid use who had recently lost access to their PCP. METHODS AND FINDINGS: We conducted a retrospective cohort study using linked administrative data among residents of Ontario, Canada whose enrolment with a physician practicing in a primary care enrolment model (PEM) was terminated between January 2016 and December 2017. We assigned individuals to 3 groups based upon their opioid use on the date enrolment ended: long-term opioid pain therapy (OPT), opioid agonist therapy (OAT), or no opioid. We fit multivariable models assessing the primary outcome of primary care reattachment within 1 year, adjusting for demographic characteristics, clinical comorbidities, and health services utilization. Secondary outcomes included rates of emergency department (ED) visits and opioid toxicity events. Among 154,970 Ontarians who lost their PCP, 1,727 (1.1%) were OAT recipients, 3,644 (2.4%) were receiving long-term OPT, and 149,599 (96.5%) had no recent prescription opioid exposure. In general, OAT recipients were younger (median age 36) than those receiving long-term OPT (59 years) and those with no recent prescription opioid exposure (44 years). In all exposure groups, the majority of individuals had their enrolment terminated by their physician (range 78.1% to 88.8%). In the primary analysis, as compared to those not receiving opioids, OAT recipients were significantly less likely to find a PCP within 1 year (adjusted hazard ratio [aHR] 0.55, 95% confidence interval [CI] 0.50 to 0.61, p < 0.0001). We observed no significant difference between long-term OPT and opioid unexposed individuals (aHR 0.96; 95% CI 0.92 to 1.01, p = 0.12). In our secondary analysis comparing the period of PCP loss to the year prior, we found that rates of ED visits were elevated among people not receiving opioids (adjusted rate ratio (aRR) 1.20, 95% CI 1.18 to 1.22, p < 0.0001) and people receiving long-term OPT (aRR 1.37, 95% CI 1.28 to 1.48, p < 0.0001). We found no such increase among OAT recipients, and no significant increase in opioid toxicity events in the period following provider loss for any exposure group. The main limitation of our findings relates to their generalizability outside of PEMs and in jurisdictions with different financial incentives incorporated into primary care provision. CONCLUSIONS: In this study, we observed gaps in access to primary care among people who receive prescription opioids, particularly among OAT recipients. Ongoing efforts are needed to address the stigma, discrimination, and financial disincentives that may introduce barriers to the healthcare system, and to facilitate access to high-quality, consistent primary care services for chronic pain patients and those with OUD.
PY - 2021
SN - 1549-1676; 1549-1277; 1549-1277
T1 - Inequities in access to primary care among opioid recipients in Ontario, Canada: A population-based cohort study
T2 - PLoS medicine
TI - Inequities in access to primary care among opioid recipients in Ontario, Canada: A population-based cohort study
U1 - Education & Workforce; Financing & Sustainability; Healthcare Disparities; Opioids & Substance Use
U2 - 34061846
U3 - 10.1371/journal.pmed.1003631
VL - 18
VO - 1549-1676; 1549-1277; 1549-1277
Y1 - 2021
Y2 - Jun 1
ER -