Given the urgency of the opioid public health crisis, accurate data collection on overdoses is a vital part in evaluating the extent of the issue and the impact of strategies. Statistical data depends on coded data captured by coders, and coded data depends on clinical documentation specificity. In order to assign a code specifically for opioid overdose (poisoning), there must be clear documentation. The following are clinical documentation requirements for capturing opioid overdose cases:

  • Document
    • “Opioid overdose” when known or when findings are clinically consistent with an opioid overdose (e.g., positive response from opioid antidote)
    • Specific opioid drug causing overdose when known
    • When an opioid antidote (e.g., naloxone ) is administered
    • Any positive response from an opioid antidote (e.g., starts breathing normally, and/or regains consciousness, opens eyes)
  • Do not document (refrain from using)
    • Qualifiers such as “possible,” questionable,” “suspected,” “query” or “?” to describe an opioid overdose when it is reasonable to consider that the case is most likely due to opioid excess (at least in part), to ensure the case is included in the opioid case reporting
      • Lab confirmation is not necessarily a requirement for documentation of an opioid overdose

Summary: In the case of a known or strongly suspected opioid overdose, ensure that the phrase “opioid overdose” is in your diagnosis. Refrain from using “?/query/possible/suspected” in your diagnosis if you have reasonable diagnostic certainty.

CIHI wishes to acknowledge and thank the Ontario Ministry of Health and Long-Term Care for its contributions.

Appendix: Clinical documentation practices and the capture of opioid overdose cases

The following table is intended to support clinicians in identifying how clinical documentation practices affect the accurate capture of opioid overdose cases.

Coding of discharge diagnosis documentation

Discharge diagnosis Coded as . . .
“Opioid overdose.”

Opioid overdose

Included in opioid case reporting

“Drug overdose” due to specific opioid drug.

Opioid overdose

Included in opioid case reporting

“Drug overdose.” Opioid antidote administration with documentation of a positive response.

Opioid overdose

Included in opioid case reporting

Multiple drug overdose, documented as including an opioid.

Multiple drug overdose

Included in opioid case reporting

“Drug overdose” with opioid antidote administration. No documentation of a positive effect.

Unknown drug overdose

Not included in opioid case reporting

“Drug overdose.” Specific drug not identified. No antidote given.

Unknown drug overdose

Not included in opioid case reporting

“Drug abuse.” No antidote given.

Classified as substance abuse

Not included in opioid case reporting

“Acute intoxication” or “Adverse effect/toxicity.”

Classified as acute intoxication or adverse effect in therapeutic use

Not included in opioid case reporting

For further information on the coding of opioid overdose scenarios, please refer to CIHI’s Bulletin Opioid Overdose Coding Direction.