Opioids part1-2010
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  • These questions will be addressed in this lecture.
  • Stafford J., & Burns, L. (2009). An overview of the 2009 IDRS: the Injecting Drug User survey preliminary findings. Drug Trends Bulletin, December 2009. Sydney: National Drug and Alcohol Research Centre, University of New South Wales
  • Degenhardt, L., Rendle, V., Hall, W., Gilmour, S. & Law, M. (2004) Estimating the size of a heroin using population after a marked reduction in heroin supply. Sydney, National Drug and Alcohol Research Centre, University of New South Wales.
  • Day C, Degenhardt L, Hall W. (2006) Changes in the initiation of heroin use after a reduction in heroin supply. Drug Alcohol Rev . 25(4):307-13
  • 1http://www.avert.org/transmission.htm Accessed November 2009. 2ASHM and NCHECR (2008) An overview of hepatitis C: Clinical management in opiate pharmacotherapy settings. Australasian Society for HIV Medicine Inc and National Centre in HIV Epidemiology & Clinical Research. 3 Dore et al. (2005) Hepatitis B in Australia: Responding to a Diverse epidemic. National Centre in HIV Epidemiology and Clinical Research.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • Dore et al. (2005) Hepatitis B in Australia: Responding to a Diverse epidemic. National Centre in HIV Epidemiology and Clinical Research and ACT-HBV Australia and New Zealand Local Chapter.
  • Dolan, K. (1997) AIDS, drugs and risk behaviour in prison: state of the art. IN NEDLES, J. & FUHRER, A. (Eds.) Harm Reduction in Prison. Bern, Peter Lang. Dolan, K. A. (2001) Can Hepatitis C transmission be reduced in Australian prisons? Medical Journal of Australia, 174, 378-379.
  • Photograph courtesy of Dr Kate Dolan.
  • WHO (2004) Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users. Evidence for Action Technical Papers. World Health Organisation, Geneva, Switzerland.
  • 1National Centre in HIV Epidemiology and Clinical Research (2003) Australian NSP Survey National Data Report 1995-2002. National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, NSW. 2National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • 1DOLAN, K. A. (2001) Can Hepatitis C transmission be reduced in Australian prisons? Medical Journal of Australia, 174 , 378-379. 2DOLAN, K. A., SHEARER, J., WHITE, B., ZHOU, J., KALDOR, J. & WODAK, A. D. (2005) Four-year follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection. Addiction, 100 , 820-828.
  • Leong M, Murnion B, Haber PS. Examination of opioid prescribing in Australia from 1992 to 2007. Intern Med J . 2009 Oct;39(10):676-81.
  • Australian Institute of Health and Welfare 2008. 2007 National Drug Strategy Household Survey: first results. Drug Statistics Series number 20.Cat. no. PHE 98. Canberra: AIHW

Opioids part1-2010 Opioids part1-2010 Presentation Transcript

  • Opioids Part 1 Epidemiology of illicit use Complications Prescription opioid use © 2010 University of Sydney
  • Learning Objectives
    • To be able to:
    • Describe the prevalence of illicit opioid use and dependence
    • Understand the complications of injecting drug use, including opioids
    • Describe the prevalence of prescription opioid use
    • Explain how to prescribe opioids responsibly to reduce risk of iatrogenic dependence
  • Overview
    • Epidemiology of illicit opioid use
    • Factors affecting substance use
    • Complications
      • Psychosocial
      • Medical
        • Viral infections
        • Overdose
        • Prevention
    • Prescription drug use
    • Responsible prescribing of opioids
  • Mr. J
    • Mr J, aged 24 , was recently released from jail
    • Commenced illicit drug experimentation at age 12
    • No home or major personal problems, just fell in with friends that were ‘into things’
    • Intermittent heroin use (mainly using stimulants) from age 14 to 19, then daily heroin use; dependence ensued
    • Questions:
      • How common is heroin use?
      • Who is more likely to develop problems with heroin?
      • What are the associated risks?
  • Epidemiology of substance abuse
    • Prevalence
    • Patterns of use
    • Recent trends
  • Assessing Prevalence of Drug Use
    • Household surveys of representative samples
    • Illicit Drug Reporting Scheme
      • Utilises multiple sources of users and their contacts
    • Consequences
      • D eaths, treatment seeking, crime
  • Life-time prevalence of drug use in Australia 2007
    • Note: Heroin: 1.6% (0.3 million); Mean age of initiation of life-time use: 29 years.
    • Household surveys underestimate use of stigmatised substances
    • Data Source: AIHW (2008) 2007 NDS Household Survey
  • Lifetime use of heroin (by age and gender) Data Source: AIHW (2008) 2007 NDS Household Survey
  • Recent use of heroin Data Source: AIHW (2008) 2007 NDS Household Survey
  • Recent use of heroin
    • Males are more likely than females to have used heroin in the last 12 months
      • ♂ 0.3% vs ♀ 0.1%
      • or ♂ 25,900 vs ♀ 10.300
    • The highest proportion of recent users found among 20-29 y.o. males
      • 0.7% (10,700)
    AIHW (2008) 2007 NDS Household Survey
  • Heroin - patterns of use
    • Most users inject heroin
      • However, a significant proportion ‘smoke’ heroin, inhaling the vapour. Known as ‘chasing the dragon’
    • Polydrug use is common
    • Experimental and recreational use more common than dependent use
      • Risks - especially of Hep C and overdose
    • Long-term dependent user has the largest impact on public health and order
    • Dependent use
      • usually daily use by injection (1-2 years from 1 st use to daily use)
  • Heroin use among Injecting Drug Users (IDUs)
    • 2009 National sample: N=881
    • Heroin is the drug of choice (52% of IDUs)
      • 64% of heroin users inject ~ 3 times a week (in the last six months)
      • 15% use daily
    Stafford J., & Burns, L. Drug Trends Bulletin, December 2009. (NDARC)
  • Estimated number of heroin dependent users in Australia Data source: Degenhardt et al 2004, NDARC
  • Dependent heroin users
    • Dependent heroin users
      • 65% male; age varies (median 30-35 years); evidence of aging cohort in Australia
      • >90% English speaking
      • Indigenous 10-15%
      • Imprisonment ~50%
      • Unemployment/pension >80%
      • Homelessness ~10%
    Day C, et al (2006) Drug Alcohol Rev. 25(4):307-13
  • Complications Drugs Social Medical Psychological
  • Psychosocial complications of heroin use
    • Generally severe. Why?
      • Illicit
      • Stigmatized
      • Expensive
      • Grossly intoxicating
    • (contrast with tobacco)
  • Social consequences
    • Illicit nature
      • Imprisonment rate up to 50%
      • (60% of prisoners are incarcerated for drug-related crime, 20% for alcohol-related crimes)
    • Stigmatised
      • Alienation from parents, spouse and children
      • Discrimination in workplace, health care
    • Expensive : $50-200 per day
      • Involvement in crime (theft, dealing, importation)
      • Prostitution
      • Homelessness and debt to unscrupulous drug dealers predispose users to becoming victims of violent crime.
    • Intoxication
      • Inability to complete education or keep jobs
      • Difficulties caring for children; family breakdown may result
  • Medical complications
    • Non-specific to opioids
      • Infections
        • Viral*, bacterial, fungal
      • Vascular damage
        • Venous, arterial, pulmonary
      • Glomerulonephritis
        • Not common, but severe complication of injecting drug use
      • Rabdomyolysis and acute renal failure
        • Not common, but severe complication resulting from compartment syndrome (caused by prolonged period of unconsciousness)
      • Malnutrition
      • Trauma
    * Major causes of harm - discussed in this topic
  • Medical complications (cont)
    • Specific to opioids
      • Overdose *
      • Dental caries
        • Mostly due to suppressed secretion of saliva
        • May cause acute or chronic pain, dental infections
    * Major causes of harm - discussed in this topic
  • Infections due to IDU
        • Viral
          • Caused by blood borne viruses (BBV)
          • HIV/AIDS, Hepatitis C (HCV), Hepatitis B (HBV)
        • Bacterial
          • Abscess, cellulitis, necrotising fasciitis, thrombophlebitis
          • Pneumonia
          • Endocarditis: R>L sided, Staph Aureus
        • Fungal
          • Mostly Candida albicans, local or systemic
  • Viral Infections: Prevalence in IDUs
  • Transmission of viral infections: Needle sharing
    • Sharing needles and other injecting equipment or “works” (syringes, spoons, filters and blood-contaminated water) is an important route of transmission of the blood born viral infections
      • Is three times more likely to transmit HIV than sexual intercourse 1
      • Is the most common mode of HCV transmission 2
      • Is the most common risk factor for HBV in adults 3
    • Needle sharing has reduced with introduction of Needle and Syringe Programs (NSP)
    1 Avert.org (2009). 2 ASHM and NCHECR (2008) An overview of hepatitis C: Clinical management in opiate pharmacotherapy settings. 3 Dore et al. (2005) Hepatitis B in Australia: Responding to a Diverse epidemic. (NCHECR)
  • Needle sharing (2004-2008) Source: NCHECR (2009) Australian NSP survey: National data report 2004-2008
  • HIV antibody prevalence in IDUs (Australia)
    • HIV prevalence low: 1.5%
      • Lower that in parts of USA, UK, Europe and Asia
      • Reduced due to NSP, peer education and opioid maintenance programs
    • Prevalence is higher in:
      • Homosexual males
      • Predominantly methamphetamine users (reporting as last drug injected), compared to heroin
    NCHECR (2009) Australian NSP survey: National data report 2004-2008
  • HIV prevalence by gender and sexual identity Source: NCHECR (2009) Australian NSP survey: National data report 2004-2008.
  • HIV prevalence by drug last injected NCHECR (2009) Australian NSP survey: National data report 2004-2008
  • HCV antibody prevalence in IDUs
    • HCV prevalence high, stable at 62%
      • Transmission reduced but not prevented by NSP
      • Higher prevalence pre-NSP, compared to HIV
    • Prevalence higher in users who are:
      • Older that 30 years of age and with a longer history of injecting
        • 20% among those injecting for less than one year
        • 50% - injecting for 8 or 9 years
        • 75% - injecting for 20 years or longer
      • Using predominantly heroin (reported as last drug injected compared to those reporting methamphetamine)
      • Imprisoned in the year prior to survey
      • From Indigenous background
    NCHECR (2009) Australian NSP survey: National data report 2004-2008
  • HCV prevalence by years of IDU NCHECR (2009) Australian NSP survey: National data report 2004-2008
  • HCV prevalence by drug last injected NCHECR (2009) Australian NSP survey: National data report 2004-2008
  • Hepatitis B in IDUs 1
    • More than 40% of acute hepatitis B cases result from unsafe use of injecting drugs
    • Risk related to duration of injecting: up to 50% HBVcAb+ in long term users
    • Less government support compared to programs aimed at reduction of HIV and HCV
    • Vaccination of IDUs against HBV is available and should be strongly recommended.
    1 Dore et al. (2005) Hepatitis B in Australia: Responding to a Diverse epidemic.
  • Intravenous Drug Use in prison
    • High risk practices persist
      • 75% continue some IDU in prison
      • 80% share needles in prison (cf 20% in community)
      • 10% of prison-IDU started in prison
      • High number of injecting partners
        • 5 partners inside v 1 outside
    Dolan, K. (1997) in Harm Reduction in Prison, Nedles & Fuhrer (Eds.); Dolan, K. A. (2001) Medical Journal of Australia, 174, 378-379.
  • IDU in prison: Confiscated needles and syringes
  • Source: Mouzos J and Smith L (2007) Of Substance, 5(4):21. Reprinted with permission.
  • Mental Health
  • Mental Health
    • Mental health problems are common among opioid users.
    • Related to dependence and associated lifestyle
    • Complex relationship and interaction between mental health and dependence
  • Prevalence
    • Prevalence of mental health problems among opioid dependent treatment seekers
      • Suicide
        • 34% lifetime history of attempted suicide
        • 13% attempted suicide in the last 12 months 1
      • Depression
        • 25% reported current major depressive episode2
      • Post traumatic stress syndrome (PTSD)
        • 92% exposed to trauma
        • 41% lifetime PTSD3
    1 Darke, S. et al (2004) Drug and Alcohol Dependence , 73, 1-10. 2 Teesson, M. et al (2005) Drug and Alcohol Dependence , 78, 309-315. 3 Mills, KL et al (2005) Drug and Alcohol Dependence , 77, 243-249.
  • Opioid Overdose: Risks and fatality rates
  • Opioid overdose
    • Relatively common among heroin and other opioid users
    • Life-threatening
    • Death from respiratory depression
  • Risk factors for opioid overdose
    • Polydrug use:
      • Concurrent alcohol & benzodiazepines use
      • Common in fatal and non-fatal overdoses
    • Variable purity (not the major factor)
    • Reduced tolerance to opioids
      • e.g. recently released from prison, not on treatment program
    • Injecting alone (common in fatal overdoses)
    • Not seeking help
      • Absence of others or fear of police involvement
    • Ineffective interventions often tried first by bystanders
  • Rates of heroin overdose
    • High in Australia in 1997-1999
    • Significant reduction in 2001, consistent with reduced availability of heroin
    • Overdose remains a major cause of heroin-related harm
  • Fatal opioid overdose rate Source: Drug and Alcohol Office, Government of Western Australia (2008) Overview of Trends in Opioid Related Mortality . Statistical Bulletin No. 40, February 2008, p.3.
  • Prevention of medical complications
  • Preventing and reducing harm from injecting heroin use
    • Non-injecting route of administration
    • Advice on safe injecting
      • Professional or peer education
    • Needle Syringe Programs (NSPs)
    • Medically Supervised Injecting Centre
    • Overdose interventions
    • Hep B Vaccination
    • Treatment programs
  • Needle and Syringe Programs (NSP)
    • One of the principal harm reduction measures
      • Aim to curb the spread of HIV among injecting drug users
      • First program established in Amsterdam in 1983
      • Now exist in more than 40 countries
    • Provide access to sterile syringes to reduce the risk of IDUs coming into contact with other users’ infected blood
    • Reduce the number of new HIV diagnoses without encouraging drug use
    • Have potential to increase recruitment into drug treatment and into primary health care
    WHO (2004) Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users.
    • Commenced 1986
    • Widespread and publicly funded
    • Bipartisan support
    • General public support 1
    • Fixed site, outreach, vending machines and pharmacy
      • Public, private and NGO operated
    • Distribution rather than exchange
    NSPs in Australia 1 Treloar & Fraser (2007) Drug Alcohol Rev, 26: 355-361
  • NSP outcomes in Australia
    • Number of distributed needles and syringes increased during the past decade (from ~27 million to ~31 million)
    • Needle sharing by IDUs reduced:
      • ~30% of users in 1995 1
      • ~10-20% in 2004, stable since then 2
    • Effectiveness of NSPs (2000-08) 2
    • NSPs have directly averted:
    • • ~30,000 new HIV infections
    • • ~100,000 new HCV infections
    • Annual national incidence of HIV and HCV among IDUs decreased:
      • HIV - from 39 to 24
      • HCV - from ~13,000 to ~8,000
    1 NCHECR (2003) Australian NSP Survey National Data Report 1995-2002. 2 NCHECR (2009) Australian NSP survey: National data report 2004-2008.
  • Overdose interventions
    • Peer education
      • Avoid polydrug use
      • Avoid injecting alone
      • Call an ambulance
    • Naloxone administration
    • Protocols to limit police intervention at overdose resuscitation
    • Supervised injecting rooms
  • Treatment Programs in Prison
    • Assessment of dependence
    • Management of intoxication and withdrawal
    • Education, counselling
    • Opioid Treatment Programs (OTP)
      • Those who remain in OTP 8/12 post -release have significant reduction in recidivism & mortality 1&2
    1 Dolan, KA (2001) Medical Journal of Australia, 174, 378-379. 2 Dolan, KA et al (2005) Addiction, 100, 820-828.
  • Prescription opioid use and responsible prescribing
  • Prescription opioid use
    • Significant increase in number of prescriptions for codeine in the 1990s, peaking in 1999, use now declining
    • Dramatic rise in the use of oxycodone between 2001 and 2007 1
      • Increasing steadily (by ~20% per year) since 2001
      • Sharp increase in 2001-02 when generic oxycodone sustained release became available
    • Increase in the use of tramadol between 2001 and 2004 (plateau in 2004-2007) 1
    • Major harms:
      • Spread of opioid dependence
      • Risk of overdose
      • Risks associated with non-sterile injection and needle sharing
    1 Leong M et al (2009) Intern Med J, 39(10):676-81.
  • Illicit use of prescription analgesics, including opioids Data source: AIHW 2008. 2007 National Drug Strategy Household Survey Prevalence of prescription drug use for non-medical purposes (Use in the last 12 months, proportion of the population aged 14 years or older, Australia.)
  • Responsible prescribing of opioids
    • Prolonged regular opioid use leads to tolerance and risk of dependence
      • Avoid use for chronic, non-terminal conditions
      • Avoid parenteral opioids for recurrent conditions such as migraine, back pain
      • Be very cautious in prescribing opioids to patients you don’t know
    • BUT: do manage pain compassionately, even in those with opioid dependence
  • Alternative treatments
    • Non-steroid anti-inflammatory analgesics
    • Psychological and other management of pain: e.g. via Pain Clinic
    • Has the cause been adequately treated?
    • Consider a drug and alcohol referral for iatrogenic dependence or mixed iatrogenic/abuse picture?
  • Medical prevention issues
    • Responsible prescribing
      • Daily dispensing where potential for loss of control over use
    • Recognise and manage drug-seeking behaviour
      • Illegal to prescribe S8 drugs to patients with known addiction to these drugs
      • Say ‘no’ (promptly and courteously: ‘I’m not allowed’, ‘I don’t prescribe … to patients I don’t know’)
    • Early referral to treatment in a D&A service
  • Legal controls on prescribing (NSW)*
    • Cannot prescribe opiates where there is known dependence without an authority
    • Methadone and buprenorphine for opioid dependence
      • Can only be prescribed by authorised doctors (or nurse practitioners) and with a NSW Health authority for each case
    *It is important to check your local laws and all laws for accuracy, as they may change.
  • Avoiding deliberate misuse/diversion
    • Scripts for opiates are usually faxed to chemist if there is risk of tampering
    • Dose in numerals and words
    • Controlled dispensing (daily, weekly or similar) from chemist or clinic makes dose escalation or diversion less likely
      • Can be arranged for any medication with a willing pharmacy
      • Sometimes a small fee involved
  • Case study: Jane
    • Jane is aged 36, and presents because panadeine forte (contains codeine 8mg) is no longer controlling her back pain
    • She is using 40 tablets per day
    • Questions:
      • What are the risks of her panadeine forte use?
      • Can you suggest a better treatment?
  • Jane: Answers
    • 40 tabs = approx 7 tabs every four hours
      • Risk of paracetamol-induced hepatic damage
      • Opioid dependence
    • Jane would be better on a long-acting opioid, if she is unable or unwilling to cease: e.g. methadone or oxycontin
    • Daily dispensing will help prevent dose escalation
    • Authority required
    • Pain Clinic referral may be useful
  • Conclusion (1)
    • Prevalence of heroin dependence in Australia is low (<1%)
    • Heroin use is associated with significant medical and psychosocial complications, especially when injected.
    • Sharing of injecting equipment is the major vector for transmission of blood bourn viral infections.
    • Introduction of NSPs has prevented the epidemic of HIV, but did not significantly reduce prevalence of HCV infection in Australia
      • Prevalence of HIV antibodies in IDUs is low (1.5%)
      • Prevalence of HCV antibodies remains high (65%) but stable
    • HBV antibodies are present in up to 50% of long term IDUs
    • Vaccination against HBV is strongly recommended.
  • Conclusion (2)
    • Mental health problems are common among opioid dependent people (e.g. depression, suicidal ideations, PTSD)
    • Opioid overdose is the major cause of heroin-related harm
    • Use prescription opioids with caution because prolonged administration leads to tolerance and risk of dependence
    • Recognise and manage drug seeking behaviour appropriately
    • Provide adequate pain relief especially in people with opioid dependence
  • Contributors
    • Associate Professor Kate Conigrave
    • Royal Prince Alfred Hospital & University of Sydney
    • Dr Ken Curry
    • Canterbury Hospital & University of Sydney
    • Dr Carolyn Day
    • University of Sydney
    • Professor Paul Haber
    • Royal Prince Alfred Hospital & University of Sydney
    • Dr Olga Lopatko
    • University of Sydney
    • Professor Richard Mattick
    • National Drug and Alcohol Research Centre,
    • University of New South Wales