The market for prescription oral solid opioids, 2010 to 2017

Canada and the United States

Introduction

Regulatory amendments regarding tramadol

• Health Canada put forward a proposal in June 2018 to add tramadol to Schedule I of the Controlled Drugs and Substances Act (CDSA) and the Schedule to the Narcotic Control Regulations (NCR).
• This is intended to help prevent diversion and protect Canadians from the health risks of unauthorized tramadol use, while maintaining its availability for legitimate medical and scientific use.
• More details on the proposed regulatory amendments are available at: https://www.canada.ca/en/health-canada/programs/consultation-amendments-tramadol.html

Purpose of this analysis

To provide an overview of the market for prescription opioids in Canada and the United States to inform discussions on the impact of the proposed regulatory changes.

Data Sources

The findings presented in this study are based on the analysis of a number of databases. The results pertaining to the Canadian national retail and hospital markets are based on data captured in the IQVIA MIDAS™ Database (all rights reserved).

The NPDUIS Database from the Canadian Institute for Health Information (CIHI), consisting of public plan data from every province (except Quebec) as well as the Yukon and NIHB, was used in the analyses of the public drug plan market, while the IQVIA Private Pay Direct Plan Database was used in the analyses of the private drug plan market. CIHI private plan data for British Columbia was used in one analysis.

The IQVIA Payer Insights Database provided information on the market breakdown by public, private, and out-of-pocket markets.

For more information on these data sources, see the Source Materials document on the Analytical Studies page of the PMPRB website.

Methods

This study focuses on the Canadian and US markets for the oral solid formulations of the prescription opioids listed below, including combination products containing the target medicines. For some analyses, oral solid formulations could not be isolated from the rest of the data, and thus, the results include all forms of each opioid. Physical units are a count of individual pills, tablets, caplets, etc. regardless of strength or formulation. Fully synthetic opioids such as fentanyl or methadone were not included in the analyses.

The following is the list of opioids included in this study, along with their respective morphine equivalents (MEQ):

Figure description

This bar graph shows the morphine equivalency of the opioids included in this analysis.

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Opioid	Morphine equivalents
Tramadol	0.17
Codeine	0.15
Morphine	1
Hydrocodone	1
Oxycodone	1.5
Oxymorphone	3
Hydromorphone	5

Morphine equivalents are a standardized measure used in this study to compare the relative potency of a milligram of each opioid to morphine.

1. National opioid markets - Canada and the United States

Per capita opioid consumption is lower in Canada than in the US, and has been declining in both countries in recent years

In 2017, enough oral solid opioids were prescribed to provide every Canadian with the equivalent of over 1 mg of morphine per day. The 419 MEQ per capita in 2017 represents an annual decline of 3.3% from the 529 MEQ per capita in 2010.

Figure 1.1 Morphine equivalents sold per capita, oral solid opioids, Canada and the US, 2010 to 2017

Figure description

This figure includes two bar graphs comparing morphine equivalents sold per capita in Canada and the United States. Results are given annually from 2010 to 2017, and compound annual growth rates are included for the period.

Canada

Year	Morphine equivalents per capita
2010	529
2011	520
2012	500
2013	487
2014	500
2015	487
2016	471
2017	419
Compound annual growth rate	-3.3%

United States

Year	Morphine equivalents per capita
2010	746
2011	783
2012	733
2013	698
2014	685
2015	661
2016	609
2017	529
Compound annual growth rate	-4.8%

While the use of most prescription opioids is declining in Canada and the US, tramadol and hydromorphone use in Canada is on the rise

As measured by MEQ sold, the use of tramadol and hydromorphone in Canada grew at a compounded annual rate of greater than 4% from 2010 to 2017.

Figure 1.2 Number of morphine equivalents indexed to 2010, oral solid opioids, Canada and the US, 2010 to 2017

Figure description

Two line graphs give the sales of each of the oral solid opioids from 2010 to 2017 indexed to their sales in 2010. An accompanying table lists the total morphine equivalents for 2010 and 2017 in billions, the indexed results for 2017, as well as the compound annual growth rate for the full period. The first graph gives the indexed trends for Canada, and the second for the United States.

Canada

Opioid	2010	2011	2012	2013	2014	2015	2016	2017	Total MEQ (billions)		Compound annual growth rate, 2010 to 2017
									2010	2017
Tramadol	1.00	1.06	1.15	1.19	1.24	1.32	1.39	1.37	0.73	1.01	4.6%
Codeine	1.00	0.84	0.66	0.66	0.91	0.87	0.81	0.74	2.84	2.12	-4.1%
Morphine	1.00	0.99	1.00	1.02	0.97	0.89	0.83	0.74	2.64	1.94	-4.3%
Hydrocodone	1.00	1.05	0.93	1.06	0.98	1.04	1.17	0.55	<0.01	<0.01	-8.1%
Oxycodone	1.00	1.01	0.92	0.80	0.78	0.76	0.74	0.65	7.97	5.20	-5.9%
Hydromorphone	1.00	1.07	1.24	1.41	1.46	1.48	1.50	1.35	3.78	5.12	4.4%

United States

Opioid	2010	2011	2012	2013	2014	2015	2016	2017	Total MEQ (billions)		Compound annual growth rate, 2010 to 2017
									2010	2017
Tramadol	1.00	1.08	0.99	1.06	1.10	1.14	1.02	0.90	25.04	22.58	-1.5%
Codeine	1.00	1.03	0.88	0.79	0.81	1.10	1.04	0.91	3.08	2.81	-1.3%
Morphine	1.00	1.08	0.98	0.91	0.87	0.82	0.74	0.63	27.74	17.53	-6.4%
Hydrocodone	1.00	1.05	1.01	0.99	0.96	0.86	0.79	0.70	59.19	41.14	-5.1%
Oxycodone	1.00	1.02	0.97	0.89	0.89	0.89	0.84	0.75	105.34	78.55	-4.1%
Oxymorphone	1.00	1.65	1.21	1.19	1.25	1.27	1.18	0.80	4.61	3.68	-3.1%
Hydromorphone	1.00	1.19	1.39	1.36	1.31	1.29	1.17	0.99	5.78	5.74	-0.1%

Tramadol, one of the least potent opioids, captures a relatively low share of opioid units and MEQ in Canada compared to the US; hydromorphone, the most potent opioid, accounts for a much more important share in Canada than it does in the US.

Oxycodone and hydromorphone accounted for most of the prescription opioid use (67% of all MEQ) and the majority of sales (60%) in Canada in 2017. In the US, oxycodone had the greatest use (46% of all MEQ), while the more potent hydromorphone accounted for only a minimal share.

Figure 1.3 Market distribution by units, morphine equivalents, and sales, oral solid opioids, Canada and the US, 2017

Figure description

Two stacked bar graphs show the distribution of units, morphine equivalents, and sales for each of the oral solid opioids in 2017. Total oral solid opioid sales are also indicated. The first graph gives results for Canada, and the second for the United States.

Canada

Opioid	Units	Morphine equivalents	Sales
Hydromorphone	14%	33%	29%
Oxymorphone	-	-	-
Oxycodone	21%	34%	31%
Hydrocodone	<1%	<1%	<1%
Morphine	6%	13%	7%
Codeine	52%	14%	15%
Tramadol	6%	7%	18%
Total			467 million CAD

United States

Opioid	Units	Morphine equivalents	Sales
Hydromorphone	2%	3%	2%
Oxymorphone	<1%	2%	7%
Oxycodone	32%	46%	61%
Hydrocodone	38%	24%	17%
Morphine	4%	10%	8%
Codeine	4%	2%	2%
Tramadol	19%	13%	2%
Total			4,574 million USD

The increase in the use of hydromorphone and tramadol in Canada since 2010 has resulted in them capturing a growing share of the opioid market, as the use of other opioids declines

Hydromorphone’s market share in terms of MEQ increased from 21% to 33% between 2010 and 2017, while tramadol’s share has nearly doubled from 4% to 7% over the same period. Figures A1 and A2 in the Appendix provide similar information in terms of units and sales, respectively.

Figure 1.4 Distribution of morphine equivalents by oral solid opioid, Canada and the US, 2010 to 2017

Figure description

This figure consists of two stacked bar graphs, one for the market in Canada and the other for the United States, with information on the annual distribution of morphine equivalents by opioid from 2010 to 2017, as a percentage of total morphine equivalents sold.

Canada

	2010	2011	2012	2013	2014	2015	2016	2017
Hydromorphone	21%	23%	27%	31%	31%	32%	33%	33%
Oxymorphone	-	-	-	-	-	-	-	-
Oxycodone	44%	45%	42%	37%	35%	35%	34%	34%
Hydrocodone	<1%	<1%	<1%	<1%	<1%	<1%	<1%	<1%
Morphine	15%	15%	15%	16%	14%	14%	13%	13%
Codeine	16%	13%	11%	11%	15%	14%	14%	14%
Tramadol	4%	4%	5%	5%	5%	6%	6%	7%

United States

	2010	2011	2012	2013	2014	2015	2016	2017
Hydromorphone	3%	3%	3%	4%	3%	4%	3%	3%
Oxymorphone	2%	3%	2%	2%	3%	3%	3%	2%
Oxycodone	46%	44%	44%	43%	43%	44%	45%	46%
Hydrocodone	26%	25%	26%	27%	26%	24%	24%	24%
Morphine	12%	12%	12%	11%	11%	11%	10%	10%
Codeine	1%	1%	1%	1%	1%	2%	2%	2%
Tramadol	11%	11%	11%	12%	13%	13%	13%	13%

Important disparities exist between the prices of opioids in Canada and in the US

The average prices per milligram of codeine, morphine, and oxycodone were markedly lower in Canada than in the US in 2017, while the price of hydromorphone was higher. Despite generic availability, the price of tramadol was over 12 times higher in Canada than in the US.

* Oral solid hydrocodone use in Canada is minimal and only covered by private plans.

Data source: IQVIA MIDAS™ Database, prescription retail and hospital markets, 2017. All rights reserved.

Prices for the highest-selling strengths of opioids have been on the rise in Canada, with the exceptions of tramadol and oxycodone

Canadian prices of the highest-selling strengths of codeine and morphine increased the most since 2010, with a compound annual growth rate (CAGR) of around 3%. There was greater price variability in the US, with tramadol showing a steep decline in recent years. Generic versions were available for all opioids in the US, and for most in Canada.

Figure 1.6 Price indexed to 2010 for highest-selling strengths of oral solid opioids, Canada and the US, 2010 to 2017

Figure description

Two line graphs provide Canadian and United States price indices for each oral solid opioid from 2010 to 2017. Annual prices are indexed to the price in 2010, and are based on the highest-selling strength for each opioid. Accompanying tables give the compound annual growth rate for each opioid over the period, as well as the price per capsule or tablet in 2010 and 2017. Opioids with generic versions available are marked with an asterisk.

Canadian price index

Opioid	Top-selling strength	2010	2011	2012	2013	2014	2015	2016	2017	Price per capsule or tablet, CAD		Compound annual growth rate, 2010 to 2017
										2010	2017
Tramadol*	37.5 mg	1.0	1.0	1.0	1.0	1.0	1.0	1.0	1.0	$0.64	$0.62	-0.5%
Codeine*	15 mg	1.0	1.0	1.0	1.0	1.0	1.1	1.1	1.2	$0.06	$0.07	2.9%
Morphine*	100 mg	1.0	0.9	0.9	1.0	1.1	1.1	1.2	1.3	$1.78	$2.23	3.3%
Hydrocodone	5 mg	1.0	1.0	1.0	1.0	1.1	1.1	1.1	1.0	$1.13	$1.14	0.1%
Oxycodone*	40 mg	1.0	1.0	1.0	0.9	1.0	0.9	1.0	1.0	$2.30	$2.19	-0.7%
Oxymorphone	-	-	-	-	-	-	-	-	-	-	-	-
Hydromorphone	12 mg	1.0	1.0	1.0	1.1	1.1	1.1	1.1	1.1	$1.72	$1.96	1.9%

United States price index

Opioid	Top-selling strength	2010	2011	2012	2013	2014	2015	2016	2017	Price per capsule or tablet, USD		Compound annual growth rate, 2010 to 2017
										2010	2017
Tramadol*	50 mg	1.0	1.1	0.9	0.8	0.8	0.8	0.6	0.6	$0.04	$0.02	-7.6%
Codeine*	30 mg	1.0	1.0	1.0	1.0	0.9	1.2	1.3	1.0	$0.09	$0.09	0.0%
Morphine*	60 mg	1.0	0.9	0.9	0.9	1.5	1.3	1.1	0.9	$1.13	$1.04	-1.2%
Hydrocodone	10 mg	1.0	1.0	1.2	1.3	1.0	1.6	1.4	1.2	$0.12	$0.14	2.3%
Oxycodone*	80 mg	1.0	1.1	1.2	1.2	1.3	1.3	1.3	1.3	$10.39	$13.81	4.1%
Oxymorphone*	40 mg	1.0	1.0	1.1	1.1	1.0	1.0	1.1	1.0	$10.35	$10.19	-0.2%
Hydromorphone*	16 mg	1.0	1.1	1.2	1.4	1.4	1.1	0.9	0.7	$14.41	$10.78	-4.1%

2. Canadian provincial and payer markets

Quebec accounts for a much smaller share of national prescriptions and sales of oral solid opioids than it does for prescription drugs in general, resulting in a proportionally higher share of the opioid market for most other provinces

Quebec accounted for 21% of national opioid prescriptions in 2017, whereas Ontario had double that share (42%) and British Columbia and Alberta each had 12%.

Figure 2.1 Distribution of retail prescriptions and sales by province, oral solid opioids versus all drugs, 2017

Figure description

This figure consists of four pie charts indicating the distribution of sales and prescriptions by Canadian province in 2017. Results are given as a share of the entire prescription drug market, and as a share of the market for oral solid opioids.

United States price index

	British Columbia	Alberta	Saskatchewan	Manitoba	Ontario	Quebec	New Brunswick	Nova Scotia	Prince Edward Island	Newfoundland and Labrador
Oral solid opioids
Prescriptions	12%	12%	3%	4%	42%	21%	2%	2%	<1%	2%
Sales	10%	15%	4%	4%	45%	15%	3%	3%	<1%	2%
All drugs
Prescriptions	8%	7%	2%	3%	32%	43%	2%	2%	<1%	1%
Sales	10%	10%	3%	3%	40%	28%	3%	3%	<1%	2%

Canadian private and out-of-pocket payers’ use of oral solid opioids is proportionally greater than their use of all drugs in terms of prescription volume

In 2017, half of the prescriptions for opioids were paid for by private and out-of-pocket payers, at 27% and 23%, respectively.

Figure 2.2 Share of retail prescriptions and sales by payer, oral solid opioids versus all drugs, 2017

Figure description

This figure consists of four pie charts indicating the Canadian market distribution of sales and prescription by payer type in 2017. Results are given as a share of the entire prescription drug market, and as a share of the market for oral solid opioids.

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	Public	Private	Out-of-pocket
Oral solid opioids
Prescriptions	50%	27%	23%
Sales	46%	33%	21%
All drugs
Prescriptions	55%	25%	20%
Sales	46%	38%	16%

The majority of retail prescriptions for oral solid opioids are paid by private and out-of-pocket payers in almost all provinces

Ontario and Quebec were the only provinces where public plans were the first payer for the majority of retail prescriptions, at 52% and 51%, respectively.

Figure 2.3 Share of retail prescriptions and sales by payer*, oral solid opioids, 2017

Figure description

Two stacked bar graphs shows the distribution of oral solid opioid prescriptions and sales in 2017 by payer. Results are given for public, private, and out-of-pockets payers in each province.

Prescriptions

	British Columbia	Alberta	Saskatchewan	Manitoba	Ontario	Quebec	New Brunswick	Nova Scotia	Prince Edward Island	Newfoundland and Labrador
Public	41%	45%	37%	38%	52%	51%	38%	44%	25%	35%
Private	28%	32%	25%	28%	30%	22%	35%	39%	40%	36%
Out-of-pocket	31%	23%	38%	34%	18%	28%	27%	17%	35%	29%

Sales

	British Columbia	Alberta	Saskatchewan	Manitoba	Ontario	Quebec	New Brunswick	Nova Scotia	Prince Edward Island	Newfoundland and Labrador
Public	33%	45%	54%	38%	48%	46%	39%	39%	22%	24%
Private	35%	37%	23%	28%	34%	26%	42%	48%	50%	52%
Out-of-pocket	32%	18%	23%	34%	17%	29%	18%	13%	27%	23%

Quebec has the lowest proportion of prescription opioids use in terms of retail prescriptions and sales, while Alberta has the highest

As a percentage of all drugs, retail prescriptions and sales for oral solid opioids in Quebec were less than half the levels observed in any other province in 2017.

Figure 2.4 Oral solid opioids share of total retail prescriptions and sales, 2017

Figure description

This figure consists of a bar graph with the 2017 share of retail prescriptions and share of sales for each province. Total results for all provinces are also given.

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Province	Share of prescriptions	Share of sales
British Columbia	4.0%	1.9%
Alberta	4.7%	2.7%
Saskatchewan	3.0%	2.4%
Manitoba	3.9%	2.4%
Ontario	3.6%	2.0%
Quebec	1.4%	0.9%
New Brunswick	3.1%	1.9%
Nova Scotia	3.0%	1.9%
Prince Edward Island	3.6%	2.3%
Newfoundland and Labrador	3.4%	2.3%
Total	2.7%	1.8%

Opioids account for a sizable share of prescriptions and drug costs, and have a higher share in private than in public plans

The share of opioid prescriptions was 4.4% in private plans and 2.9% in public plans in 2017.

Figure 2.5 Oral solid opioids share of total drug costs* and prescriptions, NPDUIS public plans and private plans, 2017

Figure description

This “butterfly” bar graph compares the share of prescriptions and drug costs in public and private drug plans. Results for each are given by jurisdiction, and totals are included for jurisdictions with both public and private data in 2017.

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	British Columbia	Alberta	Saskatchewan	Manitoba	Ontario	Quebec	New Brunswick	Nova Scotia	Prince Edward Island	Newfoundland and Labrador	Non-Insured Health Benefits Program	National†
NPDUIS public plans
Share of prescriptions	3.2%	3.0%	1.7%	3.8%	2.9%	Not available	2.7%	2.4%	2.3%	2.8%	4.5%	2.9%
Share of drug costs	1.8%	2.2%	1.8%	2.4%	1.8%	Not available	2.4%	2.0%	1.6%	2.1%	2.0%	1.9%
Private drug plans
Share of prescriptions	4.6%	4.9%	2.4%	3.5%	4.8%	1.6%	3.2%	2.6%	3.6%	3.6%	-	4.4%
Share of drug costs	2.6%	2.6%	2.4%	2.5%	2.4%	1.0%	1.7%	1.5%	2.2%	2.6%	-	2.4%

The number of prescriptions for hydromorphone has tripled in public plans since 2010, and nearly doubled in private plans

Tramadol and morphine prescriptions in private plans have also been on the rise.

Figure 2.6 Number of prescriptions indexed to 2010, oral solid opioids, NPDUIS public plans and private plans, 2010 to 2017

Figure description

Two line graphs with accompanying tables show the number of prescriptions for oral solid opioids from 2010 to 2017, indexed to 2010. The first graph models the results for NPDUIS public plans, and the second for private plans. Compound annual growth rates are also given for each opioid.

NPDUIS public plans

	2010	2011	2012	2013	2014	2015	2016	2017	Compound annual growth rate, 2010 to 2017
Codeine	1.00	1.10	1.09	1.08	1.06	1.04	1.03	0.95	-0.7%
Morphine	1.00	1.19	1.28	1.36	1.38	1.37	1.36	1.26	3.3%
Oxycodone	1.00	1.22	1.13	1.00	1.01	1.02	1.03	0.97	-0.4%
Hydromorphone	1.00	1.36	1.68	2.11	2.41	2.74	3.02	3.08	17.4%

Private plans

	2010	2011	2012	2013	2014	2015	2016	2017	Compound annual growth rate, 2010 to 2017
Tramadol	1.00	1.12	1.22	1.32	1.43	1.53	1.64	1.73	8.1%
Codeine	1.00	0.99	0.95	0.94	0.92	0.88	0.85	0.81	-3.0%
Morphine	1.00	1.08	1.18	1.27	1.35	1.40	1.44	1.44	5.3%
Hydrocodone	1.00	1.10	0.98	0.98	0.97	1.02	1.25	0.78	-3.5%
Oxycodone	1.00	1.03	0.98	1.00	1.03	1.04	1.03	0.98	-0.3%
Hydromorphone	1.00	1.13	1.29	1.47	1.63	1.78	1.89	1.93	9.9%

Hydromorphone now captures one third of the public drug plan prescription market as its use has increased markedly in recent years

In private plans, the use of hydromorphone and tramadol grew steadily from 2010 to 2017, though codeine and oxycodone remained the market leaders. Figures A3 and A4 in the Appendix provide similar information in terms of units and drug costs, respectively.

Figure 2.7 Distribution of prescriptions by oral solid opioid, NPDUIS public plans and private plans, 2010 to 2017

Figure description

This figure consists of two stacked bar graphs depicting the distribution of prescriptions by opioid for each year from 2010 to 2017. The first graph shows the results for the NPDUIS public drug plans, and the second for private drug plans.

NPDUIS public plans

	2010	2011	2012	2013	2014	2015	2016	2017
Codeine	45%	42%	41%	39%	37%	36%	34%	33%
Morphine	12%	12%	13%	13%	13%	13%	12%	12%
Oxycodone	28%	29%	27%	23%	22%	22%	22%	21%
Hydromorphone	14%	16%	20%	24%	27%	30%	32%	34%

Private plans

	2010	2011	2012	2013	2014	2015	2016	2017
Tramadol	11%	12%	13%	13%	14%	15%	16%	17%
Codeine	42%	41%	39%	37%	35%	33%	32%	31%
Morphine	6%	6%	6%	7%	7%	7%	7%	7%
Hydrocodone	<1%	<1%	<1%	<1%	<1%	<1%	<1%	<1%
Oxycodone	32%	32%	30%	30%	30%	30%	29%	28%
Hydromorphone	9%	10%	11%	13%	14%	15%	15%	16%

Due to its strong prescription growth in public plans, hydromorphone now accounts for the largest share of prescriptions and drug costs

In private plans, oxycodone was still the leader in terms of drug cost followed by tramadol, while codeine was the most prescribed opioid.

Figure 2.8 Market distribution by units, prescriptions, and drug costs*, oral solid opioids, NPDUIS public plans and private plans, 2017

Figure description

Two stacked bar graphs show the distribution of units, prescriptions, and drugs costs among oral solid opioids. The first gives the distribution for NPDUIS public drug plans and the second for private drug plans.

NPDUIS public plans

	Physical units	Prescriptions	Drug costs
Codeine	38%	33%	13%
Morphine	9%	12%	12%
Oxycodone	29%	21%	28%
Hydromorphone	24%	34%	48%

Private plans

	Physical units	Prescriptions	Drug costs
Tramadol	16%	17%	29%
Codeine	29%	31%	12%
Morphine	6%	7%	5%
Hydrocodone	<1%	<1%	<1%
Oxycodone	35%	28%	26%
Hydromorphone	14%	16%	18%

Women account for over half of the opioid use in both public and private plans, similar to the patterns observed for all prescription drugs

No meaningful differences were observed in the distributions of opioids by gender.

Figure 2.9 Number of prescriptions by gender, opioids* versus all drugs, NPDUIS public plans and private drug plans†, 2017

Figure description

The four pie charts in this figure break down oral solid opioid prescriptions by gender as a share of prescriptions for all drugs and of oral solid opioid prescriptions. Results are given separately for NPDUIS public drug plans and private drug plans.

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	Female	Male
NPDUIS public plans
Opioids*	58%	42%
All drugs	57%	43%
Private plans
Oral solid opioids	52%	48%
All drugs	55%	45%

Beneficiaries aged 65+, who make up the largest demographic group in public plans, account for the majority of oral solid opioid prescriptions, but proportionately less than their share of all drug prescriptions

The data for private plans, which was not limited to oral solid forms, demonstrates a greater alignment between the shares of opioid prescriptions by age group and the shares for all drugs.

Figure 2.10 Opioid* prescriptions by age demographic, NPDUIS public plans and private drug plans†, 2017

Figure description

This figure consists of two stacked bar graphs with information on the distribution of oral solid opioid prescriptions by age demographic in 2017. Shares are presented for each age group as a percentage of opioid prescriptions and as a percentage of all drugs. The first graph gives the results for NPDUIS public drug plans and the second for private drug plans.

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	NPDUIS public plans		Private plans
	Opioids	All drugs	Opioids	All drugs
0-24	1%	2%	6%	12%
25-34	3%	4%	9%	9%
35-44	6%	6%	17%	14%
45-54	14%	9%	28%	23%
55-64	19%	12%	31%	30%
65+	58%	67%	10%	12%

Hydromorphone is the most commonly used opioid by seniors in public plans, and its share of use across almost all age groups was higher in public than in private plans. Tramadol is the most utilized opioid by the senior population in private plans, and its share of use is sizable across all age groups

Hydromorphone made up 41% of oral solid opioid prescriptions for patients 65+ in public plans. In private plans, tramadol was more commonly used by seniors than codeine, accounting for 33% of all opioid prescriptions, including those in non-oral solid form.

Figure 2.11 Opioid* prescription distribution by age bands, NPDUIS public plans and private plans, 2017

Figure description

Two stacked bar graphs show the share of prescriptions for each opioid by age. The first graph gives the results for NPDUIS public drug plans and the second for private drug plans.

NPDUIS public plans

	0-24	25-34	35-44	45-54	55-64	65+
Codeine	65%	43%	33%	30%	31%	33%
Morphine	10%	10%	13%	16%	16%	9%
Oxycodone	12%	23%	26%	27%	26%	17%
Hydromorphone	14%	24%	27%	27%	27%	41%

Private plans

	0-24	25-34	35-44	45-54	55-64	65+
Tramadol	8%	13%	14%	14%	14%	33%
Codeine	53%	41%	33%	31%	31%	28%
Morphine	11%	6%	7%	7%	8%	6%
Hydrocodone	6%	4%	4%	3%	3%	2%
Oxycodone	13%	22%	28%	30%	27%	19%
Hydromorphone	8%	13%	15%	15%	17%	12%

While results vary across plans, on average, the dispensing costs for opioids represent nearly one third of prescription costs in public plans and less than a quarter in private plans

Jurisdictional variations in the dispensing cost share of total prescription costs may be due to a number of factors, including demographic and disease profiles, as well as the quantity dispensed with each prescription.

Figure 2.12 Drug cost* and dispensing cost share of total prescription cost for oral solid opioids, NPDUIS public plans and private plans, 2017

Figure description

A stacked bar graph shows the drug cost and dispensing cost shares of all oral solid opioid expenditures for the NPDUIS public drug plans in 2017. The graph gives the shares in percentages for each jurisdiction, as well as the share for the total of all NPDUIS public plans, while an accompanying table lists the corresponding expenditures in millions of dollars. A bar is also included with the shares for private plans.

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	NPDUIS public plans											Private plans†
	British Columbia	Alberta	Saskatchewan	Manitoba	Ontario	New Brunswick	Nova Scotia	Prince Edward Island	Newfoundland and Labrador	Non-Insured Health Benefits	All NPDUIS
Dispensing costs (share)	33%	29%	20%	28%	31%	26%	25%	35%	36%	50%	32%	22%
Drug costs (share)	67%	71%	80%	72%	69%	74%	75%	65%	64%	50%	68%	78%
Dispensing costs (millions)	$9.6	$6.9	$1.7	$3.3	$41.0	$1.7	$1.3	$0.3	$1.4	$10.2	$77.3	-
Drug costs (millions)	$19.7	$16.6	$6.7	$8.3	$92.6	$4.8	$3.9	$0.5	$2.5	$10.1	$165.7	-

Drug plans pay for the majority of prescription costs related to oral solid opioids, though the plan-paid share varies among jurisdictions

Public plan beneficiaries paid an average of 15% of the total prescription costs for oral solid opioids in 2017, compared to 12% for private plan beneficiaries. Variations across jurisdictions may be due to plan designs and reimbursement policies, as well as the demographic and disease profiles of the beneficiary populations.

Figure 2.13 Patient-paid and plan-paid share of total prescription cost, oral solid opioids, NPDUIS public plans and private plans, 2017

Figure description

This stacked bar graph shows the breakdown of oral solid opioid drug costs for NPDUIS public plans and private drug plans between plan-paid and patient-paid shares. Results are given by jurisdiction for the public plans and include total shares for all jurisdictions. An accompanying table presents the patient-paid and plan-paid amounts for each public plan in millions of dollars.

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	NPDUIS public plans											Private plans*
	British Columbia	Alberta	Saskatchewan	Manitoba	Ontario	New Brunswick	Nova Scotia	Prince Edward Island	Newfoundland and Labrador	Non-Insured Health Benefits	NPDUIS National
Plan-paid (share)	82%	78%	76%	77%	86%	89%	83%	69%	88%	92%	85%	88%
Patient-paid (share)	18%	22%	24%	23%	14%	11%	17%	31%	12%	8%	15%	12%
Plan-paid (millions)	$23.9	$18.4	$6.4	$9.0	$115.4	$5.8	$4.3	$0.6	$3.4	$18.6	$205.8	-
Patient-paid (millions)	$5.3	$5.1	$2.0	$2.6	$18.1	$0.7	$0.9	$0.3	$0.5	$1.7	$37.1	-

In British Columbia, the average annual drug cost per patient has declined for most opioids

An analysis of public and private plan data shows that the strongest opioids had the largest per-patient cost decreases from 2010 to 2017: -26% for hydromorphone; -21% for oxycodone; and -43% for morphine. Tramadol also had a decrease of -9%, while codeine had an increase of 20%.

Figure 2.14 Average opioid* drug cost per patient, British Columbia public and private plans, 2010 to 2017

Figure description

A line graph illustrates the average drug cost per claimant in the British Columbia public drug plans. Results are given by opioid for each year from 2010 to 2017.

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	2010	2011	2012	2013	2014	2015	2016	2017
Tramadol	$111	$112	$113	$112	$110	$110	$108	$102
Codeine	$21	$21	$22	$24	$25	$26	$26	$25
Morphine	$311	$245	$218	$193	$170	$163	$160	$177
Hydrocodone	$69	$52	$57	$66	$75	$93	$60	$60
Oxycodone	$245	$254	$243	$195	$188	$187	$188	$192
Hydromorphone	$222	$213	$204	$205	$195	$181	$173	$164

Appendix

Figure A1 Market distribution by units, oral solid opioids, Canada and the US, 2010 to 2017

Figure description

Two stacked bar graphs in this figure, for the Canadian and United States markets respectively, show the annual distribution of units by opioid from 2010 to 2017, as a percentage of total oral solid opioid units.

Canada

	2010	2011	2012	2013	2014	2015	2016	2017
Tramadol	3%	4%	6%	6%	5%	5%	6%	6%
Codeine	63%	56%	47%	46%	57%	55%	53%	52%
Morphine	5%	6%	7%	7%	6%	5%	6%	6%
Hydrocodone	-	-	-	-	-	-	-	-
Oxycodone	21%	25%	28%	27%	21%	21%	22%	21%
Oxymorphone	-	-	-	-	-	-	-	-
Hydromorphone	8%	10%	13%	14%	12%	13%	14%	14%

United States

	2010	2011	2012	2013	2014	2015	2016	2017
Tramadol	17%	17%	17%	18%	19%	20%	20%	19%
Codeine	3%	3%	3%	3%	3%	4%	4%	4%
Morphine	4%	4%	4%	4%	4%	4%	4%	4%
Hydrocodone	45%	45%	45%	45%	43%	39%	38%	38%
Oxycodone	28%	28%	29%	28%	29%	30%	32%	32%
Oxymorphone	0%	1%	1%	1%	1%	1%	1%	0%
Hydromorphone	2%	2%	2%	2%	2%	2%	2%	2%

Figure A2 Distribution of sales by oral solid opioid, Canada and the US, 2010 to 2017

Figure description

This figure consists of two stacked bar graphs, one for the market in Canada and the other for the United States, with information on the distribution of annual oral solid opioid sales from 2010 to 2017. Total sales amounts are also given for each year in millions of dollars.

Canada

	2010	2011	2012	2013	2014	2015	2016	2017
Hydromorphone	16%	17%	21%	26%	27%	28%	29%	29%
Oxycodone	50%	50%	45%	37%	35%	33%	33%	31%
Hydrocodone	<1%	<1%	<1%	<1%	<1%	<1%	<1%	<1%
Morphine	9%	8%	8%	9%	8%	8%	7%	7%
Codeine	15%	13%	12%	14%	15%	15%	14%	15%
Tramadol	11%	12%	13%	14%	15%	16%	17%	18%
Total sales (millions CAD)	$538	$542	$527	$494	$503	$501	$503	$467

United States

	2010	2011	2012	2013	2014	2015	2016	2017
Hydromorphone	1%	2%	4%	5%	4%	3%	3%	2%
Oxymorphone	7%	12%	9%	9%	8%	8%	9%	7%
Oxycodone	65%	59%	59%	56%	59%	57%	58%	61%
Hydrocodone	10%	12%	14%	18%	15%	18%	18%	17%
Morphine	10%	10%	9%	8%	10%	8%	8%	8%
Codeine	1%	2%	1%	1%	2%	2%	3%	2%
Tramadol	5%	5%	4%	3%	3%	3%	2%	2%
Total sales (millions USD)	$6,548	$6,378	$6,082	$6,255	$6,896	$6,674	$5,830	$4,574

Figure A3 Distribution of units by oral solid opioid, NPDUIS public plans and private plans, 2010 to 2017

Figure description

This figure consists of two stacked bar graphs, one for NPDUIS public drug plans and the other for private plans, with information on the distribution of physical units of opioids sold from 2010 to 2017. Results for each oral solid opioid are given as a percentage of total units sold.

NPDUIS public plans

	2010	2011	2012	2013	2014	2015	2016	2017
Hydromorphone	12%	13%	16%	19%	20%	22%	23%	24%
Oxycodone	31%	33%	31%	29%	29%	29%	29%	29%
Morphine	10%	10%	10%	11%	10%	10%	9%	9%
Codeine	46%	44%	43%	42%	41%	39%	39%	38%

Private plans

	2010	2011	2012	2013	2014	2015	2016	2017
Hydromorphone	9%	10%	11%	12%	13%	13%	14%	14%
Oxycodone	38%	38%	36%	36%	36%	36%	36%	35%
Hydrocodone	<1%	<1%	<1%	<1%	<1%	<1%	<1%	<1%
Morphine	6%	6%	6%	6%	6%	6%	6%	6%
Codeine	37%	35%	34%	33%	32%	30%	29%	29%
Tramadol	9%	11%	12%	12%	13%	14%	15%	16%

Figure A4 Share of costs by oral solid opioid*, NPDUIS public plans and private plans, 2010 to 2017

Figure description

Two stacked bar graphs, one for NPDUIS public drug plans and the other for private plans, provide the distribution of annual drug costs among oral solid opioids from 2010 to 2017. Results for each opioid are given as a percentage of total oral solid opioid costs.

NPDUIS public plans

	2010	2011	2012	2013	2014	2015	2016	2017
Hydromorphone	21%	22%	28%	40%	43%	45%	47%	48%
Oxycodone	56%	57%	49%	33%	30%	29%	28%	28%
Morphine	13%	11%	12%	14%	14%	13%	12%	12%
Codeine	11%	10%	11%	13%	13%	13%	12%	13%

Private plans

	2010	2011	2012	2013	2014	2015	2016	2017
Hydromorphone	12%	13%	15%	16%	17%	17%	18%	18%
Oxycodone	51%	50%	46%	42%	40%	39%	38%	36%
Hydrocodone	<1%	<1%	<1%	<1%	<1%	<1%	<1%	<1%
Morphine	7%	6%	6%	6%	6%	6%	5%	5%
Codeine	12%	12%	12%	13%	12%	11%	11%	12%
Tramadol	18%	19%	22%	23%	25%	26%	27%	29%

Figure A5 Total sales, oral solid opioids, Canada and the US, 2010 to 2017

Figure description

Two bar graphs show the total annual sales for oral solid opioids from 2010 to 2017. The first graph gives the totals for Canada in millions of Canadian dollars, and the second gives the total for the United States in millions of US dollars. A compound annual growth rate is also provided for each.

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	Canada (CAD millions)	United States (USD millions)
2010	$538	$6,548
2011	$542	$6,378
2012	$527	$6,082
2013	$494	$6,255
2014	$503	$6,896
2015	$501	$6,674
2016	$503	$5,830
2017	$467	$4,574
Compound annual growth rate	-2.0%	-5.0%

Figure A6 Tramadol sales by absolute amount and number of milligrams, Canada and the US, 2010 to 2017

Figure description

Two line graphs measure the sales and units of tramadol sold in Canada and the United States. Results are presented annually from 2010 to 2017. Totals for units are given in milligrams. Sales in Canada are given in millions of Canadian dollars, and those in the United States are given in millions of US dollars.

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	2010	2011	2012	2013	2014	2015	2016	2017
Canada
Sales (CAD millions)	$58.6	$63.1	$69.0	$71.2	$75.5	$80.2	$84.1	$82.5
Quantity (mg)	4.3	4.6	4.9	5.1	5.4	5.7	6.0	5.9
United States
Sales (USD millions)	$343.9	$313.8	$222.8	$198.6	$185.9	$169.5	$129.5	$103.3
Quantity (mg)	147.3	159.2	146.4	156.7	162.4	168.2	150.6	132.8

Figure A7 Average price per milligram, oral solid opioids, Canada, 2010 to 2017

Figure description

A line graph describes the trend in the average annual price per unit of oral solid opioids in Canada from 2010 to 2017. Prices are given in Canadian dollars per milligram for each molecule.

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	2010	2011	2012	2013	2014	2015	2016	2017
Tramadol	$0.0136	$0.0138	$0.0140	$0.0139	$0.0141	$0.0141	$0.0141	$0.0139
Codeine	$0.0049	$0.0049	$0.0053	$0.0056	$0.0052	$0.0052	$0.0055	$0.0058
Morphine	$0.0175	$0.0162	$0.0155	$0.0159	$0.0163	$0.0166	$0.0169	$0.0176
Hydrocodone	$0.2264	$0.2275	$0.2328	$0.2169	$0.2487	$0.2545	$0.2556	$0.2284
Oxycodone	$0.0505	$0.0510	$0.0491	$0.0431	$0.0422	$0.0415	$0.0418	$0.0419
Oxymorphone	-	-	-	-	-	-	-	-
Hydromorphone	$0.1134	$0.1162	$0.1188	$0.1215	$0.1233	$0.1247	$0.1280	$0.1333

Figure A8 Average price per milligram, oral solid opioids, US, 2010 to 2017

Figure description

A line graph describes the trend in the average annual price per unit of oral solid opioids in the United States from 2010 to 2017. Prices are given in US dollars per milligram for each molecule.

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	2010	2011	2012	2013	2014	2015	2016	2017
Tramadol	0.0023	0.0020	0.0015	0.0013	0.0011	0.0010	0.0009	0.0008
Codeine	0.0045	0.0046	0.0046	0.0049	0.0066	0.0067	0.0072	0.0060
Morphine	0.0235	0.0204	0.0200	0.0208	0.0279	0.0247	0.0223	0.0204
Hydrocodone	0.0114	0.0119	0.0146	0.0187	0.0186	0.0242	0.0219	0.0192
Oxycodone	0.0605	0.0523	0.0527	0.0559	0.0647	0.0613	0.0576	0.0532
Oxymorphone	0.2911	0.2908	0.2974	0.2972	0.2782	0.2732	0.2819	0.2622
Hydromorphone	0.0773	0.1026	0.1385	0.1867	0.1775	0.1382	0.1115	0.0903

Figure A9 Per capita sales by oral solid opioid, Canada, 2010 to 2017

Figure description

A line graph describes the trend in Canadian sales per capita from 2010 to 2017. Sales per capita for each opioid are given in Canadian dollars, and are listed in a table below the graph.

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	2010	2011	2012	2013	2014	2015	2016	2017
Tramadol	1.72	1.84	1.99	2.03	2.13	2.24	2.32	2.25
Codeine	2.32	2.05	1.87	1.92	2.12	2.04	1.99	1.86
Morphine	1.36	1.23	1.18	1.21	1.17	1.09	1.02	0.93
Hydrocodone	0.02	0.02	0.02	0.02	0.02	0.03	0.03	0.01
Oxycodone	7.86	7.91	6.88	5.19	4.89	4.67	4.52	3.96
Hydromorphone	2.52	2.74	3.21	3.68	3.84	3.90	4.00	3.72

Figure A10 Per capita sales by oral solid opioid, US, 2010 to 2017

Figure description

A line graph describes the trend in US sales per capita from 2010 to 2017. Sales per capita for each opioid are given in US dollars, and are listed in a table below the graph.

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	2010	2011	2012	2013	2014	2015	2016	2017
Tramadol	1.11	1.01	0.71	0.63	0.58	0.53	0.40	0.32
Codeine	0.30	0.31	0.26	0.25	0.35	0.47	0.48	0.35
Morphine	2.10	1.96	1.73	1.67	2.10	1.76	1.42	1.10
Hydrocodone	2.19	2.36	2.79	3.48	3.33	3.83	3.16	2.43
Oxycodone	13.73	12.02	11.42	11.12	12.74	11.88	10.54	8.57
Oxymorphone	1.44	2.37	1.76	1.71	1.67	1.65	1.58	0.99
Hydromorphone	0.29	0.45	0.71	0.93	0.84	0.64	0.47	0.32

Figure A11 Per capita milligrams sold by oral solid opioid, Canada, 2010 to 2017

Figure description

A line graph describes the trend in the milligrams of oral solid opioids sold per capita in Canada. Milligrams per capita are given annually for each opioid with sales, and are listed in a table below the graph.

	2010	2011	2012	2013	2014	2015	2016	2017
Tramadol	126.88	133.70	142.25	146.24	151.13	158.49	164.87	161.47
Codeine	470.98	420.92	351.58	345.70	404.23	393.85	361.67	317.94
Morphine	77.55	75.87	76.13	76.32	72.07	65.83	60.69	52.85
Hydrocodone	0.10	0.11	0.10	0.11	0.10	0.10	0.11	0.05
Oxycodone	155.73	155.24	140.04	120.35	116.04	112.55	107.93	94.44
Oxymorphone	-	-	-	-	-	-	-	-
Hydromorphone	22.25	23.58	27.00	30.27	31.13	31.33	31.22	27.87

Figure A12 Per capita milligrams sold by oral solid opioid, US, 2010 to 2017

Figure description

A line graph describes the trend in the milligrams of oral solid opioids sold per capita in the United States. Milligrams per capita are given annually for each opioid, and are listed in a table below the graph.

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	2010	2011	2012	2013	2014	2015	2016	2017
Tramadol	476.19	510.89	466.56	495.61	509.03	523.31	466.15	408.60
Codeine	66.48	67.79	57.46	51.57	52.48	70.13	66.41	57.74
Morphine	89.68	95.92	86.35	79.97	75.25	71.03	63.64	53.93
Hydrocodone	191.34	198.68	190.39	185.86	178.47	158.55	144.00	126.59
Oxycodone	227.02	229.80	216.48	198.74	196.86	193.93	182.93	161.13
Oxymorphone	4.96	8.14	5.91	5.77	6.00	6.05	5.59	3.78
Hydromorphone	3.74	4.40	5.12	4.97	4.76	4.64	4.21	3.53