Overview of Opiate Addiction
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 22 17 20 14 1 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 oxymothers.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 abstinencebased 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 - Goals 1. Survival and stability 2. Stop opioids, stop injecting 3. Stop other drugs 4. Grow emotionally, develop success in life 5. 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 = structure 3. 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 Death Diversion well Dispensing errors Inappropriate patients in treatment Physician norms can change Education, support of colleagues, College oversight are all necessary
Suboxone ( a milder SUBOXONE - methadone) 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
Methadone Saves Lives