Overview of Opiate Addiction

• Conflict of interest – 2 talks for Purdue about dangers of opioid addiction

• Bias – support patients in both abstinence and methadone – but seeing more stability on MMT

Opioid Addiction in Canada

• Until 1990’s, heroin was the major opiate – mainly in coastal cities

• At the same time -

• Pain clinics were gaining acceptance for more opioid prescribing for pain

• Shortage of physicians – no longer one physician who knew his patients well over years of service

Then….• Mid 1990’s – oxycontin produced,

with major marketing campaign

• Newfoundland had major “epidemic” of oxycontin addiction, which travelled westward – also widespread abuse of other prescription opioids

• In Ontario, aboriginal communities were particularly affected

Canada - World Leader

Where Are These Drugs Going?

Sad but True• Physicians and prescriptions are part

of the problem!

• Prescription opioids have surpassed heroin as the primary narcotic of abuse….Canadian Opioid Guideline

Opioid Addiction in Winnipeg

• Rare – some T & R addiction in the inner city – and codeine addiction

• 2005 – assessed ~20 patients with opioid addiction

• 2009 – assessed over 300 patients

Methadone Resources• Until summer 2008, no wait list

• Now wait list at AFM methadone clinic is over 150 patients – wait time is months

• 2 other clinics providing services

Access to Methadone

• Brandon – wait list, new doctor starting

• Rural Manitoba – no MMT providers

• Comparisons

• MMT in Manitoba ~ 700

• MMT in Saskatchewan ~ 2000

• MMT in Ontario ~ 24,000

Does Access Matter?• Patients in treatment often improve

dramatically

Patients on wait lists deteriorate (health and social consequences) and may die

• Crime decreases with treatment access

Typical Patient in 2007-2008

• Wave 1 – Suburban

• Middle-class male aged 17-30, with supports in regards to family, education, work, finances – using oxycontin, usually snorting - in significant trouble after 6-24 months of use with debt, some crime, estranged family, failing at school or work

• Most stabilize rapidly

• They become tax-payers!

Demographics Evolve• Wave 2 – inner city – more use of

morphine and dilaudid - more injection use – multiple family members may use together (high rates of Hep C, some HIV)

Family Tree

24 14201722

1

1

• Treatment is more difficult because of chaotic lives

• The opioid addiction responds but many are repeatedly “knocked down by life”

• Past trauma issues resurface

Northern Ontario Reserves

• “I just admitted two young oxy-mothers…….the opioid wave has hit these communities like a tsunami”

Dr M.D

• What’s going to happen in Manitoba? Who’s doing prevention?.

And in 2010…• Ongoing oxycontin – now progressing

to fentanyl with several deaths

• More rural patients

• More chronic pain patients with addiction

• More Women....and more babies

• More aboriginal patients

Harm and Injection Use• Increasing rates of HIV in Manitoba

• IV drug use is a factor

Harm- Pregnancy and Families

• Increasing numbers of addicted mothers- diagnosed on the labor floor

• Babies require many days of care –and most are apprehended

Codeine• Canada is the only developed country to sell over

the counter codeine

• 80% of those addicted are female with a history of early life difficulties

• In their teens or twenties, they try T1’s or T3’s, and get a feeling of positivity and energy

Codeine• After about 10 years, patients face

increasing consequences – increasing dysfunction

• When we see them, they are using:• 50-100 tylenol 1’s per day

• 20-50 tylenol 3’s per day

• adding benzo’s or gravol

Talwin• Poor analgesic – T’s and R’s are a

problem only in the prairie cities –“poor man’s speedball”

Slow death from talc lung

This is a combined stimulant/opioid addiction – methadone might bring stability

Percocet• 5 mg oxycodone – widely available•• Oxycodone has surpassed marijuana

as teenagers’ experimental drug of choice in the U.S.

• Swallow, chew, or snort – gateway to oxycontin

Oxycontin

• Oxycontin: comes in 10, 20, 40, 80 mg strengths. It can be chewed, snorted, or injected – then it is a rapid intense high

• “ Safe and fun”

Oxycontin….• Often minimal alcohol or cocaine –

only the oxy matters

Street benzo’s help withdrawal

• "I don’t even get high anymore..”

• Use ranges from 80-600 mg/day

• Costs 50 cents or more per milligram

Morphine and Dilaudid• Injection use is more common with

these

• Not much dilaudid use in Winnipeg, but increasing

Fentanyl • Often cut up into “chiclets” and used

orally

• Many reports of respiratory arrest and several deaths after injection use

Benzodiazepines• Benzo’s are a problem too – widely

sold

• Ashton manual – how to get people off (download from internet)

Abstinence and Success Rates

• Doctors – 90% abstinent

• Long term, street-hardened – 3% abstinent

• In Winnipeg – only a few successfully abstinent – over 90% relapse

Relapse is the Norm• The death rate is higher in abstinence-

based treatment, because tolerance is lost and accidental (or deliberate) overdose occurs

• Drugs are so available on the street – or by prescription - relapse is easy

• “my best friend is my neighbor – and my dealer!”

• Currently no long-term follow-up program to support abstinence

Methadone • Reasonable to use as first treatment

approach, especially in unstable lives

Methadone - Goals1. Survival and stability

2. Stop opioids, stop injecting

3. Stop other drugs

4. Grow emotionally, develop success in life

5. Consider weaning off, ONLY if appropriate

It’s Not Just a Substitute Drug

1. They feel normal – energy goes into creating a life

2. Tight rules and consequences = structure

3. Relationships with staff promote maturity and emotional skills

The patient is still on an opioid but the addictive behaviour lessens or disappears.

Methadone - Outcomes

• 30% do very well

• 30% markedly improved, still problems

• 30% somewhat improved

• 10% wean off or leave yearly

Methadone – if not done well…

• Death

• Diversion

• Dispensing errors

• Inappropriate patients in treatment

• Physician norms can change

• Education, support of colleagues, College oversight are all necessary

Suboxone ( a “milder” methadone)

• SUBOXONE -

It has less side effects, and is much safer - and it’s easier to wean off

• In use in Europe for 10 years – too expensive for Canada?

• If you do the online course at www.suboxonecme.ca you can apply for a combined methadone/suboxone exemption

Financial Impact• Cost of treatment – in methadone

clinic, about $3000 per patient per year – in “methadone only clinic” about $1,000 per year

• Cost of an untreated heroin addict -$44,000 per year – costs include health, family services, incarceration, crime

Human Impact• Most patients in methadone programs

“get their life back” – almost all of my “young suburban” patients are back at school or work within a few months

• Patients not in treatment suffer financially and socially - risk of legal consequences and debt and family breakdown are huge

Challenge Stigma

• Preconceived ideas about addicts, treatment, hopelessness

• Methadone - Hard Work and Good Outcomes Go Unrecognized

So….• Support methadone clinics and

patients in your community or hospital

• Consider becoming part of the prescribing network

• -full clinic

• -general practice following stable patients

• -hospitalist

Methadone Saves Lives