By Drs Melanie Willows and Kim Corace

1. Getting the Low Down On
Prescription Opioids: How to
recognize the signs and seek help
Dr. Melanie Willows
Clinical Director
Substance Use and Concurrent Disorders Program
Dr. Kim Corace
Project Director, Regional Opioid Intervention Service
Substance Use and Concurrent Disorders Program
January 17, 2013

2. Learning points
•
•
•
The current state of prescription opioid abuse and
addiction in Ontario
How to recognize when you or someone you love is
in trouble with prescription opioids
The Royal's new Regional Opioid Intervention
Service to treat opioid addiction and related
mental health issues

3. What is an Opioid?
• Opioids are depressants-- they slow down certain
brain functions
• Opioids are also referred to as narcotics
• Opioids can be effective painkillers
• Some opioids are prescription medications (like oxys,
fentanyl) and others are not (ie., heroin)

4. Prescription Opioid Abuse
• Opioid abuse is a growing problem
• Canada is the world’s third largest per capita
consumer of opioids. Ontario tops the list in Canada
• Prescription opioids has become the predominant
form of illicit opioid use (rather than heroin)
• Increase in number of individuals seeking treatment
for opioid dependence in the last 10 years
• Opioids are a commonly abused substance by youth
and young adults

5. Why Opioids, Why now?
• Increasing availability of prescription opioids
–
–
–
–
–
–
–
–
–
1977
1989
1991
1992
1993
1996
1996
2000
2000
Oxycodone/Acetaminophen (Percocet)
Hydromorphone Hydrochloride (Dilaudid)
Morphine (MS IR)
Duragesic patch (fentanyl)
Morphine (MS Contin)
Oxycodone Hydrochloride CR (Oxycontin)
Duragesic patch added to Ontario Drug Benefits Formulary
Oxycodone IR (Oxycontin IR)
Oxycodone Hydrochloride CR (Oxycontin) added to
Ontario Drug Benefits Formulary
– 2001 Hydromorphone Hydrochloride (Hydromorph Contin CR)
– 2002 Hydromorphone Hydrochloride (Hydromorph IR)
– 2006 RanFentanyl Patch (generic) added to Ontario Drug Benefits Formulary

6. Why Prescription Opioids? Why now?
•
•
•
•
•
•
Think it’s safe because it’s a prescription
More socially acceptable than heroin
Purity
Strong opioid
Easy access
Possible to alter how you use it:
chew, suck, snort, smoke, inject

7. Commonly Abused Prescription Opioids
Drug Name
Active Ingredients
Tylenol #1,2, 3
Codeine with acetaminophen
M-Eslon, MS Contin
Morphine
Percocet
Oxycodone with acetaminophen
OxyNeo, Oxycontin
Oxycodone
Dilaudid
Hydromorphone
Duragesic patch
Fentanyl

8. Table 1. Past Year Drug Use (%) for the Total Sample,
and by Sex and Grade, 2011 OSDUHS (CAMH)
Total
Male
Female
G7
G8
G9
G10
G11
G12
Alcohol
54.9
54.6
55.1
17.4
26.4
50.5
59.6
75.5
78.4
Cannabis
22.0
23.0
21.0
2.4
5.9
11.9
23.5
36.8
36.4
Binge
Drinking
22.3
22.7
21.8
1.1
4.1
13.7
24.4
35.3
39.7
Opioid Pain
Relievers
(NM)
14.0
12.9
15.2
8.5
10.9
13.0
14.9
18.0
16.0
Cigarettes
8.7
9.3
8.2
2.8
3.7
10.3
14.5
14.4

9. A Generation Exposed....
• Although experimentation with alcohol and other
drugs is a natural part of adolescence, experimentation
involving opioids is high risk as addiction occurs much
more rapidly than with other drugs
» National Institute of Drug Addiction (NIDA)

10. Risks of Opioid Misuse
• Overdose (high risk new users, unknown dose,
combined with alcohol and/or benzodiazepines, after
a period of stopping opioids)
• Death
• Accidents
• Addiction
• Infectious diseases from intravenous use and sharing
drug equipment (Hepatitis C, HIV)

11. Opioid Intoxication: What do others
observe?
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•
•
•
Drowsiness or “the Nod”
Constricted or pinpoint pupils
Slurred speech
Impairment in attention or memory

12. Opioid Withdrawal: What can you
observe?
•
•
•
•
Dilated pupils
Anxiety, irritability, anger (drug craving)
Agitation & Restlessness (cannot sit still)
Appears to be ill: nausea, vomiting,
diarrhea, sweats and chills, watery eyes,
runny nose
• Yawning
• Insomnia

13. Not everyone who takes prescribed opioids
has a problem....
• Prescription opioids are effective pain relievers
• Some people require long-term prescription opioids
for chronic pain
• Many people take their opioids as prescribed
• Experiencing withdrawal symptoms if you stop your
prescription opioids abruptly would be expected

14. How do you know you may have a
problem? (Drug Abuse Screening Test-10*)
1. Have you used drugs other than those required for
medical reasons?
2. Do you abuse more than one drug at a time?
3. Are you able to stop abusing drugs when you want
to?
4. Have you ever experienced black-outs or flashbacks
as a result of your drug use?
5. Do you ever feel bad or guilty about your drug use?
* DAST-10; H.A. Skinner, 1982

15. How do you know you may have a
problem? (Drug Abuse Screening Test-10)
6. Does your spouse (or parents) ever complain about
your involvement with drugs?
7. Have you neglected your family because of your
use of drugs?
8. Have you engaged in illegal activities in order to
obtain drugs?
9. Have you ever experienced withdrawal symptoms
(felt sick) when you stopped taking drugs?
10. Have you had medical problems as a result of your
drug use (e.g. memory loss, hepatitis, convulsions,
bleeding)?

16. What are the warning sign that your loved
one may have a problem?
• Missing school or work, change in performance in
school or work
• Change in peer group
• Money issues, possessions are lost/missing
• Irritability, mood swings, secretive, isolation
• Finding drug paraphernalia: tin foil, needles, straws,
empty pens

17. Prevention of Opioid Use Problems
• Delaying onset of all substance use
• Safe storage of opioids in the home and
disposal of opioids once no longer required
• Treatment of any underlying mental health
issues

18. Mental Health and Substance Use
• People with substance use problems have higher
rates of mental health problems than the general
population
• People with mental health problems have higher
rates of substance use problems than the general
population
• Young people age 15-24 are more likely to report
mental health and/or substance use problems than
other age groups
• Concurrent Disorders = condition in which a person
struggles with both a mental health and a substance
use problem

19. Rates of Concurrent Disorders
• 40-70% of people with substance use problems
have mental health issues
• Most common combinations:
– Substance use problems + Anxiety disorder
– Substance use problems + Mood disorder

20. Concurrent Treatment is Key
• Treating both mental health and substance use
problems together = Greater chance of success
• If mental health and substance use problems are
caught and treated early, people have a better chance
of a quicker and fuller recovery

21. Stages of Change Model*
Maintenance:
Change
6 months
PreContemplation
Contemplation:
Change date <6
months
Preparation:
Change date <1
month
*Prochaska & DiClemente

22. Regional Opioid Intervention Service
• We are one of the first of it’s kind in Ontario
• We provide early intervention for opioid addiction on
an outpatient basis alongside treating mental health
problems
• Our team has many types of health professionals
• We partner with community and hospital service
providers to offer a full spectrum of care
• We provide training and education to health care
providers to build capacity to treat opioid addiction

24. Why did we develop the Regional Opioid
Intervention Service?
• More young people and those using for shorter
periods of time are seeking treatment
• Very long wait times for inpatient medical detox
• High rates of concurrent mental health and
substance use problems issues, which need to be
treated together

25. Why did we develop the Regional Opioid
Intervention Service?
• Experience/expertise with the use of opioid
substitution medication [Buprenorphine/Naloxone
(Suboxone)]
• Buprenorphine/Naloxone (Suboxone) is an
appropriate office based treatment for use by family
doctors with training

26. Buprenorphine/Naloxone (Suboxone)
•
•
•
•
Approved in Canada in November 2007
Is a partial opioid agonist
Long acting
Tablet taken sublingually under the tongue

27. Buprenorphine/Naloxone (Suboxone)
• May be safer in overdose than methadone*
• May be easier to taper off this medication than
methadone*
• May be better for youth, young adults and for early
intervention**
• High risk of precipitated withdrawal discourages
ongoing opioid use
*Methadone Maintenance Treatment Program Standards and Clinical Guidelines, 4th
edition February 2011 CPSO
**Buprenorphine/Naloxone for Opioid Dependence: Clinical Practice Guideline CAMH
2011

28. Regional Opioid Intervention Service
• We mainly serve people who are under 30 years old
or who have been using opioids for less than five
years.
• Treatments based on your unique needs:
– Outpatient opioid detoxification and maintenance
• Detox lasts about 3 weeks, and requires you to attend the program
almost every day
– Mental health assessment and treatment
– Counseling and case management supports
– Follow up services

29. How can you participate in the Regional
Opioid Intervention Service?
• First step is to register and attend one of our monthly
orientation sessions
OR
• Contact our addiction counsellor
• Family members are encouraged to attend the
orientation session. We will provide information on
support for family members

30. What happens next?
• A team member will contact you by phone to ask you
some more questions to see if this treatment is a
good fit for you
• If this program does not meet your needs, then we
will discuss alternatives and help you to access other
treatments either here at the Royal or with one of
our partners

31. Treatment doesn’t end here…..
You will need ongoing support to maintain the gains
you’ve made…….
• Continued counseling and support
• Referral to programs for addiction and mental health
treatment within The Royal and with our community
partners

32. What if the treatment doesn’t work?
• Relapse in addiction is common and does not mean
that you should give up
• Your team will work with you to help determine what
the best next step might be

33. What does this new initiative mean for
patients and families?
• No more knocking on the wrong door, if this service
is not a good fit we will help you find the right door
in the SUCD program at the Royal or in a community
program
• Customized treatment based on your addiction and
mental health picture
• Education and support for patients and families

34. What will this mean for the community?
• Further linkages of community agencies
• Formation of links between family doctors and
community addiction and mental health agencies
• Increased capacity of the region to identify and treat
opioid addiction and mental health problems
• Increased access to addiction and mental health care
for opioid users where they live

35. References
• Methadone Maintenance Treatment Program Standards and Clinical
Guidelines, 4th edition February 2011 CPSO
• Buprenorphine/Naloxone for Opioid Dependence: Clinical Practice
Guideline 2011 (CAMH)
• Paglia-Boak, A, Mann, RE, Adlaf, EM (2011). Drug use among
Ontario students,1977-2011: OSDUHS highlights. (CAMH Research
Document Series No. 32). Toronto, ON: Centre for Addiction and
Mental Health.
• NIDA National Institute on Drug Abuse
• Substance Abuse: A Comprehensive Textbook 4th Ed. Lewinson et
al. 2005

36. References
• Principles of Addiction Medicine 4th ed. , American Society of
Addiction Medicine. 2009
• Lowinson & Ruiz’s Substance Abuse: A Comprehensive Textbook
Fifth Edition Chapter 57 Adolescent Substance Abuse R. Milin and S.
Walker. Editors Pedro Ruiz &Eric Strain. Lippincott Williams &
Wilkins, Philadelphia, PA, 2011
• Skinner, H.A. (1982). The Drug Abuse Screening Test. Addictive
Behaviors, 7, 363-371. The DAST-10 was developed and copyrighted
by Dr. Harvey A. Skinner, PhD, Department of Public Health Services
at the University of Toronto, and the Centre for Addiction and
Mental Health, Toronto, Canada.