Prescription drugs first do no harm update

First Do No Harm
Responding to Canada’s Prescription
Drug Crisis
An update specific to First Nations,
Remote/Isolated and Rural
Communities and Implementation of
this national strategy

About CCSA
• Vision: All Canadians should live in a healthy
society, free of alcohol- and drug-related
harm
• Mission: Provide national leadership and
advance solutions to address alcohol and
other drug-related harm
• National non-profit, non-governmental
organization
• Pan-Canadian and international role
2
www.ccsa.ca • www.cclt.ca

About NNAPF
Vision:
Cultivating and empowering
relationships that connect us to our
cultural strengths and identity within
holistic and healthy communities.
Mandated to:
• Advocate on behalf of & support
addictions programming for First
Nations and Inuit
• Leadership role in implementing the
Honoring Our Strengths: A Renewal
Framework to Address Substance
Use Issues Among First Nations in
Canada
Culture, Respect, Community, Compassion
www.nnapf.com

Prescription Drug Abuse
• What issues are specific to First Nations
Communities?
• What efforts have you developed to address these?
• What challenges have emerged in addressing the
issue?
• What are the next steps?
• What advise can you give to the national level that
would support regional and community efforts?
CCSA.NNAPF

• 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
• Limited access to national data/research, generally and for specific
populations (e.g., Inuit, seniors, corrections, military) or effective
solutions
CCSA.NNAPF 5
A Complex Social Issue

• Involves
– A diverse group of stakeholders with potentially competing interests
• Governments; healthcare practitioners; patients & families; First Nations, Inuit, &
Metis; enforcement; regulators; researchers; industry
– Involves other complex issues such as pain, mental
health/intergenerational trauma, addictions, social determinants of
health, access to and availability of equitable health services
– First Nations, youth, women, rural/remote communities experience
Issues of health equity and are affected differently
– 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 6
A Complex Social Issue
CCSA.NNAPF

Prescription Drug Issues Among
First Nations in Canada
• Non-Insured Health Benefits (NIHB) program show that 898 opioid
prescriptions were dispensed per 1,000 First Nations individuals aged 15
and older in Ontario in 2007, with 119 prescriptions for oxycodone
formulations alone (Health Canada, 2010)
Changes made under the NIHB program have led to a 50% reduction in the
amount of long-acting oxycodone provided since 2010 and no significant shift
in other opioids (Health Canada, 2012c). These measures include:
• Monitoring prescriptions to identify potential harms and prevent double-
doctoring;
• Establishing maximum monthly and daily drug limits;
• Changing the listing status of extended release oxycodone to exception
status;
• Real-time warning and claims rejection messaging to pharmacists at the
point of sale; and
• Establishing an external, expert drug and therapeutics advisory
committee.
CCSA.NNAPF

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)
8CCSA.NNAPF

The Mandate from First Nations
• Resolutions passed at both AFN Annual General
Assemblies and Special Chief Assemblies
• Honouring Our Strengths: A Renewed Framework
to Address Substance Use Issues Among First
Nations in Canada
• Regional and National Concerns – Atlantic,
Saskatchewan, Alberta and Chief of Ontario,
Assembly of First Nations Resolutions
• Prescription Drug Abuse Coordinating Committee
• First Do No Harm National Advisory Council
CCSA.NNAPF

Unintended Consequences of
Prescription Drugs on First Nations
1. Community Capacity
2. Withdrawal Management & Pharmacological
Interventions
3. Neonatal Abstinence Syndrome
4. HepC, HIV, Aids
5. Violence and Crime
6. Increased pressure on the health care system
7. Stigma and Discrimination
8. Child Welfare and Family Functioning
CCSA.NNAPF

Community Capacity
Issues:
• not enough mental health and addictions workers in First Nations communities
• Residential Treatment programs (NNADAP and YSAP) are faced with a lack of resources to ensure they
have the right set of skills and service capacity to support opiate replacement therapy
• high number of children with behaviour issues related to opiate addiction within the family – pressures on
school and community
• clients on methadone do not get accurate information regarding the care pathway that can lead to getting
off of methadone altogether
• A poor relationship with health care generally leaves First Nations people more vulnerable to physicians as
figures of authority and therefore less likely to question courses of treatment
Strategies:
Where communities have taken a culturally relevant community development approach to addressing
prescription drug issues, there has been community wide success – observed in the following ways:
1. Family relationships improved: more quality care for children
2. Family resources redirected from drug use (80% of income) to family functioning (food available in the
home, home furnishings and children’s toys restored)
3. Reconnection to culture and First Nations identity, predicting maintenance of wellness more long term
4. Pooled resources across community programs and services, increasing more coordinated efforts across
programs and services but these efforts first required additional resources to initiate and manage this
process
5. More effective partnerships and better care management for clients on methadone orsuboxone when
program is delivered in a First Nations community with support of community health programs
CCSA.NNAPF

Withdrawal Management &
Pharmacological Approaches
Issues:
• From 2000 to 2010, NIHB’s methadone claimants (using the simple definition)
increased from 598 in 2000 to 6,038 in 2011 (11-year annualized growth rate: 23%).
• In 2012, the utilization of Suboxone® increased, from 41 clients in 2011 when NIHB
policies made the drug available by “exception” to a projected 750 in 2012.
• Cost per client annually for opiate replacement therapy as reported by NIHB in 2012
suggests that methadone averaged at 1400.00 and Suboxone® at 1200.00
• Policies around Suboxone® (available by exception) limit community ability to
respond in a way that best reflects the First Nations community capacity to manage
client daily transportation to obtain methadone & continuing care
• Withdrawal itself poses increased risk of suicide and overdose
• Limited to no access to withdrawal management programs off reserve
Strategies:
• Community based programs designed with cultural interventions and Suboxone®
have improved wellness and many non-opiate users were motivated to work on
mental health and substance use related issues. Community wide healing was
inspired through the community & culturally based strategy to address opiate
addiction
CCSA.NNAPF

Neonatal Abstinence Syndrome
Issue:
• The prevalence has increased significantly over time from 171 in 2003 to 654 cases
in 2010.
• Rates for NAS are five times higher among infants born to mothers who delivered
their first child prior to age 19 compared to mothers who were older at first
delivery.
• At least 20% of First Nations births are to teenaged mothers.
• It is critical to streamline access to buprenorphine (Subutex®). Approved by
exception which often takes several weeks. An untreated opiate dependent
mother and her baby is a critical trauma to First Nations communities.
• Pregnant women addicted to opioids tend to deliver earlier and faster. They also
need postnatal care that is close to home. This is a significant issue for members
of rural, isolated and remote communities.
• Babies on methadone often require hospital stays for up to a month after birth.
Strategies:
Research indicates that the issues with neonatal abstinence are lessened with
Subutex®, including shorter hospital stays.
CCSA.NNAPF

HepC/HIV/AIDS
Issues:
• This progression from oral to nasal to intravenous use of “oxys” is a
consistent story among those seeking help to address the addiction.
• Risks associated with injection drug use include the spread of blood-borne
infections such as HIV and hepatitis C, as well as secondary complications
such as injection site infections.
• injection drug use accounted for 58.8% (compared to 14% in general
Canadian population) of HIV-positive test reports
• Aboriginal people experienced HIV at rates about 3.6 times higher than
other Canadians in 2008 & nearly two-thirds (65.7%) of people who inject
drugs had evidence of past or current hepatitis C infection
• 25.5% of men and 29.9% of women reported that they began to inject
drugs at age 16 or younger
Strategies:
• Needle exchange programs
• Access to opiate replacement therapy
CCSA.NNAPF

Violence and Crime
Issues:
• A growing number of First Nations have associated elevated rates of prescription drug
misuse/abuse with increased levels of violent criminality, illicit prescription drug trafficking,
other forms of abuse, and suicide within their communities
• Communities have reported that the main targets for drug trafficking, smuggling and playing
the role of the “mule” are vulnerable youth. Women and children have been sexually
exploited to feed prescription drug abuse habits
• There are consistent reports of increased break-ins and robberies of homes in First Nations to
finance drug use.
• People suffering from cancer/vulnerable populations become victims of extreme abuse and
other crimes which often leave these populations without the drugs they need to manage
their pain; also increasing risk of harm to palliative care workers in First Nations homes.
• At the same time there have been reports of elderly people selling their own medication for
profit.
Strategies:
• The $2,389,319 in federal (Public Safety Canada) funding over five years for Project Journey, a
crime prevention project that will help Aboriginal youth in Pikangikum First Nation is a good
start
• Youth in treatment report a connection to culture made the biggest difference in their
healing CCSA.NNAPF

Increased pressure on the health care
system
Region 2008/2009 emergency visits 2010/2011 emergency visits
All of Ontario 2.6 for every 10,000 people 3.7 for every 10,000 people
Northern Ontario only 9.2 for every 10,000 people 22.9 for every 10,000 people
First Nations 12.1 for every 10,000 people 55 for every 10,000 people
• Almost 250 per cent increase in the number of emergency room visits
related to narcotics withdrawal, overdose, intoxication, psychosis,
harmful use and other related diagnoses.
• First Nations communities health stations are usually solely staffed by
nurses. These nurses may not have adequate resources or expertise to
deal with the demand for addiction or pain treatment.
Strategies:
• Further planning and community development
• Physician education in pain management
• Ongoing capacity for First Nations organizations who support First
Nations communities in responding to the PDA crisis
Issues:
CCSA.NNAPF

Stigma and Discrimination
Issues:
• People who have experienced addiction often encounter stigma
and discrimination associated with their drug use in many places –
in health care, in the community, within the family and at the
workplace
• Stigma and discrimination may prevent people from accessing or
maintaining necessities such as housing, relationships, employment
and health care. It may even prevent people from admitting that
they have a substance misuse problem, especially if they began
taking opioids for pain management reasons.
• Stigma and discrimination is even more challenging for women and
most significant for pregnant women.
Strategies:
???
CCSA.NNAPF

Child Welfare and Family
Functioning
Issues:
• Addiction can have a profound impact on the relationship between parent
and child and can affect a parent’s ability to provide adequate care.
Neglect or abuse associated with substance abuse and addiction is one of
the main reasons child welfare agencies intervene
• A family environment characterized by intergenerational trauma, grief and
loss will also be characterized by an erosion of cultural values visible
through inadequate child rearing, disengagement from parental/family
responsibilities, violence, abuse, and the problematic use of substances
are all risk factors that contribute to alcohol and drug abuse.
• Lastly the epidemic needs to be understood as the self-medication efforts
to alleviate the suffering of intergenerational trauma and current social
conditions and poverty experienced in our communities.
Strategies:
• Decolonization through education and early intervention programs
CCSA.NNAPF

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
19CCSA.NNAPF

• Pan-Canadian strategy
• 58 recommendations
• 7 Implementation Teams
• Prevention
• Education
• Treatment
• Monitoring & Surveillance
• Enforcement
• Legislation & Regulations
• Evaluation & Performance Measurement
• 1st yr of implementation phase completed
First Do No Harm:
Responding to Canada’s Prescription Drug Crisis

FDNH National Advisory Council
• Multi-sectoral cross-section of organizations in
Canada with a role in responding to the PDM crisis
– Healthcare
– Governments
– First Nations
– Individuals and Families
– Research
– Industry
• Membership reflects complexity & commitment to
coordinated action
22

First Nations and First Do No
Harm
• Early in the development of the strategy, CCSA formed a strategic
partnership with Health Canada’s First Nations and Inuit Health Branch
(FNIHB) and the Assembly of First Nations to address prescription drug
misuse.
• FNIHB had an existing Prescription Drug Abuse Coordinating Committee
and was planning to produce a national strategy for First Nations and
Inuit populations.
• This partnership ensured a comprehensive approach to the issue for
Canada and avoided duplication of effort
• NNAPF and AFN
– were actively involved in the development of FDNH
– wrote Strategy Linkages with First Nations Issues and Activities section of
the strategy
– continue their involvement in the Strategy’s implementation

First Nations and First Do No
Harm
• First Nations health is widely understood to be affected by a range of
historical and culturally-specific factors (sometimes referred to as First
Nations- or Aboriginal-specific determinants of health), which include:
– colonization
– loss of language and connection to the land
– residential school abuses
– systemic racism
– environmental destruction
– cultural, spiritual, emotional, and mental disconnectedness
• Unresolved trauma and intergenerational trauma presents difficulty in
distinguishing psychological and physical pain
• Many First Nations communities aim to achieve wellness, which is distinct
from the often-medicalized model of “health” in that it is holistic and
promotes an equal balance of mental, physical, emotional and spiritual
aspects of life.

Governance Structure
Implementation phase
25

FDNH in Action since Launch
• 20 partner organizations added since launch / total 50 at the table
ongoing
• Annual NAC meeting in March 2014 reviewed progress & maintain
momentum
• Implementation Teams have identified 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 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

Prevention Team achievements (Y1)
Co-chairs: Dr. Brian Emerson & Anne Bowlby
• Overdose Prevention
– Participated in Second Chances study - effectiveness of take-home naloxone
– Conducted literature search - overdose death prevention programs
– Initiated scan of provincial corrections services OD death prevention
programs
– Linked with Correctional Investigator of Canada
– Reviewed: Deaths in Custody and An Investigation of the Correctional Service
of Canada’s Mortality Review Process
• Prescribing practices
– Identified policies to guide a scan/literature review
• Community capacity development
– Partnership initiated with Federation of Canadian Municipalities

Prevention Team priorities (Y2)
• Promote appropriate prescribing practices
– Literature review & environmental scan to identify existing policies &
programs, & their effectiveness
• Promote public awareness, knowledge, skills & behaviors
– Scan of social marketing campaigns including safe storage & disposal
– Advise HC on development of campaign(s)
• Overdose & overdose fatality prevention
– Secure new partnerships
– Scan of existing activities

Education Team achievements (Y1)
Co-chairs: Dr. Norm Buckley & Dr. David Mock
• Developed Competencies for Health Professionals in Pain Management, Drug Prescribing,
Dependency, Addiction & Abuse
• Identified key stakeholders - health education, accreditation bodies, regulatory bodies,
faculty associations & professional associations
• Completed scan of continuing education opportunities in pain management, prescribing
practices, dependency, addiction & abuse

Education Team priorities (Y2)
• Finalize Competencies for Health Professionals in Pain Management,
Drug Prescribing, Dependency, Addiction & Abuse
• Develop continuing education programs for health practitioners to
reflect the competencies
• Conduct a gap analysis to identify missing curriculum content and
revise healthcare professional curricula to reflect the competencies

Treatment Team priorities (Y1)
Co-chairs: Dr. Peter Selby & Dr. Ramm Hering
• Scan of existing guidelines by province & territory
– Mental health
– Pain
– Addiction
• Develop 4 treatment pathways
– Pain
– Misuse of pain medication
– Addiction
– Pain and Addiction
• Identify, develop, evaluate & implement effective evidence-informed SBIRT Resources

Monitoring & Surveillance Team achievements (Y1)
Chair: Dr. Beth Sproule
• Established links with FPT Prescription Drug Abuse Working Group
– Hosted conference (May 22-23, 2014), with funding from NS, resulting in
• Consensus on a vision for the future for a national surveillance system for
prescription drug
• A plan for building on existing initiatives to achieve this goal
• An action plan for moving forward on developing a PMP network for Canada
• Conducted Canadian PMP review (in progress)
• Involved in Health Canada substance use population survey core
indicator consensus process (in progress)
• CRISM grant application & success (CIHR research network grant)
• Meeting with RADARS director and CCSA

Monitoring & Surveillance Team priorities (Y2)
• Establish core indicators & key elements of a Canadian
prescription drug surveillance strategy
• Working in collaboration with FPT working group
– Establish a Canadian prescription monitoring program community
of practice
– Establish a Canadian prescription monitoring program research
network

Enforcement Team achievements (Y1)
Co-chairs: Chief Mark Mander & Micheline Lavoie
• National Prescription Drug Drop-Off Day
– 1st Annual - May 11, 2013
• Over 2 tons of medications were dropped off nation-wide
– Secured funding for Coordination (at CACP) for 2014 event
– Developed an Evaluation Toolkit to assist evaluation (AB Health)
– 2nd Annual event – May 10, 2014
• Preliminary results: over 2600 pounds returned
• Cost-impact Assessment completed (not yet released)
– Will be made available in both official languages by Summer 2014
• Workshop associated with development of practice guidelines for death
investigations

Enforcement Team priorities (Y2)
• Annual National Prescription Drug Drop-Off Day
• Awareness raising and outreach to key law enforcement &
criminal justice stakeholders
• Use results from the cost-impact assessment of prescription
drug misuse on Canadian law enforcement and criminal
justice system
• Development of guidelines for death investigations in
Canada

Legislation & Regulations Team achievements
(Y1)
Co-chairs: Cameron Bishop & Dr. Mel Kahan
• Submitted letter to Health Canada regarding:
– new medication approval
– product monograph review
• Scanned initiatives in Ontario (not under FDNH umbrella) on:
– Naloxone
– Buprenorphine in First Nations communities
– Prescribing limits for opioids (ODB)
– New pain medications

Legislation & Regulations Team priorities (Y2)
• Work with Health Canada to strengthen regulatory oversight of
medications with addiction potential
– Ensure that risk of addiction is considered before approving new meds (e.g., Zohydro)
– Ensure that product monographs provide accurate information on indications,
precautions and dosing
• Work with NIHB, provincial funders & medical regulators to ensure access
to medications to treat addiction and reduce overdose deaths, especially:
– Methadone, Buprenorphine, Naloxone
• Work with funders & medical regulators to reduce harms from prescribing
high opioid doses to high-risk patients
– Funding mechanisms: Limited Use codes, Exceptional Access programs
– Medical regulators: Opioid prescribing standards

Next Steps
• Work to secure funding to support the strategy Implementation Teams
– 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
• Finalize evaluation plan to assess impact and change
• Release FDNH Annual Report – June 2014

Opportunities for collaboration
• What are your related priorities and activities and how can the work of
the Implementation Teams be of help to you?
• Where can CCSA support your efforts in addressing the harms
associated with prescription drugs
• What opportunities exist for CCSA to work even more closely together
with the National Faculty to find new and innovative approaches to
addressing issues related to prescription drugs

Opportunities for Collaboration
• Explore existing data sources or collect data to gain a
greater understanding of the issue in Inuit communities
• Develop an addendum to the FDNH strategy that describes
the issue from a Inuit perspective (similar to the chapter
related to FN)
• Include ITK representation on the NAC &/or Implementation
Teams
• Your ideas?

Thank You
Contact Information:
Carol Hopkins, MSW Paula Robson
Executive Director Knowledge Broker
NNAPF CCSA
Satellite Office: 519.692.9357 Main Office: (613) 235-4048
Main Office: 866.763.4714 Fax: (613) 235-8101
Fax: 866.236.7705 PRobeson@ccsa.ca
www.nnapf.com www.ccsa.ca

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