Getting the low down on prescription opioids: Learn how to notice the signs and seek help


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By Drs Melanie Willows and Kim Corace

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Getting the low down on prescription opioids: Learn how to notice the signs and seek help

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 11. Opioid Intoxication: What do others observe? • • • • Drowsiness or “the Nod” Constricted or pinpoint pupils Slurred speech Impairment in attention or memory
  12. 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. 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. 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. 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. 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. 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. 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. 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. 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. 21. Stages of Change Model* Maintenance: Change 6 months PreContemplation Contemplation: Change date <6 months Preparation: Change date <1 month *Prochaska & DiClemente
  22. 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
  23. 23. 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
  24. 24. 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
  25. 25. Buprenorphine/Naloxone (Suboxone) • • • • Approved in Canada in November 2007 Is a partial opioid agonist Long acting Tablet taken sublingually under the tongue
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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.