overview of opiate addiction. conflict of interest – 2 talks for purdue about dangers of opioid...
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Overview of Opiate Overview of Opiate AddictionAddiction
Overview of Opiate Overview of Opiate AddictionAddiction
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• 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
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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
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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
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Canada - World Leader
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Where Are These Drugs Going?
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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
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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
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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
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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
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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
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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
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• Most stabilize rapidly
• They become tax-payers!
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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)
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Family Tree
24 14201722
1
1
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• Treatment is more difficult because of chaotic lives
• The opioid addiction responds but many are repeatedly “knocked down by life”
• Past trauma issues resurface
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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?.
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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
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Harm and Injection Use• Increasing rates of HIV in
Manitoba
• IV drug use is a factor
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Harm- Pregnancy and Families
• Increasing numbers of addicted mothers- diagnosed on the labor floor
• Babies require many days of care – and most are apprehended
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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
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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
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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
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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
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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”
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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
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Morphine and Dilaudid• Injection use is more common with
these
• Not much dilaudid use in Winnipeg, but increasing
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Fentanyl • Often cut up into “chiclets” and
used orally
• Many reports of respiratory arrest and several deaths after injection use
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Benzodiazepines• Benzo’s are a problem too –
widely sold • Ashton manual – how to get
people off (download from internet)
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Abstinence and Success Rates
• Doctors – 90% abstinent• Long term, street-hardened – 3%
abstinent
• In Winnipeg – only a few successfully abstinent – over 90% relapse
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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
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Methadone • Reasonable to use as first
treatment approach, especially in unstable lives
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Methadone - Goals1. Survival and stability2. Stop opioids, stop injecting3. Stop other drugs4. Grow emotionally, develop success
in life5. Consider weaning off, ONLY if
appropriate
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It’s Not Just a Substitute Drug
1. They feel normal – energy goes into creating a life
2. Tight rules and consequences = structure3. Relationships with staff promote maturity
and emotional skills
The patient is still on an opioid but the addictive behaviour lessens or disappears.
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Methadone - Outcomes
• 30% do very well• 30% markedly improved, still
problems• 30% somewhat improved
• 10% wean off or leave yearly
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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
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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
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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
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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
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Challenge Stigma • Preconceived ideas about addicts,
treatment, hopelessness
• Methadone - Hard Work and Good Outcomes Go Unrecognized
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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
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Methadone Saves Lives