Prescription drugs first do no harm update

First Do No HarmResponding to Canada’s Prescription Drug Crisis

An update specific to First Nations, Remote/Isolated and Rural Communities

and Implementation of this national strategy

About CCSA

• Vision: All Canadians should live in a healthy society, free of alcohol- and drug-related harm

• Mission: Provide national leadership and advance solutions to address alcohol and other drug-related harm

• National non-profit, non-governmental organization

• Pan-Canadian and international role

2www.ccsa.ca • www.cclt.ca

About NNAPFVision:Cultivating and empowering relationships that connect us to our cultural strengths and identity within holistic and healthy communities.

Mandated to:• Advocate on behalf of & support

addictions programming for First Nations and Inuit

• Leadership role in implementing the Honoring Our Strengths: A Renewal Framework to Address Substance Use Issues Among First Nations in Canada

Culture, Respect, Community, Compassion

www.nnapf.com

Prescription Drug Abuse

• What issues are specific to First Nations Communities?

• What efforts have you developed to address these?• What challenges have emerged in addressing the

issue?• What are the next steps?• What advise can you give to the national level that

would support regional and community efforts?

CCSA.NNAPF

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• Legal substances with therapeutic uses– Requires different approaches than other substance

• Strategy must be balanced with the need to enable access to products for therapeutic use• A subset of individuals abusing/misusing these products may also have a therapeutic need for

them, adding complexity to assessment, prevention & treatment approaches

• Includes opioids, sedatives-hypnotics & stimulants• No single cause, factors include:

– Effective marketing by drug manufacturers – Addition of some drugs to public insurance plans– Limited education related to pain & addiction for health care providers

• Limited access to national data/research, generally and for specific populations (e.g., Inuit, seniors, corrections, military) or effective solutions

A Complex Social Issue

www.ccsa.ca • www.cclt.ca 6

• Involves – A diverse group of stakeholders with potentially competing interests

• Governments; healthcare practitioners; patients & families; First Nations, Inuit, & Metis; enforcement; regulators; researchers; industry

– Involves other complex issues such as pain, mental health/intergenerational trauma, addictions, social determinants of health, access to and availability of equitable health services

– First Nations, youth, women, rural/remote communities experience Issues of health equity and are affected differently

– Use, abuse, misuse, non-medicinal, diversion

• As a federation, Canada requires cooperation among federal & 13 provincial/territorial levels– Lack of national data– Regional differences

A Complex Social Issue

CCSA.NNAPF

Prescription Drug Issues Among First Nations in Canada• Non-Insured Health Benefits (NIHB) program show that 898 opioid

prescriptions were dispensed per 1,000 First Nations individuals aged 15 and older in Ontario in 2007, with 119 prescriptions for oxycodone formulations alone (Health Canada, 2010)

Changes made under the NIHB program have led to a 50% reduction in the amount of long-acting oxycodone provided since 2010 and no significant shift in other opioids (Health Canada, 2012c). These measures include:• Monitoring prescriptions to identify potential harms and prevent double-

doctoring;• Establishing maximum monthly and daily drug limits;• Changing the listing status of extended release oxycodone to exception

status;• Real-time warning and claims rejection messaging to pharmacists at the

point of sale; and• Establishing an external, expert drug and therapeutics advisory committee.

CCSA.NNAPF

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Prescription Drug Use in Canada

• Second largest per capita consumer of opioids

– Up by 203% from 2000–2010; steeper rise than US (INCB, 2013)

• 23% 15+ reported use at least once in past 12 months (CADUMS 2011)

• 898 opioid prescriptions per 1,000 First Nations individuals 15+ in 2007

– 119 prescriptions for oxycodone formulations alone (Health Canada, 2010)

CCSA.NNAPF

The Mandate from First Nations

• Resolutions passed at both AFN Annual General Assemblies and Special Chief Assemblies

• Honouring Our Strengths: A Renewed Framework to Address Substance Use Issues Among First Nations in Canada

• Regional and National Concerns – Atlantic, Saskatchewan, Alberta and Chief of Ontario, Assembly of First Nations Resolutions

• Prescription Drug Abuse Coordinating Committee• First Do No Harm National Advisory Council

CCSA.NNAPF

Unintended Consequences of Prescription Drugs on First Nations

1. Community Capacity2. Withdrawal Management & Pharmacological

Interventions3. Neonatal Abstinence Syndrome4. HepC, HIV, Aids5. Violence and Crime6. Increased pressure on the health care system7. Stigma and Discrimination8. Child Welfare and Family Functioning

CCSA.NNAPF

Community CapacityIssues:• not enough mental health and addictions workers in First Nations communities • Residential Treatment programs (NNADAP and YSAP) are faced with a lack of resources to ensure they have the

right set of skills and service capacity to support opiate replacement therapy• high number of children with behaviour issues related to opiate addiction within the family – pressures on

school and community• clients on methadone do not get accurate information regarding the care pathway that can lead to getting off of

methadone altogether• A poor relationship with health care generally leaves First Nations people more vulnerable to physicians as

figures of authority and therefore less likely to question courses of treatment

Strategies:Where communities have taken a culturally relevant community development approach to addressing prescription drug issues, there has been community wide success – observed in the following ways: 1. Family relationships improved: more quality care for children2. Family resources redirected from drug use (80% of income) to family functioning (food available in the home,

home furnishings and children’s toys restored)3. Reconnection to culture and First Nations identity, predicting maintenance of wellness more long term4. Pooled resources across community programs and services, increasing more coordinated efforts across programs

and services but these efforts first required additional resources to initiate and manage this process5. More effective partnerships and better care management for clients on methadone or suboxone when program

is delivered in a First Nations community with support of community health programsCCSA.NNAPF

Withdrawal Management & Pharmacological Approaches

Issues:• From 2000 to 2010, NIHB’s methadone claimants (using the simple definition) increased from

598 in 2000 to 6,038 in 2011 (11-year annualized growth rate: 23%). • In 2012, the utilization of Suboxone® increased, from 41 clients in 2011 when NIHB policies

made the drug available by “exception” to a projected 750 in 2012.• Cost per client annually for opiate replacement therapy as reported by NIHB in 2012 suggests

that methadone averaged at 1400.00 and Suboxone® at 1200.00 • Policies around Suboxone® (available by exception) limit community ability to respond in a way

that best reflects the First Nations community capacity to manage client daily transportation to obtain methadone & continuing care

• Withdrawal itself poses increased risk of suicide and overdose• Limited to no access to withdrawal management programs off reserveStrategies:• Community based programs designed with cultural interventions and Suboxone® have improved

wellness and many non-opiate users were motivated to work on mental health and substance use related issues. Community wide healing was inspired through the community & culturally based strategy to address opiate addiction

CCSA.NNAPF

Neonatal Abstinence Syndrome

Issue:• The prevalence has increased significantly over time from 171 in 2003 to 654 cases in 2010. • Rates for NAS are five times higher among infants born to mothers who delivered their first

child prior to age 19 compared to mothers who were older at first delivery. • At least 20% of First Nations births are to teenaged mothers.• It is critical to streamline access to buprenorphine (Subutex®). Approved by exception

which often takes several weeks. An untreated opiate dependent mother and her baby is a critical trauma to First Nations communities.

• Pregnant women addicted to opioids tend to deliver earlier and faster. They also need postnatal care that is close to home. This is a significant issue for members of rural, isolated and remote communities.

• Babies on methadone often require hospital stays for up to a month after birth.

Strategies:Research indicates that the issues with neonatal abstinence are lessened with Subutex®, including shorter hospital stays.

CCSA.NNAPF

HepC/HIV/AIDSIssues:• This progression from oral to nasal to intravenous use of “oxys” is a consistent story

among those seeking help to address the addiction.• Risks associated with injection drug use include the spread of blood-borne infections

such as HIV and hepatitis C, as well as secondary complications such as injection site infections.

• injection drug use accounted for 58.8% (compared to 14% in general Canadian population) of HIV-positive test reports

• Aboriginal people experienced HIV at rates about 3.6 times higher than other Canadians in 2008 & nearly two-thirds (65.7%) of people who inject drugs had evidence of past or current hepatitis C infection

• 25.5% of men and 29.9% of women reported that they began to inject drugs at age 16 or younger

Strategies: • Needle exchange programs• Access to opiate replacement therapy

CCSA.NNAPF

Violence and CrimeIssues:• A growing number of First Nations have associated elevated rates of prescription drug

misuse/abuse with increased levels of violent criminality, illicit prescription drug trafficking, other forms of abuse, and suicide within their communities

• Communities have reported that the main targets for drug trafficking, smuggling and playing the role of the “mule” are vulnerable youth. Women and children have been sexually exploited to feed prescription drug abuse habits

• There are consistent reports of increased break-ins and robberies of homes in First Nations to finance drug use.

• People suffering from cancer/vulnerable populations become victims of extreme abuse and other crimes which often leave these populations without the drugs they need to manage their pain; also increasing risk of harm to palliative care workers in First Nations homes.

• At the same time there have been reports of elderly people selling their own medication for profit.

Strategies:• The $2,389,319 in federal (Public Safety Canada) funding over five years for Project Journey, a

crime prevention project that will help Aboriginal youth in Pikangikum First Nation is a good start

• Youth in treatment report a connection to culture made the biggest difference in their healing

CCSA.NNAPF

Increased pressure on the health care system

Region 2008/2009 emergency visits 2010/2011 emergency visits All of Ontario 2.6 for every 10,000 people 3.7 for every 10,000 people Northern Ontario only 9.2 for every 10,000 people 22.9 for every 10,000 people First Nations 12.1 for every 10,000 people

55 for every 10,000 people

• Almost 250 per cent increase in the number of emergency room visits related to narcotics withdrawal, overdose, intoxication, psychosis, harmful use and other related diagnoses.

• First Nations communities health stations are usually solely staffed by nurses. These nurses may not have adequate resources or expertise to deal with the demand for addiction or pain treatment.

Strategies:• Further planning and community development • Physician education in pain management • Ongoing capacity for First Nations organizations who support First

Nations communities in responding to the PDA crisis

Issues:

CCSA.NNAPF

Stigma and Discrimination

Issues:• People who have experienced addiction often encounter stigma and

discrimination associated with their drug use in many places – in health care, in the community, within the family and at the workplace

• Stigma and discrimination may prevent people from accessing or maintaining necessities such as housing, relationships, employment and health care. It may even prevent people from admitting that they have a substance misuse problem, especially if they began taking opioids for pain management reasons.

• Stigma and discrimination is even more challenging for women and most significant for pregnant women.

Strategies:???

CCSA.NNAPF

Child Welfare and Family FunctioningIssues:• Addiction can have a profound impact on the relationship between parent and child

and can affect a parent’s ability to provide adequate care. Neglect or abuse associated with substance abuse and addiction is one of the main reasons child welfare agencies intervene

• A family environment characterized by intergenerational trauma, grief and loss will also be characterized by an erosion of cultural values visible through inadequate child rearing, disengagement from parental/family responsibilities, violence, abuse, and the problematic use of substances are all risk factors that contribute to alcohol and drug abuse.

• Lastly the epidemic needs to be understood as the self-medication efforts to alleviate the suffering of intergenerational trauma and current social conditions and poverty experienced in our communities.

Strategies:• Decolonization through education and early intervention programs

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Solving Complex Social Issues

• No single agency can adequately address complex social issues

• Large-scale social change requires a collaborative approach that involves those in government, civil society & the private sector

• Commitment of a group of actors to a common agenda• Coordination of efforts and working together around clearly

defined goals• Backbone organization to provide leadership, guidance and

support

CCSA.NNAPF

Prescription Drug Abuse

• What issues are specific to First Nations Communities?

• What efforts have you developed to address these?• What challenges have emerged in addressing the

issue?• What are the next steps?• What advise can you give to the national level that

would support regional and community efforts?

CCSA.NNAPF


• Pan-Canadian strategy

• 58 recommendations

• 7 Implementation Teams• Prevention• Education• Treatment• Monitoring & Surveillance• Enforcement• Legislation & Regulations• Evaluation & Performance Measurement

• 1st yr of implementation phase completed

First Do No Harm: Responding to Canada’s Prescription Drug Crisis

FDNH National Advisory Council

• Multi-sectoral cross-section of organizations in Canada with a role in responding to the PDM crisis– Healthcare– Governments– First Nations– Individuals and Families– Research– Industry

• Membership reflects complexity & commitment to coordinated action

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First Nations and First Do No Harm

• Early in the development of the strategy, CCSA formed a strategic partnership with Health Canada’s First Nations and Inuit Health Branch (FNIHB) and the Assembly of First Nations to address prescription drug misuse.

• FNIHB had an existing Prescription Drug Abuse Coordinating Committee and was planning to produce a national strategy for First Nations and Inuit populations.

• This partnership ensured a comprehensive approach to the issue for Canada and avoided duplication of effort

• NNAPF and AFN – were actively involved in the development of FDNH– wrote Strategy Linkages with First Nations Issues and Activities section of

the strategy– continue their involvement in the Strategy’s implementation


First Nations and First Do No Harm

• First Nations health is widely understood to be affected by a range of historical and culturally-specific factors (sometimes referred to as First Nations- or Aboriginal-specific determinants of health), which include:– colonization– loss of language and connection to the land– residential school abuses– systemic racism– environmental destruction– cultural, spiritual, emotional, and mental disconnectedness

• Unresolved trauma and intergenerational trauma presents difficulty in distinguishing psychological and physical pain

• Many First Nations communities aim to achieve wellness, which is distinct from the often-medicalized model of “health” in that it is holistic and promotes an equal balance of mental, physical, emotional and spiritual aspects of life.

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Governance StructureImplementation phase


FDNH in Action since Launch• 20 partner organizations added since launch / total 50 at the table

ongoing• Annual NAC meeting in March 2014 reviewed progress & maintain

momentum• Implementation Teams have identified priorities for next 12 months• Activities underway to support implementation

– Implementation Teams collaborating with FPT Working Group on Prescription Drug Misuse

– Expansion of NADS in Speech from the Throne (October 2013)– CCSA and other partners presented at HESA in Fall/Winter 2013-14– CCSA and Minister Ambrose co-hosted a Symposium on January 24, 2014– Submitting letter to Health Canada regarding review of CDSA

• Exploring funding options to support continued work


Prevention Team achievements (Y1)Co-chairs: Dr. Brian Emerson & Anne Bowlby

• Overdose Prevention– Participated in Second Chances study - effectiveness of take-home naloxone – Conducted literature search - overdose death prevention programs– Initiated scan of provincial corrections services OD death prevention

programs– Linked with Correctional Investigator of Canada– Reviewed: Deaths in Custody and An Investigation of the Correctional Service

of Canada’s Mortality Review Process• Prescribing practices

– Identified policies to guide a scan/literature review• Community capacity development

– Partnership initiated with Federation of Canadian Municipalities


Prevention Team priorities (Y2)• Promote appropriate prescribing practices

– Literature review & environmental scan to identify existing policies & programs, & their effectiveness

• Promote public awareness, knowledge, skills & behaviors– Scan of social marketing campaigns including safe storage & disposal– Advise HC on development of campaign(s)

• Overdose & overdose fatality prevention– Secure new partnerships– Scan of existing activities


Education Team achievements (Y1)Co-chairs: Dr. Norm Buckley & Dr. David Mock• Developed Competencies for Health Professionals in Pain Management, Drug Prescribing,

Dependency, Addiction & Abuse

• Identified key stakeholders - health education, accreditation bodies, regulatory bodies, faculty associations & professional associations

• Completed scan of continuing education opportunities in pain management, prescribing practices, dependency, addiction & abuse


Education Team priorities (Y2)• Finalize Competencies for Health Professionals in Pain Management,

Drug Prescribing, Dependency, Addiction & Abuse

• Develop continuing education programs for health practitioners to reflect the competencies

• Conduct a gap analysis to identify missing curriculum content and revise healthcare professional curricula to reflect the competencies


Treatment Team priorities (Y1)Co-chairs: Dr. Peter Selby & Dr. Ramm Hering

• Scan of existing guidelines by province & territory– Mental health– Pain– Addiction

• Develop 4 treatment pathways– Pain– Misuse of pain medication– Addiction– Pain and Addiction

• Identify, develop, evaluate & implement effective evidence-informed SBIRT Resources


Monitoring & Surveillance Team achievements (Y1)Chair: Dr. Beth Sproule

• Established links with FPT Prescription Drug Abuse Working Group– Hosted conference (May 22-23, 2014), with funding from NS, resulting in

• Consensus on a vision for the future for a national surveillance system for prescription drug

• A plan for building on existing initiatives to achieve this goal

• An action plan for moving forward on developing a PMP network for Canada

• Conducted Canadian PMP review (in progress)

• Involved in Health Canada substance use population survey core indicator consensus process (in progress)

• CRISM grant application & success (CIHR research network grant)

• Meeting with RADARS director and CCSA


Monitoring & Surveillance Team priorities (Y2)

• Establish core indicators & key elements of a Canadian prescription drug surveillance strategy

• Working in collaboration with FPT working group– Establish a Canadian prescription monitoring program community

of practice

– Establish a Canadian prescription monitoring program research network


Enforcement Team achievements (Y1)Co-chairs: Chief Mark Mander & Micheline Lavoie

• National Prescription Drug Drop-Off Day– 1st Annual - May 11, 2013

• Over 2 tons of medications were dropped off nation-wide

– Secured funding for Coordination (at CACP) for 2014 event– Developed an Evaluation Toolkit to assist evaluation (AB Health)– 2nd Annual event – May 10, 2014

• Preliminary results: over 2600 pounds returned

• Cost-impact Assessment completed (not yet released)– Will be made available in both official languages by Summer 2014

• Workshop associated with development of practice guidelines for death investigations


Enforcement Team priorities (Y2)

• Annual National Prescription Drug Drop-Off Day

• Awareness raising and outreach to key law enforcement & criminal justice stakeholders

• Use results from the cost-impact assessment of prescription drug misuse on Canadian law enforcement and criminal justice system

• Development of guidelines for death investigations in Canada


Legislation & Regulations Team achievements (Y1)Co-chairs: Cameron Bishop & Dr. Mel Kahan

• Submitted letter to Health Canada regarding:– new medication approval– product monograph review

• Scanned initiatives in Ontario (not under FDNH umbrella) on:– Naloxone– Buprenorphine in First Nations communities– Prescribing limits for opioids (ODB)– New pain medications


Legislation & Regulations Team priorities (Y2)• Work with Health Canada to strengthen regulatory oversight of

medications with addiction potential– Ensure that risk of addiction is considered before approving new meds (e.g., Zohydro)– Ensure that product monographs provide accurate information on indications,

precautions and dosing

• Work with NIHB, provincial funders & medical regulators to ensure access to medications to treat addiction and reduce overdose deaths, especially:– Methadone, Buprenorphine, Naloxone

• Work with funders & medical regulators to reduce harms from prescribing high opioid doses to high-risk patients

– Funding mechanisms: Limited Use codes, Exceptional Access programs– Medical regulators: Opioid prescribing standards


Next Steps• Work to secure funding to support the strategy Implementation Teams

– Provide continued leadership on this issue– Coordinate collective action– Maintain focus on common agenda– Expand partner engagement– Implement specific recommendations– Evaluate the strategy for impact

• Continue recruitment by implementation team in accordance with the priorities for action

• Finalize evaluation plan to assess impact and change

• Release FDNH Annual Report – June 2014


Opportunities for collaboration

• What are your related priorities and activities and how can the work of the Implementation Teams be of help to you?

• Where can CCSA support your efforts in addressing the harms associated with prescription drugs

• What opportunities exist for CCSA to work even more closely together with the National Faculty to find new and innovative approaches to addressing issues related to prescription drugs


Opportunities for Collaboration

• Explore existing data sources or collect data to gain a greater understanding of the issue in Inuit communities

• Develop an addendum to the FDNH strategy that describes the issue from a Inuit perspective (similar to the chapter related to FN)

• Include ITK representation on the NAC &/or Implementation Teams

• Your ideas?

Thank You

Contact Information:

Carol Hopkins, MSW Paula RobsonExecutive Director Knowledge Broker NNAPF CCSA

Satellite Office: 519.692.9357 Main Office: (613) 235-4048Main Office: 866.763.4714 Fax: (613) 235-8101Fax: 866.236.7705 [email protected]

www.nnapf.com www.ccsa.ca

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Prescription drugs first do no harm update

Health & Medicine

Transcript of Prescription drugs first do no harm update