6/6/2017. Faculty/Presenter Disclosure. Disclosure of Commercial Support

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1 Opioids in Ontario, Canada: The need to reduce the prescribed opioid load; and need for mass casualty preparation Kieran Moore, Professor of Emergency Medicine, Queen s University, Associate Medical Officer of Health, KFLA Public Health kmoore@kflapublichealth.ca Faculty/Presenter Disclosure Faculty: Kieran Moore Relationships with commercial interests: Honorarium from MD Brief for an educational event on adult immunization 2 Disclosure of Commercial Support This program has not received financial or in-kind support from any organization Potential for conflict(s) of interest: Not applicable 3 1

2 Mitigating Potential Bias Not applicable 4 Objectives Epidemiology of Prescribed Opioids and harms in Ontario, Canada- UPDATE Review Mass Casualty Illicit Opioid Outbreak Management Framework-Exercise recommendations Emergency Medicine prescribing guidelines/policy Questions Do you have a policy or guideline on opioid prescribing in your Emergency Department? Hospital? Community? Do you have a response plan for a sudden surge in illicit opioid overdoses for your Emergency Department? Do you know your roles and responsibilities? Do you know how to respond? 2

3 ODPRN April 2017 Report 3

4 Trends in Ontario 250 percent increase in ED visits for overdose, withdrawal, harmful use, intoxication from Diversion of opioid prescriptions is a significant problem anecdotal evidence at addictions center interviews of up to 30 percent of prescriptions diverted for profit or non medical use in Ontario Prediction if current trends continue: You will see more patients with overdose of narcotics plus. You will see more complex overdoses with fentanyl and analogues. You will see mass casualties from overdoses of opioids. You will see more patients wanting narcotics and renewals. You will see more patients with opioid use disorder.neonatal abstinence syndrome You will see more patients in withdrawal. You will see more IVDU. You will see more patients using heroin. You will see more patients with endocarditis. You will see more patients with HIV, HCV and Hep B. There will be a higher risk of diversion of opioids given supply demand and market pressures. 4

5 Context we continue to prescribe in higher opioid doses in Ontario HQO report 2017 Health Quality Ontario REPORT-14 million people 5

6 Prevention-reduce unnecessary prescribing-community Opioid Loadupstream solutions 6

7 ED Opioid prescribing Reducing prescribed opioid diversion-evidence supports for a 8 percent reduction in prescribing, 12 percent reduction in overdose death ( also some benefit in reducing heroin death ) Health Affairs October :10 potential 100 less deaths in Ontario The more prescribed initially the higher the risk of addiction and long term use.risk increases after 5 days of opioids if 8 days of opioids 13.5 percent use at one year MMWR March :Vol 66/No.10 A. Shah Guideline Development: ED We have created in partnership with the Provincial ED and Primary care leadership guidelines on prescribing opiates in the Emergency Department and Walk in clinic settings Support the availability and eventual mandatory real time access to a pharmacy narcotic monitoring system 7

8 Guideline Development: ED cont d. Non-opioid options are first-line for all patients with pain Assess for risk of addition or misuse using targeted history or screening tool, such as the Opioid Risk Tool and Opioid Manager Ask whether the patient and primary care physician signed a treatment agreement typically includes statement that the patient will not seek opioid prescriptions from other physicians and ED Set limits for dosing and dispensing New York State guideline (no more than 3 days), Washington State guideline (max. 30 tablets) Now: Risk of adulterated drugs in community with illicit fentanyls and analogues 8

9 How can we prepare for a surge in overdoses? Table top exercises-held in Kingston with 90 members of community Anticipate Plan Prevent Respond Recover 9

10 Preparation: Do you know How much Naloxone does your hospital have? How much naloxone do your EMS partners carry? How much naloxone is required in outbreaks per patient? How are your going to communicate this risk to the community? How do we prepare our communities? What are the key communication strategies? What are roles and responsibilities? Ontario Opioid Surveillance Monitor The Ontario Opioid Surveillance Monitor has been created in response to the gap in available provincial opioid-related data, especially in real-time. The tool displays ACES hospital triage data relating to opiate overdoses and abuse. (Figure shows data from 2016 for participating hospitals). We also provide ICD coded data from NACRS and DAD on the site as well and update this data as soon as updates occur in intellihealth. ts Our Eyes and Ears for the Opioid Outbreak-Local Advisory Group-TASK FORCE Drug using community Paramedics, Dispatch Police, Fire Harm reduction services Acute Care services Addictions and Mental Health Primary Health Care Poison Control Center Regional Coroner 10

11 Probable Case Definition: Opioid Overdose Reportable to Public Health Fatal or non-fatal overdose of unintentional or unknown exposure to suspected illicit or counterfeit drug AND Patient demonstrates clinically compatible signs and symptoms of opioid overdose syndrome Decreased respiratory rate, pin point pupils, obtundation, cyanosis AND Positive response to naloxone if provided CONFIRM TOXICOLOGY Confirmation of Toxicological Cause Best practices Gas Chromatography, Mass spectroscopy, EIA Police - Health Canada Coroner - Centre of Forensic Sciences Provincial resources: if the patient is alive: CAMH, HSC, Ontario Poison Center 11

12 Communication Pathway for Notifying the Health System During an Opioid Overdose S Decision Instrument to Activate Municipal/Community Control Group and IMS Decision instrument to activate an emergency control group adapted from the WHO (2008) International Health Regulations (2005) 2 nd ed. Public Health Opioid Overdose Surge Response Utilizing an Incident Management Structure 12

13 Public Health Opioid Overdose Surge Response Pathway Review Case Definition Confirm Diagnosis Operationalize OBMT Implement Control Measures Surveillance Generate Hypothesis Ongoing Communication Chain of Survival-OPIATES: Persistent and Consistent Canadian Guideline for Safe and Effective Use of Opioids for CNCP 13

14 Harm Reduction-Be Aware in your community Monitor Drug related infections-hep C/HIV Naloxone-free to all through pharmacies Needle Exchanges in all communties Safe Injection Sites-starting Methadone Suboxone Addiction and Mental Health services Summary Epidemiology of Prescribed Opioids and harms in Ontario, Canada- UPDATE Review Mass Casualty Illicit Opioid Outbreak Management Framework-Exercise recommendations Emergency Medicine prescribing guidelines/policy 14