Overview of Opiate Addiction
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Transcript of Overview of Opiate Addiction
Overview of Opiate Overview of Opiate AddictionAddiction
Overview of Opiate Overview of Opiate AddictionAddiction
• 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
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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 stability2. Stop opioids, stop injecting3. Stop other drugs4. Grow emotionally, develop success
in life5. 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 = structure3. 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