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Understanding the fentanyl crisis in

Canada: A public health lens

Public Health Ontario Grand Rounds, May 24, 2016

Dr. Pamela Leece and Dr. Meldon Kahan

Financial Disclosures

Pamela Leece

Research: Health Canada funding 2015-2017, “Improving

Canadian Family Physician Knowledge and Performance in Safe

Prescribing of Opioids for Chronic Non-Cancer Pain”

Meldon Kahan

Speaking: presentation sponsored by Indivior several years ago

Research: PI on METAPHI project (Mentoring Education and

Tools for Addiction: Primary Care Hospital Integration) –

funded by ARTIC program and Health Quality Ontario

Objectives

Describe the current situation of opioid-related harms in Canada and, in

particular, Ontario.

Discuss current initiatives designed to reduce opioid-related harms, and the use of these interventions in

various jurisdictions.

Agenda

Describe interventions

Outline opioid-related harms

Summarize trends in opioid use

Discuss fentanyl

Fentanyl in Canada

What is fentanyl?

Health Canada Drug Product Database: http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp

Controlled Drugs and Substances Act: http://laws-lois.justice.gc.ca/eng/acts/c-38.8/

•Opioid analgesic

•Several fentanyls, salts, derivatives, analogues Synthetic

•Rapid onset, short duration Fast

•50-100x more potent than morphine Potent

•Controlled Drugs and Substances Act,

Schedule I Controlled

• Cancer pain, severe/continuous pain (opioid tolerant patients), anesthesia Therapeutic

What is fentanyl?

Friesen et al CMAJ Apr 4 2016

CCENDU Bulletin August 2015

Sources

Prescribing

- Often unsafe

- Diversion

Uncontrolled

- Often imported

- Powder, tablets, mixed

Fentanyl Crisis

Alberta Timeline – fentanyl-detected deaths 2011

• 6

2012

• 29

2013

• 66

2014

• 120

2015

• 274

2016 (Q1)

• (69)

http://www.health.alberta.ca/health-info/AMH-Naloxone-Take-home.html

2012

• 13

• 5%

2013

• 49

2014

• 91

2015

• 152

2016 (Q1)

• (98)

• 49%

British Columbia Timeline – fentanyl-detected deaths

http://www2.gov.bc.ca/gov/content/safety/public-safety/death-investigation/statistical-reports

Year Codeine* Fentanyl Heroin Hydromorphone Methadone Morphine Oxycodone TOTAL

Decedents**

2002 18 10 23 18 69 62 31 210

2003 17 20 7 14 74 64 45 225

2004 23 28 8 13 65 66 55 246

2005 21 30 10 16 85 73 90 299

2006 20 26 2 21 75 80 107 292

2007 28 36 10 25 81 81 123 341

2008 24 50 19 31 69 80 133 355

2009 33 73 15 42 63 87 202 449

2010 34 91 39 46 92 86 211 514

2011 39 112 45 53 118 85 217 548

2012 45 140 57 85 118 96 189 598

2013 56 136 60 111 147 129 154 633

2014 60 176 100 127 127 139 146 673

TOTAL 418

(413-428) 928

(925-934) 395

(389-407) 602 (599-608)

1183 (1182-1185)

1128 1703 5383

Number of Opioid Toxicity Deaths and Opioid + Alcohol Toxicity Deaths by Drug in Ontario from 2002 to 2014

*For years where the number of deaths was reported as “<5” the number of deaths was assumed to be 2 for the purposes of summing and

displaying the data. In the total number of deaths column, the minimum and maximum number of deaths possible are given in brackets.

**Some deaths can be attributed to multi-drug toxicity, therefore a single decedent may account for more than one drug in each row. The

Total Decedents column gives the total number of unique individual opioid toxicity deaths per year.

Source: Office of the Chief Coroner,

Ontario

Fentanyl death data

Very limited National

Canandian Community Epidemiology Network on Drug Use

http://www.ccsa.ca/Resource%20Library/CCSA-CCENDU-Fentanyl-Deaths-Canada-Bulletin-2015-en.pdf

British Columbia

BC Coroners Service http://www2.gov.bc.ca/gov/content/safety/public-safety/death-investigation/statistical-reports

Alberta

Alberta Health Services http://www.health.alberta.ca/health-info/AMH-Naloxone-Take-home.html

Ontario

Office of the Chief Coroner (2014)

Major Data Limitations

• Challenges with classification: 1) drug testing, 2) drug detection, 3) multiple drugs, 4) determining cause of death

Numerator

• Who is “exposed”? vs. total population

Denominator

• Timing: Lag to finalize coroner’s investigations

• Grouping: e.g., “drug-related,” “opioid-related,” ”illicit drug-related,” “fentanyl-detected,” “fentanyl- implicated”

Reporting

Fentanyl-detected deaths

It appears fentanyl deaths…

• Increasing in absolute numbers #

• Increasing proportion of drug-related deaths %

• These changes are happening rapidly !

• Incomplete information about circumstances ?

• Often other substances detected +

Fentanyl within the

Broader Opioid Crisis

Figure 3: The total number of deaths with which a drug was associated for opioid toxicity deaths and opioid

+ alcohol toxicity deaths in Ontario from 2002 to 2014. For years where the number of deaths associated

with a drug were reported as “<5” the number of deaths was assumed to be 2.

0

40

80

120

160

200

240

2002 2004 2006 2008 2010 2012 2014

Num

ber

of

Death

s

Year

Drugs Contributing to opioid toxicity and opioid + alcohol toxicity deaths in Ontario per year from 2002-2014

Codeine

Fentanyl

Heroin

Hydromorphon

eMethadone

Morphine

Oxycodone

Source: Office of the Chief Coroner,

Ontario

0

50

100

150

200

250

300

350

400

450

500

550

2002 2004 2006 2008 2010 2012 2014

Num

ber

of

Death

s

Year

Yearly Number of Opioid Toxicity Deaths in Ontario by Drug, 2002-2014

Codeine

Fentanyl

Heroin

Hydromorpho

neMethadone

Morphine

Oxycodone

Total Deaths

Figure 4: The total number of deaths with which a drug was associated and the total number of unique

individual opioid toxicity deaths annually in Ontario from 2002 to 2014. Some deaths can be attributed to

multi-drug toxicity, therefore a single decedent may have more than one opioid contributing to death.

Source: Office of the Chief Coroner,

Ontario

Opioid Use in Canada

Opioid Use in Canada

Utilization of Prescription Opioids in Canada's Public Drug Plans, 2006/07 to

2012/13April 2014. Government of Canada.

Available: http://www.pmprb-cepmb.gc.ca/view.asp?ccid=1033

Opioid Use in Canada

Utilization of Prescription Opioids in Canada's Public Drug Plans, 2006/07 to

2012/13April 2014. Government of Canada.

Available: http://www.pmprb-cepmb.gc.ca/view.asp?ccid=1033

PEI NS

SK ON

Opioid Use in Canada

Utilization of Prescription Opioids in Canada's Public Drug Plans, 2006/07 to

2012/13April 2014. Government of Canada.

Available: http://www.pmprb-cepmb.gc.ca/view.asp?ccid=1033

PEI NS

SK ON

Opioid Use in Ontario

http://odprn.ca/wp-content/uploads/2016/03/FINAL-UPDATED_Opioid-Hosp-Report-_March-2016.pdf

• Opioid Prescribing (ODB), age 15-64

• 11,610 prescriptions per 1,000 beneficiaries per year

• Range by county 3,808 to 42,201

+47%

2006-2010 vs. 2011-2013

Opioid Harms in Canada

Outcomes

• Drug poisoning deaths

• Opioid-related deaths

• Life expectancy Mortality

• Non-fatal overdose

• Non-medical opioid use/ Addiction

• Neonatal abstinence syndrome

• Other: e.g., motor vehicle collisions

Morbidity

Injury Pyramid

Adapted from:

http://apps.who.int/iris/bitstream/10665/149798/1/9789241508018_eng.pdf?ua=1&ua=1&ua=1

http://www.cdc.gov/drugoverdose/pdf/policyimpact-prescriptionpainkillerod-a.pdf

Fatal

Hospitalizations

Emergency department visits

Primary care

Not treated/ Not reported

1 opioid-related death

10 addiction treatment

admissions

32 ED visits

for misuse or abuse

130 who abuse

or are dependent

825 nonmedical

users

CDC Estimates:

Canadian Opioid-Related

Harm Data

Canadian Trends: Opioid-related harms

Murphy Y, Goldner EM, Fischer B. Prescription Opioid Use, Harms and Interventions in Canada: A Review

Update of New Developments and Findings since 2010. Pain Physician. 2015 Jul-Aug;18(4):E605-14.

• Declining in general population (adults, students)

• Not declining in special populations (e.g., street drug users, First Nations)

Non-medical prescription opioid use

• Plateaued in Ontario (DATIS)

• Note: does not include methadone; increasing; ~50,000 on MMT

Addiction treatment demand

• Student – 4.3% drove under influence of opioids

• Higher opioid dose - increased odds of road trauma Driving risks

• Increased 15x from 1992 to 2011 in ON

• First Nations community in ON – 18%

Neonatal-morbidity

• Rising in various jurisdictions Mortality

Rates of prescription opioid-related death in British Columbia (BC) and Ontario (ON) from

2004 to 2013.

©2015 by BMJ Publishing Group Ltd

Reproduced from Emilie J Gladstone et al. Inj Prev doi:10.1136/injuryprev-

2015-041604 with permission from BMJ Publishing Group Ltd.

Additional information:

2013 ON

4.65/ 100,000

(Chief Coroner for

Ontario)

Year Codeine* Fentanyl Heroin Hydromorphone Methadone Morphine Oxycodone TOTAL

Decedents**

2002 18 10 23 18 69 62 31 210

2003 17 20 7 14 74 64 45 225

2004 23 28 8 13 65 66 55 246

2005 21 30 10 16 85 73 90 299

2006 20 26 2 21 75 80 107 292

2007 28 36 10 25 81 81 123 341

2008 24 50 19 31 69 80 133 355

2009 33 73 15 42 63 87 202 449

2010 34 91 39 46 92 86 211 514

2011 39 112 45 53 118 85 217 548

2012 45 140 57 85 118 96 189 598

2013 56 136 60 111 147 129 154 633

2014 60 176 100 127 127 139 146 673

TOTAL 418

(413-428) 928

(925-934) 395

(389-407) 602 (599-608)

1183 (1182-1185)

1128 1703 5383

Number of Opioid Toxicity Deaths and Opioid + Alcohol Toxicity Deaths by Drug in Ontario from 2002 to 2014

*For years where the number of deaths was reported as “<5” the number of deaths was assumed to be 2 for the purposes of summing and

displaying the data. In the total number of deaths column, the minimum and maximum number of deaths possible are given in brackets.

**Some deaths can be attributed to multi-drug toxicity, therefore a single decedent may account for more than one drug in each row. The

Total Decedents column gives the total number of unique individual opioid toxicity deaths per year.

Outcomes

WHY?

Unintentional injuries 4th cause of death; increasing

Unintentional poisoning 1st cause of injury death; increasing 14.7 per 100,000

(Opioid-related deaths represent 5.9 per 100,000) (40%)

Life Expectancy

United States 2013 vs. 2014

Unchanged 78.8 years

Decreased 0.1 years in non-Hispanic White

http://www.cdc.gov/nchs/products/databriefs/db244.htm

http://www.cdc.gov/nchs/data/hus/hus15.pdf#015

http://www.cdc.gov/injury/images/lc-charts/leading_causes_of_injury_deaths_unintentional_injury_2014_1040w740h.gif

Opioids in Ontario

http://odprn.ca/wp-content/uploads/2016/03/FINAL-UPDATED_Opioid-Hosp-Report-_March-2016.pdf

• Emergency Department Visits • 19,769 visits 2006-2013 (88% age 15-64)

• 2.7 per 10,000 (range 1.6 to 11.3) +23%

• Hospital Admission • 10,689 admissions 2006-2013 (78% age 15-64)

• 1.1 to 1.3 per 10,000 (range 0.5 to 4.0) +18%

2006-2010 vs. 2011-2013, age 15-64

Opioids in Ontario

• increased 15x between 1992 and 2011 (majority since 2007)

Neonatal abstinence syndrome

• increased 250% in past 2 decades, reaching 42 per million by 2010

Overdose deaths

• increased 3x from 1992 to 2010

• 1 in 8 deaths among age 25-34 in 2010

Years of potential life lost (YLL)

• among 32.6% of younger ODB recipients on long-acting oxycodone

• 3x risk of overdose, similar for motor vehicle injuries

> 200mg morphine equivalents (“high

dose”)

Gomes T, Juurlink DN. Opioid Use and Overdose: What We've Learned in Ontario.

Healthc Q. 2016;18(4):8-11.

Context: Other Deaths in Ontario

• Motor vehicle deaths (2014) • http://www.mto.gov.on.ca/english/publications/pdfs/preli

minary-2014-orsar-selected-statistics.pdf 481

• Streptococcus pneumoniae

• #1 for average annual infectious deaths

•http://www.publichealthontario.ca/en/eRepository/ONBoID_ICES_Report_ma18.pdf

623

• Opioid-related (2014) • Office of the Chief Coroner, Ontario 673

Direct links: Prescribing and Harms

• Prescription in the year before death (Dhalla 2009)

• 56% in month before death 89%

• Prescribed opioids after non-fatal overdose (Larochelle 2016) 91%

• First exposed by prescribing – among those with heroin or nonmedical prescription opioid use (Butler 2016) 59%

• Prescription source before addiction treatment (Sproule 2009) 37%

• Develop addiction in chronic opioid therapy (Juurlink 2012) Up to 1/3

• Risk of opioid-related mortality on 200mg/d vs. <20mg/d (Gomes 2011) 3x

• Sedative prescription 30d before opioid death (Fulton-Kehoe 2015) 48%

How did we get here?

How did we get here?

• 1990’s: Assertion that opioids were safe (Kolodny 2015)

• Opioid sales USA skyrocketed Marketing

• American Pain Society: “Fifth Vital Sign” (Kolodny 2015)

• Higher potency opioids and doses for chronic pain Champions • Conflict of interest in medical education (Persaud

2014)

• Lack of pain and addiction training (NACPDM 2013) Education

• Canada Health Act: physician and hospital services Funding

• Specialized pain and addiction services (NACPDM 2013) Gaps

• Focus on individual behaviour; barrier to treatment (Broyles 2014) Stigma

Epidemiologic Triad: Opioids

Agent:

Highly psychoactive

Host:

Co-morbidities

Co-prescribing

Social determinants of health

Adverse childhood experiences

Environment:

Prescribing

Health care services

(pain and addiction)

“Street” sources

Physicians = vector?

Evidence for Opioid Use

Benefits

• RCTs < 12 weeks

• Short-term benefit

• Improved pain and function

• Noncancer nociceptive and neuropathic pain

Risks

• Side effects: constipation, dry mouth, nausea, vomiting, drowsiness, confusion, hypogonadism, tolerance, physical dependence, and withdrawal symptoms

• Complications: opioid use disorder, respiratory depression, hyperalgesia, fractures, and death

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.

Kolodny A, et al. The prescription opioid and heroin crisis: a public health approach to

an epidemic of addiction. Annu Rev Public Health. 2015 Mar 18;36:559-74.

Interventions in Canada

and United States

Canadian Trends: Interventions

• BC: Decreased “double doctoring” 32.8% in 6 months after introduction 1995

• NS: Reduced meperidine prescriptions 12% over 2 yr

• ON: Decrease in prescriptions highly suggestive of misuse (1.6% to 1.0%, 2011 to 2013)

Prescription monitoring programs

(BC, ON, NS Results)

• Decrease in oxycodone dispensing

• Increase in other opioid prescribing

Oxycodone delisting

(Ontario Results)

Murphy Y, Goldner EM, Fischer B. Prescription Opioid Use, Harms and Interventions in Canada: A Review

Update of New Developments and Findings since 2010. Pain Physician. 2015 Jul-Aug;18(4):E605-14.

Gomes T, Juurlink DN. Opioid Use and Overdose: What We've Learned in Ontario. Healthc Q. 2016;18(4):8-11.

Canadian Trends: Interventions

• Self-referred MD’s no difference

• CPSO-referred MDs decreased (prior to course) – sustained 2yr

Physician education

(Ontario Results)

• Oxycodone prescribing slowed when US news coverage of the problem peaked in 2001 and declined when Canadian news coverage peaked 2004

Media reporting

(NS Results)

Murphy Y, Goldner EM, Fischer B. Prescription Opioid Use, Harms and Interventions in Canada: A Review

Update of New Developments and Findings since 2010. Pain Physician. 2015 Jul-Aug;18(4):E605-14.

Gomes T, Juurlink DN. Opioid Use and Overdose: What We've Learned in Ontario. Healthc Q. 2016;18(4):8-11.

Comprehensive Interventions

• 2016 Washington State Interagency Opioid Working Plan http://stopoverdose.org/

Washington State

• Action Plan to Address the Opioid Epidemic in The Commonwealth (2015)

Massachusetts

• Rhode Island’s Strategic Plan on Addiction and Overdose (2015) Rhode Island

• Prescription Drug Abuse Prevention Plan (2011) • https://www.whitehouse.gov/the-press-

office/2016/02/02/president-obama-proposes-11-billion-new-funding-address-prescription

United States

Comprehensive Interventions

• Alberta’s Mental Health Review Committee Recommendations (2015) Alberta

• Drug Overdose and Alert Partnership (DOAP) Opioid Overdose Response Strategy (DOORS) (2016)

British Columbia

• First Do No Harm: Responding to Canada’s Prescription Drug Crisis (2013)

Canada

Comprehensive Interventions

Prevention & Rescue

Education Treatment &

Harm Reduction

Surveillance

& Research

Enforcement

& Regulation

Washington State

Approximately 600 opioid-related deaths/ yr

(Based on 6,724,540 population ~ 8.9/ 100,000)

Interagency Opioid Working Plan:

http://stopoverdose.org/FINAL%20State%20Response%20Plan_Jan2016.pdf

Goals Prevent

opioid misuse

and abuse

Treat opioid

dependence

Prevent

deaths from

overdose

Use data to

monitor and

evaluate

Actions Improve

prescribing

practices

Expand access

to treatment

Distribute

naloxone to

people who

use heroin

Optimize and

expand data

sources

Washington State

State Prescribing Guidelines 2007 (dose limit 120mg/d)

2006-2010 Results

Fulton-Kehoe D, et al. Opioid poisonings in Washington State Medicaid: trends, dosing, and

guidelines. Med Care. 2015 Aug;53(8):679-85. (Including references within)

Medicaid Population

• Decreased high dose prescribing

• Leveling off of opioid poisonings

General Population

• Steady rate of opioid poisonings

• Decrease hospitalized opioid poisonings

Workers’ compensation

• Decrease in workers developing chronic opioid use

• Decrease high dose prescribing

• No decrease in non-fatal opioid poisonings

CDC: Washington State drug overdose deaths 2013 vs. 2014: -0.7%

Washington State

State Prescribing Guidelines 2007 (dose limit 120mg/d)

2006-2010 Results

Fulton-Kehoe D, et al. Opioid poisonings in Washington State Medicaid: trends, dosing, and

guidelines. Med Care. 2015 Aug;53(8):679-85. (Including references within)

Next steps:

Most opioid poisonings: At lower prescribed doses (high dose 16.7%)

Not in chronic users (chronic 40%)

Co-prescription of sedatives (~50% of decedents)

Local strategy: Kingston

• 4 pillar community overdose prevention strategy

Pillars

• Regional coroner, police, emergency departments, street health, prison health, pain and addiction specialists, LHIN

Partners

• Community adopting CDC guidelines – basis for new emergency department opioid guidelines

Guidelines

• Use local data from ODPRN on opioid hospitalization rates

• Local surveillance system Data

Communication with Dr. Kieran Moore, AMOH, KFL&A Public Health

Naloxone

Photo source: Toronto Public Health

Naloxone

• Systematic Reviews – at least 4 • Time series analysis: decreased mortality

• Weaker studies: improve knowledge and attitudes

• Calling EMS: 29-100%, 6 of 9 studies <50% • (Clark 2014, EMCDDA 2015, Giglio 2015, McAuley 2015)

Evidence

• World Health Organization (2014) • People likely to witness an opioid overdose

should have access to naloxone and be instructed in its administration

Guidance

• Take-Home Naloxone in Canada

• 7 of 13 provinces and territories

• At risk, first responders, pharmacies • (CCENDU 2016)

Implementation

Natural history of disease timeline

Susceptible Subclinical Diseases

Clinical Disease

Recovery, Disability or Death

Opioids

(Exposure)

Naloxone

(Intervention)

Adapted from:

http://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section9.html

Prevention

Kolodny A, et al. The prescription opioid and heroin crisis: a public health approach to

an epidemic of addiction. Annu Rev Public Health. 2015 Mar 18;36:559-74.

Primary

• Prevent new addictions

• Avoid opioids; cautious opioid prescribing; safely discard unused opioids; social marketing

Secondary

• Early identification of addiction

• Point of care use of prescription drug monitoring programs; urine drug screening

Tertiary

• Access to addiction treatment; Harm reduction

• Pharmacotherapy and psychosocial

• Needle exchange, supervised injection services; naloxone

Education

Opioid Prescribing Guidelines

Issues

Best practices guidelines ≠ improved care

Need effective implementation strategies

Self-regulation, limited information on

physician performance

Physician education limited: chronic pain,

addictions, and mental health

Treatment

Medication-Assisted Treatment (MAT) Methadone and Buprenorphine/Naloxone

Evidence: decreased mortality, reduced opioid use, treatment retention (Mattick 2014; Sokya 2011)

Psychological (i.e., counseling)

Issues

Primary care structure No incentives to manage mental health and

addictions

Non-physician services do not have public coverage

Access to evidence-based services

Quality of care

Monitoring and Surveillance

Prescription Drug Monitoring Programs

• No studies evaluating the effectiveness of PDMPs on outcomes related to overdose, addiction, abuse, or misuse (CDC 2016)

Evidence

• Prescriber should review PDMP profile at start of opioid therapy and periodically after (CDC 2016)

Guidance

• 7 provinces operational, 2 developing, 1 territory linked to a province

• Real-time prescriber access limited (Sproule 2015)

Implementation:

Adapt Familiar Public Health Practices?

Adverse Event Following Immunization Reporting

Adverse Event on Opioid Therapy Reporting

Antibiotic Stewardship Opioid Stewardship

Foodborne Illness Outbreak Response Protocol

Opioid Poisoning Outbreak Response

Protocol

Best Practices for Infection Prevention and Control

Programs in Ontario

Best Practices for Opioid Control Programs in

Ontario

Is fentanyl a public health issue?

Three main public health functions:

1. The assessment and monitoring of the health of

communities and populations at risk to identify health

problems and priorities.

2. The formulation of public policies designed to

solve identified local and national health problems and

priorities.

3. To assure that all populations have access to

appropriate and cost-effective care, including

health promotion and disease prevention services.

http://www.who.int/trade/glossary/story076/en/

What is public health?

“Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases. Thus, public health is concerned with the total system and not only the eradication of a particular disease.” http://www.who.int/trade/glossary/story076/en/

What is a public health priority?

Magnitude of the problem: How much of a burden is placed on the community, in terms of financial losses, years of potential life lost, potential worsening of the problem, etc.?

Seriousness of the consequences of the problem: What benefits would accrue from correcting the problem? Would other problems be reduced in magnitude if the problem were corrected?

Feasibility of correcting the problem: Can the problem be addressed with existing technology, knowledge, and resources? How resource-intensive are the interventions?

http://www.cdc.gov/od/ocphp/nphpsp/documents/Prioritization.pdf

Conclusions

The problem of opioid-related harms in Canada is

BIG

Complex

Worsening

The solutions need to be

Comprehensive

Timely

Evaluated

Public health practitioners have excellent

training and skills to be part of the solution!

Other Key References Broyles LM, et al. Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and

response. Subst Abus. 2014;35(3):217-21.

Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from

the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50).

Retrieved from http://www.samhsa.gov/ data/

Clark AK et al. A systematic review of community opioid overdose prevention and naloxone distribution programs.

J Addict Med. 2014 May-Jun;8(3):153-63.

European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)

http://www.emcdda.europa.eu/publications/emcdda-papers/naloxone-effectiveness

Felitti VJ et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in

adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998 May;14(4):245-58.

Fulton-Kehoe D1, et al. Opioid poisonings in Washington State Medicaid: trends, dosing, and guidelines. Med Care.

2015 Aug;53(8):679-85.

Giglio RE et al. Effectiveness of bystander naloxone administration and overdose education programs: a meta-

analysis.. Injury Epidemiology. 2015. 2:10.

Gomes T1, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients

with nonmalignant pain. Arch Intern Med. 2011 Apr 11;171(7):686-91.

Other Key References Juurlink DN1, Dhalla IA. Dependence and addiction during chronic opioid therapy. J Med Toxicol. 2012 Dec;8(4):393-

9.

Larochelle MR, et al. Opioid Prescribing After Nonfatal Overdose and Association With Repeated Overdose: A

Cohort Study. Ann Intern Med. 2016 Jan 5;164(1):1-9.

McAuley A et al. Exploring the life-saving potential of naloxone: A systematic review and descriptive meta-analysis of

take home naloxone (THN) programmes for opioid users. Int J Drug Policy. 2015 Dec;26(12):1183-8.

National Advisory Committee on Prescription Drug Misuse. (2013). First do no harm: Responding to Canada’s

prescription drug crisis. Ottawa: Canadian Centre on Substance Abuse.

Persaud N. Questionable content of an industry-supported medical school lecture series: a case study. J Med Ethics.

2014 Jun;40(6):414-8.

Sproule B. (2015). Prescription Monitoring Programs in Canada: Best Practice and Program Review, Ottawa, ON,

Canadian Centre on Substance Abuse.

Thank you!

Questions?