www.ccsa.ca www.cclt.ca Addressing the Harms of Prescription Drugs in Canada Innovations & Policy Solutions for Addressing Prescription Drug Abuse April 30, 2014 Rita Notarandrea, Canadian Centre on Substance Abuse Dr. Beth Sproule, Centre for Addiction and Mental Health
Objectives Describe the complex urgent issue of prescription drug use, misuse, and associated harms Canadian data on use, misuse, and harms Come together to address the issue First Do No Harm strategy Related activities National, provincial, community www.ccsa.ca www.cclt.ca 2
A Complex Social Issue 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 www.ccsa.ca www.cclt.ca 3
A Complex Social Issue Involves A diverse group of stakeholders with potentially competing interests Governments, healthcare practitioners, patients & families, First Nations, enforcement, regulators, researchers, industry Involves other complex issues such as pain, mental health, addictions, social determinants of health Issues of health equity as different populations are affected differently (e.g., First Nations, youth, women, rural/remote communities) Use, abuse, misuse, non-medicinal, diversion As a federation, Canada requires cooperation among federal & 13 provincial/territorial levels Lack of national data Regional differences www.ccsa.ca www.cclt.ca 4
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) www.ccsa.ca www.cclt.ca 5
Prescription Drug Misuse in Canada 8.2% youth grades 6 12 reported past-year use to get high (Youth Smoking Survey, 2010-11) 72% of youth who misused these drugs got them from home (Brands et al, 2010) In some provinces, 1/5 middle and high school students misuse (AB Health Services, 2009) 11.7% of Nova Scotia students used pain pills not prescribed to them (Nova Scotia Student Drug Use Survey, 2012) Reported misuse doubled for BC Aboriginal youth, grades 7 12 from 2003 to 2008 (11% to 22%) (Tsuruda, Hoogeveen, Smith, Poon, Saewyc, & McCreary Centre Society, 2012) www.ccsa.ca www.cclt.ca 6
Prescription Drug-related Harm in Canada Addiction Admissions doubled to Ontario treatment programs for prescription opioids (2004-2009) Of those seeking addiction treatment in Ontario 10.6% for prescription drugs in 2005 2006 18.6% for prescription drugs in 2010 2011 112% increase in number people in withdrawal management for opioid dependence in Nova Scotia (women: 161%; men: 91%) Risky behaviour 7.2% drove within an hour of taking a prescription pain relief pill (NSSDUS 2012) www.ccsa.ca www.cclt.ca 7
Prescription Drug-related Harm in Canada Deaths Opioids account for over ½ of accidental deaths in ON (Madadi, Hildebrandt, Lauwers, & Koren, 2013) BC prescription opioid death rate (2.7/100,000) similar to motor vehicle crash deaths related to alcohol (2-3/100,000) (Corneil et al., 2012) Of 431 drug-related deaths in Nova Scotia (2007-2012) Prescription opioids: 74% Methadone: 15% Benzodiazepines & other sedative-hypnotics: 62% Cost Data is lacking for Canada; US: $50 billion (lost productivity and crime account for 94%) www.ccsa.ca www.cclt.ca 8
Pharmaceutical Product Abuse Schema Therapeutic Domain Use Recreational Domain Benefits Risks Side-Effects Misuse Physical Dependence Abuse Disorder Dependence Disorder www.ccsa.ca www.cclt.ca 9
Prescription Drug Abuse Diverted from distribution path Abuse within a therapeutic context thefts deception to obtain illegitimate prescriptions OTC (codeine) forged prescriptions legitimate prescriptions www.ccsa.ca www.cclt.ca 10
# Admissions CAMH Opioid withdrawal management admissions 100 90 80 70 60 50 40 30 20 10 0 2000 2001 2002 2003 2004 Oxycodone CR Other oxycodone Other Rx opioids Heroin n=78 n=96 n=120 n=111 n=166 Sproule BA, et.al., Changing patterns in opioid addiction: Characterizing users of oxycodone and other opioids. Canadian Family Physician, 2009;55:68-9.e1-5. www.ccsa.ca www.cclt.ca 11
% Clients Prescription Opioid Source by Age Group 70 60 50 40 30 20 10 Street Rx Street & Rx OTC 0 25 & under 26-35 36-45 46-55 over 55 Age Categories (years) Sproule BA, Brands B, Li S, Catz-Biro L. Can Family Physician 2009;68-9.e1-5 www.ccsa.ca www.cclt.ca 12
Opioid-Related Deaths in Ontario Increase in deaths due to inadvertent toxicity rather than suicide Most deaths also involved another CNS depressant Physician visits prior to death 66% had at least one within 4 weeks median 11 days between office visit and death; 9 days for emergency visits reasons for visit - mental health problems and pain Opioid prescriptions 56% had opioid Rx in month before death median 10 opioidrxs in year before death (Dhalla et.al. 2009) www.ccsa.ca www.cclt.ca 13
Opioid-Related Deaths in Ontario www.ccsa.ca www.cclt.ca 14
% Subjects % Subjects Pathways to Prescription Opioid Addiction 80 70 60 Recreational Periods Only N=347 ON NB NL 50 40 30 20 10 0 35 years Current Age > 35 years Recreational and Therapeutic/Mixed Periods Therapeutic/Mixed Perioids Only 38 yo mean (18-63 yo) 60 50 40 30 20 10 Recreational Periods Only Recreational and Therapeutic/Mixed Periods Therapeutic/Mixed Perioids Only 0 Ontario New Brunswick Newfoundland & Labrador Province Health Canada Funded Study www.ccsa.ca www.cclt.ca 15
Newfoundland and Labrador OxyContin Task Force June 2004 OxyContin prescriptions almost tripled 2001 to 2003 OxyContin users came from a variety of environments, including a growing number of users among the adolescent population Source of street OxyContin originated with prescriptions generated in the province Only a small number of physicians were prescribing controlled substances in an excessive manner Diversion of OxyContin was widespread and associated with an increase in criminal activities such as break and enters of pharmacies and homes, and personal robberies to obtain the drug www.ccsa.ca www.cclt.ca 16
Brockville Coroner s Inquest June 2011 2 prescription drug related overdose deaths 48 broad-ranging recommendations Monitoring Education Access to alternative treatments Product restrictions www.ccsa.ca www.cclt.ca 17
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Ontario First Nations leadership and communities have expressed concerns that the abuse of certain prescription drugs has become an epidemic in First Nations communities. www.ccsa.ca www.cclt.ca 19
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 www.ccsa.ca www.cclt.ca 20
About CCSA Substance abuse is a complex problem too significant and too deeply rooted to be solved by one group or approach Created in 1988, CCSA is Canada s only national agency with a legislated mandate to reduce alcohol- and drug-related harm We serve Canadians by giving the tools and resources to front-line professionals serving those with substance use disorders We set a long term vision for Canada to address substance abuse and advance solutions that reflect key national priorities Structured as a not-for-profit corporation, governed by a Board of Directors, operating at arms-length from the federal government We leverage federal funding with support from provinces and territories, not-for-profit and private sectors, to support a national agenda while mobilizing a pan-canadian response www.ccsa.ca www.cclt.ca 21
CCSA s National Priorities Children & Youth Canada s North & First Nations, Inuit, Métis Mental Health & Substance Abuse Canada s National Framework for Action Prescription Drug Misuse National Alcohol Strategy National Framework for Action (2005): Collective action for collective impact Workforce Development Impaired Driving National Treatment Strategy www.ccsa.ca www.cclt.ca 22
The Strategy First Do No Harm: Responding to Canada s Prescription Drug Crisis Pan-Canadian strategy 58 recommendations 7 Implementation Teams Prevention Education Treatment Monitoring & Surveillance Enforcement Legislation & Regulations Evaluation & Performance Measurement 1 st yr of implementation phase completed www.ccsa.ca www.cclt.ca 23
FDNH in Action Collective Action shared vision, a roadmap providing guidance for the work, commitment and engagement from all that have a role to play in addressing the problem and implementing the solution as described in the recommendations Added 20 partner organizations since launch Annual NAC meeting in March 2014 to review progress, plans & maintain momentum Implementation Teams have identified their 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 other partners presented at SOCI in Winter 2014 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 www.ccsa.ca www.cclt.ca 24
FDNH - Year 1 Achievements Patient, Family and Community Safety Overdoes prevention Created linkages with Canadian Drug Policy Coalition to further the work Hosted 1 st annual National Prescription Drug Drop-Off Day May 11, 2013 Prescribing practices Drafted set of Competencies for Health Professionals in Pain Management, Drug Prescribing, Dependency, Addiction & Abuse Completed scan of continuing education opportunities in pain management, prescribing practices, dependency, addiction & abuse Surveillance Secured funding for PMP research network via CRISM grant Surveillance & PMP meeting via NS Department of Health & Wellness (May 2014) Initiated collaboration with FPT Prescription Drug Abuse Working Group to develop network and address surveillance-related needs www.ccsa.ca www.cclt.ca 25
FDNH - Year 1 Achievements Treatment Initiated scan of existing guidelines by province & territory to inform clinical pathway development Mental health Pain Addiction Research Completed cost-impact assessment of PDM on enforcement Conducted review of Canadian PMP programs effectiveness and core components www.ccsa.ca www.cclt.ca 26
FDNH Achievements: Alberta Health CCSA was contracted by Alberta Health to support activities of the Strategy, and through this work increase access to best practices, resources and tools to address prescription drug misuse in Alberta. Is assisting in hosting a Methadone Maintenance Treatment (MMT) Workshop for physicians & pharmacists Is exploring online options to increase access to MMT training Completed a survey to determine health professionals perceptions of this issue & identify necessary local strategies for action Reviewed of models and identification of the core components of effective PMPs is close to completion Developed a resource to assist communities in evaluating Drop-Off initiatives Advised on the development of AB s Prescription Drug Misuse Project to guide recommendations for an effective provincial strategy www.ccsa.ca www.cclt.ca 27
Priorities for 2014-2015 Patient, Family & Community Safety Prevent overdoses through naloxone distribution, education & legislation Inform citizens of risks & harms through Social marketing Promote safe storage and disposal via National Prescription Drug Drop-Off Day Consult with Health Canada on product monographs & CDSA review Prescribing & Dispensing Practice Revise core competencies for prescribers & dispensers based on stakeholder review Improving prescribing practice by promoting core competencies Improving health care provider education by identifying & addressing gaps in education www.ccsa.ca www.cclt.ca 28
Priorities for 2014-2015 Treatment Develop four clinical pathways Pain Misuse of pain medication Addiction Pain & Addiction Identify, develop, evaluate & implement effective evidence-informed SBIRT resources Surveillance Identify core components of effective PMP programs & share across jurisdictions Assemble a PMP research network with CRISM funding Identify & reach agreement on core indicators & data sources Develop guidelines for prescription drug-related death investigations to ensure consistency in practice & data collection www.ccsa.ca www.cclt.ca 29
Next Steps Work to secure funding to Support the strategy 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 Develop evaluation plan to assess impact and change Release FDNH Annual Report Spring 2014 www.ccsa.ca www.cclt.ca 30
Questions? www.ccsa.ca www.cclt.ca 31