Prevalence of Prescribed Opioid Claims Among Persons With Traumatic Spinal Cord Injury in Ontario, Canada: A Population-Based Retrospective Cohort Study

Published:September 02, 2020DOI:


      • Thirty-five percent of Ontarians living with traumatic spinal cord injury use prescription opioids.
      • Male sex; age between 40 and 60 years; thoracic, lumbar, or sacral injury level; osteoarthritis; and low income increase the risk of chronic opioid use.
      • Time since injury, age between 40 and 50 years, and higher comorbidity increase the risk of chronic high dose use.



      To examine prescription opioid claims among individuals with traumatic spinal cord injury (SCI) and to identify factors associated with both chronic opioid and chronic high-dose opioid use.


      Retrospective cohort study using population-level administrative data.


      Ontario, Canada.


      Individuals (N=1842) with traumatic SCI between April 1, 2004 and March 31, 2015.


      Not applicable.

      Main Outcome Measures

      Proportion of cohort with chronic opioid use (≥90d supply) and proportion with chronic high-dose opioid use (≥90d supply exceeding 90 mg morphine equivalent) between April 1, 2016 and March 31, 2017 (observation period).


      A total of 1842 individuals with traumatic SCI were identified (74% men), with a median age of 51 years (interquartile range [IQR], 34-64y) and median duration of injury of 6 years (IQR, 4-9y). During the observation period, 35% were dispensed at least 1 opioid and 19.8% received chronic opioids, 39% of whom received more than 90 mg daily (chronic high dose). The median daily morphine equivalent dose was 212 mg morphine equivalent (IQR, 135.5-345.3 mg) for chronic high-dose users. Significant risk factors for chronic opioid use were male sex; age between 40 and 60 years; lower income; multimorbidity; thoracic, lumbar, or sacral level of injury; and having a previous diagnosis of osteoarthritis. Risk factors for chronic high-dose opioid use were an extended time since injury, age between 40 and 50 years, and increasing comorbidity.


      A large proportion of individuals with traumatic SCI were dispensed an opioid in a recent 1-year period. A substantial proportion were dispensed more than 90 mg of morphine equivalents, which is the maximum recommended by the Canadian opioid guideline. Further research is needed to understand the risk factors associated with chronic, high-dose opioid use in this population.


      List of abbreviations:

      ADG (aggregated diagnosis group), CI (confidence interval), IQR (interquartile range), RR (relative risk), SCI (spinal cord injury)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Dijkers M.
        • Bryce T.
        • Zanca J.
        Prevalence of chronic pain after traumatic spinal cord injury: a systematic review.
        J Rehabil Res Dev. 2009; 46: 13-29
        • van Gorp S.
        • Kessels A.G.
        • Joosten E.A.
        • van Kleef M.
        • Patijn J.
        Pain prevalence and its determinants after spinal cord injury: a systematic review.
        Eur J Pain. 2015; 19: 5-14
        • Norrbrink Budh C.
        • Lund I.
        • Ertzgaard P.
        • et al.
        Pain in a Swedish spinal cord injury population.
        Clin Rehabil. 2003; 17: 685-690
        • Siddall P.J.
        • Taylor D.A.
        • McClelland J.M.
        • Rutkowski S.B.
        • Cousins M.J.
        Pain report and the relationship of pain to physical factors in the first 6 months following spinal cord injury.
        Pain. 1999; 81: 187-197
        • Norrbrink Budh C.
        • Lund I.
        • Hultling C.
        • et al.
        Gender related differences in pain in spinal cord injured individuals.
        Spinal Cord. 2003; 41: 122-128
        • Ravenscroft A.
        • Ahmed Y.S.
        • Burnside I.G.
        Chronic pain after SCI. A patient survey.
        Spinal Cord. 2000; 38: 611-614
        • Anke A.G.
        • Stenehjem A.E.
        • Stanghelle J.K.
        Pain and life quality within 2 years of spinal cord injury.
        Paraplegia. 1995; 33: 555-559
        • Hagen E.M.
        • Rekand T.
        Management of neuropathic pain associated with spinal cord injury.
        Pain Ther. 2015; 4: 51-65
        • Duenas M.
        • Ojeda B.
        • Salazar A.
        • Mico J.A.
        • Failde I.
        A review of chronic pain impact on patients, their social environment and the health care system.
        J Pain Res. 2016; 9: 457-467
        • Khazaeipour Z.
        • Norouzi-Javidan A.
        • Kaveh M.
        • Khanzadeh Mehrabani F.
        • Kazazi E.
        • Emami-Razavi S.-H.
        Psychosocial outcomes following spinal cord injury in Iran.
        J Spinal Cord Med. 2014; 37: 338-345
        • McCarberg B.H.
        • Nicholson B.D.
        • Todd K.H.
        • Palmer T.
        • Penles L.
        The impact of pain on quality of life and the unmet needs of pain management: results from pain sufferers and physicians participating in an Internet survey.
        Am J Ther. 2008; 15: 312-320
        • Widerstrom-Noga E.G.
        • Felipe-Cuervo E.
        • Yezierski R.P.
        Chronic pain after spinal injury: interference with sleep and daily activities.
        Arch Phys Med Rehabil. 2001; 82: 1571-1577
        • Ataoglu E.
        • Tiftik T.
        • Kara M.
        • Tunc H.
        • Ersoz M.
        • Akkus S.
        Effects of chronic pain on quality of life and depression in patients with spinal cord injury.
        Spinal Cord. 2013; 51: 23-26
        • Middleton J.
        • Tran Y.
        • Craig A.
        Relationship between quality of life and self-efficacy in persons with spinal cord injuries.
        Arch Phys Med Rehabil. 2007; 88: 1643-1648
        • Guy S.D.
        • Mehta S.
        • Casalino A.
        • et al.
        The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: recommendations for treatment.
        Spinal Cord. 2016; 54: S14-23
        • Hadjipavlou G.
        • Cortese A.M.
        • Ramaswamy B.
        Spinal cord injury and chronic pain.
        BJA Educ. 2016; 16: 264-268
        • Siddall P.J.
        Management of neuropathic pain following spinal cord injury: now and in the future.
        Spinal Cord. 2009; 47: 352-359
        • Eide P.K.
        • Stubhaug A.
        • Stenehjem A.E.
        Central dysesthesia pain after traumatic spinal cord injury is dependent on N-methyl-D-aspartate receptor activation.
        Neurosurgery. 1995; 37: 1080-1087
        • Attal N.
        • Guirimand F.
        • Brasseur L.
        • Gaude V.
        • Chauvin M.
        • Bouhassira D.
        Effects of IV morphine in central pain: a randomized placebo-controlled study.
        Neurology. 2002; 58: 554-563
        • Bryce T.N.
        Opioids should not be prescribed for chronic pain after spinal cord injury.
        Spinal Cord Ser Cases. 2018; 4: 66
        • Wong T.K.
        • Alexander M.S.
        • New P.W.
        • Delgado A.D.
        • Bryce T.N.
        Pulse article: opioid prescription for pain after spinal cord damage (SCD), differences from recommended guidelines, and a proposed algorithm for the use of opioids for pain after SCD.
        Spinal Cord Ser Cases. 2019; 5: 39
        • Busse J.W.
        • Craigie S.
        • Juurlink D.N.
        • et al.
        Guideline for opioid therapy and chronic noncancer pain.
        CMAJ. 2017; 189: E659-E666
        • Canadian Institute for Health Information
        Pan-Canadian trends in the prescribing of opioids and benzodiazepines, 2012 to 2017.
        Canadian Institute for Health Information, Ottawa2018
      1. Opioid Management 2018. Available at: Accessed August 14, 2020.

      2. Safe Prescribing of Drugs with Potential for Misuse/Diversion 2018. Available online: Accessed August 14, 2020.

        • Kahan M.
        • Wilson L.
        • Mailis-Gagnon A.
        • Srivastava A.
        • National Opioid Use Guideline Group
        Canadian guideline for safe and effective use of opioids for chronic noncancer pain: clinical summary for family physicians. Part 2: special populations.
        Can Fam Physician. 2011; 57: 1269-1276,e419-28
        • Atkins A.M.
        • Gonzalez F.
        • Joyo B.
        • et al.
        Tapering opioid prescriptions and reducing polypharmacy for inpatients with spinal cord injury at Rancho Los Amigos National Rehabilitation Center.
        J Rehabil Res Dev. 2014; 51: vii-xiv
        • Guilcher S.J.T.
        • Craven B.C.
        • Lemieux-Charles L.
        • Casciaro T.
        • McColl M.A.
        • Jaglal S.B.
        Secondary health conditions and spinal cord injury: an uphill battle in the journey of care.
        Disabil Rehabil. 2013; 35: 894-906
        • Guilcher S.J.T.
        • Hogan M.E.
        • Calzavara A.
        • et al.
        Prescription drug claims following a traumatic spinal cord injury for older adults: a retrospective population-based study in Ontario, Canada.
        Spinal Cord. 2018; 56: 1059-1068
        • Wodchis W.P.
        • Bushmeneva K.
        • Nikitovic M.
        • McKillop I.
        Guidelines on person-level costing using administrative databases in Ontario.
        Working paper series. 1. Health System Performance Research Network, Toronto2013
        • Williams J.
        • Young W.
        Appendix: a summary of studies on the quality of health care administrative databases in Canada.
        in: Goel V. Williams J. Anderson G. Blackstein-Hirsh P. Fooks C. Naylor C. Patterns of health care in Ontario: the ICES practice atlas. 2nd ed. Canadian Medical Association, Ottawa1996
        • Juurlink D.
        • Preyra C.
        • Croxford R.
        • et al.
        Canadian Institute for Health Information discharge abstract database: a validation study.
        Institute for Clinical Evaluative Sciences, Toronto2006
        • Jaglal S.B.
        • Munce S.E.
        • Guilcher S.J.
        • et al.
        Health system factors associated with rehospitalizations after traumatic spinal cord injury: a population-based study.
        Spinal Cord. 2009; 47: 604-609
        • Guilcher S.J.
        • Munce S.E.
        • Couris C.M.
        • et al.
        Health care utilization in non-traumatic and traumatic spinal cord injury: a population-based study.
        Spinal Cord. 2010; 48: 45-50
        • Couris C.M.
        • Guilcher S.J.
        • Munce S.E.
        • et al.
        Characteristics of adults with incident traumatic spinal cord injury in Ontario, Canada.
        Spinal Cord. 2010; 48: 39-44
        • Morgan S.G.
        • Gladstone E.J.
        • Weymann D.
        • Khan N.
        The effects of catastrophic drug plan deductibles on older women's use of cardiovascular medicines: a retrospective cohort study.
        CMAJ Open. 2017; 5: E198-204
        • Morgan S.G.
        • Weymann D.
        • Pratt B.
        • et al.
        Sex differences in the risk of receiving potentially inappropriate prescriptions among older adults.
        Age Ageing. 2016; 45: 535-542
        • Gershon A.S.
        • Wang C.
        • Guan J.
        • Vasilevska-Ristovska J.
        • Cicutto L.
        • To T.
        Identifying patients with physician-diagnosed asthma in health administrative databases.
        Can Respir J. 2009; 16: 183-188
        • Schultz S.E.
        • Rothwell D.M.
        • Chen Z.
        • Tu K.
        Identifying cases of congestive heart failure from administrative data: a validation study using primary care patient records.
        Chronic Dis Inj Can. 2013; 33: 160-166
        • Gershon A.S.
        • Wang C.
        • Guan J.
        • Vasilevska-Ristovska J.
        • Cicutto L.
        • To T.
        Identifying individuals with physcian diagnosed COPD in health administrative databases.
        COPD. 2009; 6: 388-394
        • Tu K.
        • Campbell N.R.
        • Chen Z.L.
        • Cauch-Dudek K.J.
        • McAlister F.A.
        Accuracy of administrative databases in identifying patients with hypertension.
        Open Med. 2007; 1: e18-26
        • Hux J.E.
        • Ivis F.
        • Flintoft V.
        • Bica A.
        Diabetes in Ontario: determination of prevalence and incidence using a validated administrative data algorithm.
        Diabetes Care. 2002; 25: 512-516
        • Widdifield J.
        • Bombardier C.
        • Bernatsky S.
        • et al.
        An administrative data validation study of the accuracy of algorithms for identifying rheumatoid arthritis: the influence of the reference standard on algorithm performance.
        BMC Musculoskelet Disord. 2014; 15: 216
        • Jaakkimainen R.L.
        • Bronskill S.E.
        • Tierney M.C.
        • et al.
        Identification of physician-diagnosed Alzheimer's disease and related dementias in population-based administrative data: a validation study using family physicians' electronic medical records.
        J Alzheimers Dis. 2016; 54: 337-349
        • Koné Pefoyo A.J.
        • Bronskill S.E.
        • Gruneir A.
        • et al.
        The increasing burden and complexity of multimorbidity.
        BMC Public Health. 2015; 15: 415
        • Canadian Institute for Health Information
        Pan-Canadian trends in the prescribing of opioids, 2012 to 2016.
        (Available at:) (Accessed August 14, 2020)
        • Fischer B.
        • Jones W.
        • Vojtila L.
        • Kurdyak P.
        Patterns, changes, and trends in prescription opioid dispensing in Canada, 2005-2016.
        Pain Physician. 2018; 21: 219-228
        • Hwang C.S.
        • Kang E.M.
        • Ding Y.
        • et al.
        Patterns of immediate-release and extended-release opioid analgesic use in the management of chronic pain, 2003-2014.
        JAMA Netw Open. 2018; 1e180216
        • Ontario Drug Policy Research Network
        Ontario Prescription Opioid Tool: technical appendix.
        (Available at:) (Accessed August 14, 2020)
        • Dowell D.
        • Haegerich T.M.
        • Chou R.
        CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016.
        MMWR Recomm Rep. 2016; 65: 1-49
        • Berterame S.
        • Erthal J.
        • Thomas J.
        • et al.
        Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study.
        Lancet. 2016; 387: 1644-1656
        • Compton W.M.
        • Boyle M.
        • Wargo E.
        Prescription opioid abuse: problems and responses.
        Prev Med. 2015; 80: 5-9
        • Hand B.N.
        • Krause J.S.
        • Simpson K.N.
        Dose and duration of opioid use in propensity score-matched, privately insured opioid users with and without spinal cord injury.
        Arch Phys Med Rehabil. 2018; 99: 855-861
        • Gomes T.
        • Pasricha S.
        • Martin D.
        • et al.
        Behind the prescriptions: a snapshot of opioid use across all Ontarians.
        Ontario Drug Policy Research Network, Toronto2017
      3. Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. Canada: National Opioid Use Guideline Group (NOUGG); 2010, Available at:, Accessed August 14, 2020.

        • Kertesz S.G.
        • Manhapra A.
        The drive to taper opioids: mind the evidence, and the ethics.
        Spinal Cord Series Cases. 2018; 4: 64
        • Brose S.W.
        • Schneck H.
        • Bourbeau D.J.
        An interdisciplinary approach to reducing opioid prescriptions to patients with chronic pain in a spinal cord injury center.
        PM R. 2019; 11: 135-141
        • Kaplovitch E.
        • Gomes T.
        • Camacho X.
        • Dhalla I.A.
        • Mamdani M.M.
        • Juurlink D.N.
        Sex differences in dose escalation and overdose death during chronic opioid therapy: a population-based cohort study.
        PLoS One. 2015; 10e0134550
        • Dunn K.M.
        • Saunders K.W.
        • Rutter C.M.
        • et al.
        Opioid prescriptions for chronic pain and overdose: a cohort study.
        Ann Intern Med. 2010; 152: 85-92
        • Herder M.
        • Juurlink D.
        High-strength opioid formulations: the case for a ministerial recall.
        CMAJ. 2018; 190: E1404
        • Bohnert A.S.B.
        • Valenstein M.
        • Bair M.J.
        • et al.
        Association between opioid prescribing patterns and opioid overdose-related deaths.
        JAMA. 2011; 305: 1315-1321
        • Gomes T.
        • Juurlink D.N.
        • Mamdani M.M.
        • Paterson J.M.
        • van den Brink W.
        Prevalence and characteristics of opioid-related deaths involving alcohol in Ontario, Canada.
        Drug Alcohol Depend. 2017; 179: 416-423
        • Gomes T.
        • Juurlink D.N.
        • Antoniou T.
        • Mamdani M.M.
        • Paterson J.M.
        • van den Brink W.
        Gabapentin, opioids, and the risk of opioid-related death: a population-based nested case-control study.
        PLoS Med. 2017; 14e1002396
        • Ballantyne J.C.
        • Shin N.S.
        Efficacy of opioids for chronic pain: a review of the evidence.
        Clin J Pain. 2008; 24: 469-478
        • Juurlink D.N.
        Rethinking “doing well” on chronic opioid therapy.
        CMAJ. 2017; 189: E1222