overview of opiate addiction - cphm development... · relapse is the norm • the death rate is...
TRANSCRIPT
Overview of Opiate Addiction
• Conflict of interest – 2 talks for Purdue about dangers of opioid addiction
• Bias – support patients in both abstinence and methadone – but seeing more stability on MMT
Opioid Addiction in Canada
• Until 1990’s, heroin was the major opiate – mainly in coastal cities
• At the same time -
• Pain clinics were gaining acceptance for more opioid prescribing for pain
• Shortage of physicians – no longer one physician who knew his patients well over years of service
Then….• Mid 1990’s – oxycontin produced,
with major marketing campaign
• Newfoundland had major “epidemic” of oxycontin addiction, which travelled westward – also widespread abuse of other prescription opioids
• In Ontario, aboriginal communities were particularly affected
Canada - World Leader
Where Are These Drugs Going?
Sad but True• Physicians and prescriptions are part
of the problem!
• Prescription opioids have surpassed heroin as the primary narcotic of abuse….Canadian Opioid Guideline
Opioid Addiction in Winnipeg
• Rare – some T & R addiction in the inner city – and codeine addiction
• 2005 – assessed ~20 patients with opioid addiction
• 2009 – assessed over 300 patients
Methadone Resources• Until summer 2008, no wait list
• Now wait list at AFM methadone clinic is over 150 patients – wait time is months
• 2 other clinics providing services
Access to Methadone
• Brandon – wait list, new doctor starting
• Rural Manitoba – no MMT providers
• Comparisons
• MMT in Manitoba ~ 700
• MMT in Saskatchewan ~ 2000
• MMT in Ontario ~ 24,000
Does Access Matter?• Patients in treatment often improve
dramatically
Patients on wait lists deteriorate (health and social consequences) and may die
• Crime decreases with treatment access
Typical Patient in 2007-2008
• Wave 1 – Suburban
• Middle-class male aged 17-30, with supports in regards to family, education, work, finances – using oxycontin, usually snorting - in significant trouble after 6-24 months of use with debt, some crime, estranged family, failing at school or work
• Most stabilize rapidly
• They become tax-payers!
Demographics Evolve• Wave 2 – inner city – more use of
morphine and dilaudid - more injection use – multiple family members may use together (high rates of Hep C, some HIV)
Family Tree
24 14201722
1
1
• Treatment is more difficult because of chaotic lives
• The opioid addiction responds but many are repeatedly “knocked down by life”
• Past trauma issues resurface
Northern Ontario Reserves
• “I just admitted two young oxy-mothers…….the opioid wave has hit these communities like a tsunami”
Dr M.D
• What’s going to happen in Manitoba? Who’s doing prevention?.
And in 2010…• Ongoing oxycontin – now progressing
to fentanyl with several deaths
• More rural patients
• More chronic pain patients with addiction
• More Women....and more babies
• More aboriginal patients
Harm and Injection Use• Increasing rates of HIV in Manitoba
• IV drug use is a factor
Harm- Pregnancy and Families
• Increasing numbers of addicted mothers- diagnosed on the labor floor
• Babies require many days of care –and most are apprehended
Codeine• Canada is the only developed country to sell over
the counter codeine
• 80% of those addicted are female with a history of early life difficulties
• In their teens or twenties, they try T1’s or T3’s, and get a feeling of positivity and energy
Codeine• After about 10 years, patients face
increasing consequences – increasing dysfunction
• When we see them, they are using:• 50-100 tylenol 1’s per day
• 20-50 tylenol 3’s per day
• adding benzo’s or gravol
Talwin• Poor analgesic – T’s and R’s are a
problem only in the prairie cities –“poor man’s speedball”
Slow death from talc lung
This is a combined stimulant/opioid addiction – methadone might bring stability
Percocet• 5 mg oxycodone – widely available•• Oxycodone has surpassed marijuana
as teenagers’ experimental drug of choice in the U.S.
• Swallow, chew, or snort – gateway to oxycontin
Oxycontin
• Oxycontin: comes in 10, 20, 40, 80 mg strengths. It can be chewed, snorted, or injected – then it is a rapid intense high
• “ Safe and fun”
Oxycontin….• Often minimal alcohol or cocaine –
only the oxy matters
Street benzo’s help withdrawal
• "I don’t even get high anymore..”
• Use ranges from 80-600 mg/day
• Costs 50 cents or more per milligram
Morphine and Dilaudid• Injection use is more common with
these
• Not much dilaudid use in Winnipeg, but increasing
Fentanyl • Often cut up into “chiclets” and used
orally
• Many reports of respiratory arrest and several deaths after injection use
Benzodiazepines• Benzo’s are a problem too – widely
sold
• Ashton manual – how to get people off (download from internet)
Abstinence and Success Rates
• Doctors – 90% abstinent
• Long term, street-hardened – 3% abstinent
• In Winnipeg – only a few successfully abstinent – over 90% relapse
Relapse is the Norm• The death rate is higher in abstinence-
based treatment, because tolerance is lost and accidental (or deliberate) overdose occurs
• Drugs are so available on the street – or by prescription - relapse is easy
• “my best friend is my neighbor – and my dealer!”
• Currently no long-term follow-up program to support abstinence
Methadone • Reasonable to use as first treatment
approach, especially in unstable lives
Methadone - Goals1. Survival and stability
2. Stop opioids, stop injecting
3. Stop other drugs
4. Grow emotionally, develop success in life
5. Consider weaning off, ONLY if appropriate
It’s Not Just a Substitute Drug
1. They feel normal – energy goes into creating a life
2. Tight rules and consequences = structure
3. Relationships with staff promote maturity and emotional skills
The patient is still on an opioid but the addictive behaviour lessens or disappears.
Methadone - Outcomes
• 30% do very well
• 30% markedly improved, still problems
• 30% somewhat improved
• 10% wean off or leave yearly
Methadone – if not done well…
• Death
• Diversion
• Dispensing errors
• Inappropriate patients in treatment
• Physician norms can change
• Education, support of colleagues, College oversight are all necessary
Suboxone ( a “milder” methadone)
• SUBOXONE -
It has less side effects, and is much safer - and it’s easier to wean off
• In use in Europe for 10 years – too expensive for Canada?
• If you do the online course at www.suboxonecme.ca you can apply for a combined methadone/suboxone exemption
Financial Impact• Cost of treatment – in methadone
clinic, about $3000 per patient per year – in “methadone only clinic” about $1,000 per year
• Cost of an untreated heroin addict -$44,000 per year – costs include health, family services, incarceration, crime
Human Impact• Most patients in methadone programs
“get their life back” – almost all of my “young suburban” patients are back at school or work within a few months
• Patients not in treatment suffer financially and socially - risk of legal consequences and debt and family breakdown are huge
Challenge Stigma
• Preconceived ideas about addicts, treatment, hopelessness
• Methadone - Hard Work and Good Outcomes Go Unrecognized
So….• Support methadone clinics and
patients in your community or hospital
• Consider becoming part of the prescribing network
• -full clinic
• -general practice following stable patients
• -hospitalist
Methadone Saves Lives