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CSAM-SCAM Fundamentals Opioids – A Review Presentation provided by Meldon Kahan, MD Family & Community Medicine University of Toronto Fundamentals: Opioid Addiction Conflict of interest statement Dr. Christy Sutherland - none Dr. Elena Zoe Paraskevopoulos - none Fundamentals: Opioid Addiction Outline: Context: Canada’s opioid crisis Prescription opioids: a major source of the epidemic Family physician perspectives Prevention of opioid use disorders Diagnosis/Detection Management of opioid use disorder Fundamentals: Opioid Addiction Opioids: Overview of the The National Crisis Fundamentals: Opioid Addiction The Opioid Crisis Canada, US, heaviest opioid users Relentless pharmaceutical pressure 0.5 - 3% of Canadians are currently using opioids April 14, 2016, British Columbia declares a public health emergency BC, overdose deaths will surpass deaths from motor vehicle collisions this year. Estimated 800 deaths in BC in 2016 Fundamentals: Opioid Addiction The Opioid Crisis In 2014, 700 opioid overdose deaths, ON ON, opioid overdose the #1 cause of death 24 – 35 50 000 individuals in OST tx in Ontario Only 12% of SUD receive tx Fundamentals: Opioid Addiction Opioids - America 2015, NIH estimates 9.4 million Americans take chronic opioids for “long term pain” (3% of population) Estimate 2.1 million have an opioid use disorder Fundamentals: Opioid Addiction The Opioid Crisis These deaths are preventable Iatrogenic: MD prescriptions are the major source of opioids, directly or through diversion Number of opioid deaths is very well aligned with the number of opioids dispensed to the population Fundamentals: Opioid Addiction Case: Anna 22 yo female Suffers from social anxiety disorder, panic disorder, severe ASI Prescribed opioids X 2 years Hydromorphone 40 mg PO (200 MED) Clonazepam 1 mg BID PO IVDU Supplements with street hydromorphone Fundamentals: Opioid Addiction Prescription Opioids 1991 – 2007 annual prescriptions of opioids increased from 458 – 591 per 1000 individuals Prescriptions of oxycodone increased by 850% between 1991 and 2007 Fundamentals: Opioid Addiction 9x increase in oxycodone-related deaths 14.00 Before addition of OxyContin onto public drug formulary After addition of OxyContin onto public drug formulary Number of deaths per 1 000 000 per year 12.00 12.93 11.24 10.00 8.40 8.00 7.17 5.78 6.00 4.03 4.00 2.91 1.64 2.00 0.76 0.65 1.71 1.02 1.94 1.51 1.39 0.10 0.00 1991 1992 1993* 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Dhalla et al CMAJ 2009 Fundamentals: Opioid Addiction Most deaths occur in people who were prescribed opioids 56% dispensed an opioid in the 4 weeks prior to death 82% dispensed an opioid in the year prior to death Median number of opioid prescriptions in year prior to death 10 prescriptions Fundamentals: Opioid Addiction Opioids: Physician Perspectives Fundamentals: Opioid Addiction Number of patients on opioids causing concerns Wenghofer 2010 Number of Patients Causing Concerns for FP None Percent of FPs (%) 15.1 1 – 3 47.9 4 – 6 23.4 7 – 9 6.4 10 or more 7.2 Fundamentals: Opioid Addiction FPs very concerned about… Concerns Running out early, demanding fit-in appointments, lost scripts Lack of specialized pain clinics Very concerned (%) 44.8 42.2 Getting patient addicted (n=641) 38.4 Patients getting high doses 28.0 Lack of addiction treatment resources 26.4 Disagreements with patients about opioids 22.0 Fundamentals: Opioid Addiction Opioids: Tolerance & Withdrawal Fundamentals: Opioid Addiction Opioid Addiction: Repeated drug positive reinforcement leads to dysfunction of the pain and reward pathways Opioids & all drugs act on ‘reward centre’ Tolerance and withdrawal develop Fundamentals: Opioid Addiction Tolerance Neurobehavioural adaptation Tolerance to analgesic effects develops slowly Rapid tolerance to psychoactive effects Tolerance disappears within days Fundamentals: Opioid Addiction Withdrawal: Symptoms Psychological: Intense anxiety Craving for opiates Restlessness, insomnia, fatigue Physical: Myalgias Nausea, vomiting, cramps, diarrhea, sweating Agitation, dilated pupils, chills, goosebumps Fundamentals: Opioid Addiction Withdrawal: Time Course Begins Peaks 1- 2 half lives after administration at 2-3 days Physical days symptoms largely resolve by 5-10 Insomnia months and dysphoria can last weeks to Symptoms quickly relieved with opioid use Fundamentals: Opioid Addiction Withdrawal Usually mild, transient in patients taking low to moderate doses for analgesia More severe in patients taking higher doses for psychoactive effects Fundamentals: Opioid Addiction Opioid Use Disorder: PREVENTION Fundamentals: Opioid Addiction Major cause of the increase… Prescribing higher doses of opioids to greater numbers of high risk people High risk patients more likely to experience euphoria or anxiety relief with opioids This may lead to tolerance, dose escalation, withdrawal and addiction Fundamentals: Opioid Addiction Prevention Risk stratify Use as trial only, limited evidence Use only in conjunction with strong non opioid pain management plan Opioid contract Provincial pharmacy databases, (Pharmanet, DSQ) UDS Monitor aberrant drug behaviour Fundamentals: Opioid Addiction When to taper Severe pain and poor function despite high dose Complications: Depression, fatigue, sleep apnea, sexual dysfunction, falls, osteoporosis, constipation, cognitive dulling, opioid induced hyperalgesia, overdose Fundamentals: Opioid Addiction How to taper Explain that tapering improves pain, mood and function During taper, ask about positive effects not just withdrawal Use scheduled doses Frequent dispensing with no early refills Taper by no more than 10% of dose q 2 weeks Also taper benzodiazepines Fundamentals: Opioid Addiction Opioid Use Disorder: DIAGNOSIS Fundamentals: Opioid Addiction Opioid Use Disorder: History Tolerance Withdrawal Cravings Use under hazardous circumstances Failure to meet obligations: work and family Failed attempts to cut back Ongoing use despite negative consequences Fundamentals: Opioid Addiction Laboratory Work Elevated AST, ALT (viral or alcoholic hepatitis) Gamma GT, MCV (alcohol) Hepatitis B, C HIV Fundamentals: Opioid Addiction Other Sources of Information Addiction is chronic relapsing remitting disease It is beneficial to obtain collateral information to make the diagnosis Other physicians Spouse, family Urine drug screen history Fundamentals: Opioid Addiction Red Flags for addiction Binge use (“unsanctioned dose escalations”) Early refills “lost” medications Alters route of entry chew, crush, snort, inject Accesses opioids from other sources Other doctors, the street Fundamentals: Opioid Addiction Why do patients do this? Overcome tolerance Achieve psychoactive effect of euphoria Avoid withdrawal Financial gain Fundamentals: Opioid Addiction Limitations of behaviour monitoring Patients will hide these behaviours These behaviours not always seen if physician prescribes higher doses Some patients take oral opioids without running out early yet experience psychoactive effects, withdrawal, dysphoria and decreased function Fundamentals: Opioid Addiction Urine Drug Screening Used for detection of: Diversion and non-compliance Use of other drugs such as cocaine, benzodiazepines Chronic Pain patients have high prevalence of unauthorized drug use on UDS, or absence of the drug they are prescribed Fundamentals: Opioid Addiction Types of UDS: Immunoassay Opioids, cocaine, benzodiazepines etc. Detects use for up to five days False positive and False negative are rare as the immunoassays become more sensitive and specific Some brands do not test for synthetic opioids Remember that heroin and codiene will show as morphine Fundamentals: Opioid Addiction Chromatography Depending on your lab, you have to specifically ask for synthetic opioids such as: Oxycontin Hydromorphone Fentanyl Buprenorpine Methadone Fundamentals: Opioid Addiction Opioid Use Disorder: TREATMENT Fundamentals: Opioid Addiction Management of Suspected Opioid Addiction Buprenorphine Methadone Fundamentals: Opioid Addiction Methadone treatment: Indications Opioid Use Disorder Patients with untreated opioid use disorder are at high risk of death, HIV, Hepatitis C, and crime Methadone decreases all of these negative outcomes Fundamentals: Opioid Addiction Methadone treatment Slow onset, long duration of action Relieves withdrawal, cravings without sedation or euphoria Can be monitored with UDS Fundamentals: Opioid Addiction Methadone Three components: Daily dispensing with gradual introduction of take-home doses Regular UDS Counselling and medical care Provincial College guidelines about methadone Rx who prescribes & how Fundamentals: Opioid Addiction Limitations of methadone treatment High risk of overdose early in treatment Optimal candidate is highly tolerant to opioids Not all communities have methadone providers Major commitment of time for patient and provider Fundamentals: Opioid Addiction Buprenorphine Suboxone (buprenorphine + naloxone) Sublingual partial opioid agonist Long duration of action As effective as methadone at doses above 16mg Lower risk of overdose than methadone (ceiling effect because partial agonist) Fundamentals: Opioid Addiction Abstinence-based treatments Medical detoxification Detox alone has been shown to increase mortality and increase HIV seroconversion NA, AA, and counseling have no evidence for benefit for Opioid Use Disorder Fundamentals: Opioid Addiction Addiction and pain: Paradigm shift MDs see pain treatment in opposition to addiction treatment ‘Patient is addicted but also has severe pain – if I stop opioids his/her pain will be unbearable’ Yet evidence shows this is false: Opioid addiction increases pain perception and depression, worsens function Patient’s pain, mood and functioning improves with treatment, by resolving withdrawal-mediated pain and opioidinduced depression Conclusion Chronic non-cancer pain does not generally benefit from opioids Patients with Opioid Use Disorder should be treated with Buprenorphine, or Methadone It can be hard to tell these two populations apart – it takes time, urine testing, and clinical acumen