Framing the issue of OxyContin use in KFL&A
and Ontario
Dr. Ariella Zbar, PGY-1 Public Health & Preventive Medicine
Queen’s University March 22nd, 2012
Conflict of interest
None declared
Opioids in Canada & Ontario
Canada is the world’s third largest per capita consumer of opioids1.
Ontario has the highest rate of narcotics use in the country2:
900% increase in # oxycodone prescriptions written in the last 20 years.
Each year, 300-400 people die from overdoses involving prescription opioids.
Recently, the opioid most commonly implicated is
oxycodone. 1. International Narcotics Control Board. Narcotic drugs: estimated world requirements for
2010; statistics for 2008. New York, United Nations, 2010 (E/INCB/2009/2). 2. Ontario Public Drug Programs Division. Notice from the Executive Officer: RE:
Important Notice Regarding Change in Funding Status of Oxycodone Controlled Release Tablet. Toronto: Ontario Public Drug Programs Division; 2012.
Opioids in Ontario
Gomes T, et al. Geographical variation in
opioid prescribing and opioid-related mortality
in Ontario. Healthcare Q. 2011;14(1):22-4.
Investigated the association between opioid prescribing and opioid-related mortality in Ontario.
Between Jan 1st, 2004 and Dec 31st, 2006, the following relationship was described…
Opioids in Ontario
Opioids in Ontario
Each additional opioid prescription dispensed per OPDP beneficiary annually = increase in annual opioid-related mortality rate by 0.54 per 100,000 residents.
In context, annual mortality rates3 for… Malignant neoplasms = 163.6 Heart disease = 107.9 Tuberculosis = 0.2 Meningitis = 0.1
3. Statistics Canada. Age-standardized mortality rates by selected causes, by sex. 2008. Reproduced and distributed on an "as is" basis with the permission of Statistics Canada.
Health Unit Mortality Rate per
100,000 averaged over 2004-
2006 Hastings and Prince Edward Public Health Unit 3.49
Huron Public Health Unit 2.17
Kent-Chatham Public Health Unit 3.27 Kingston-Frontenac-Lennox and
Addington PHU 4.54
Lambton Public Health Unit 3.52 Leeds-Grenville-Lanark Public Health Unit 1.59
Opioids in KFL&A
Upcoming presentations
Dr. Roger Skinner, Regional Supervising Coroner, East Region Coroner Inquest in Brockville and recommendations of the jury
Dr. Keith Duggan, Department of Anesthesiology and Perioperative Medicine Use of opioids for chronic non-cancer pain
Sherri Elms, Pharmacist, Queen’s Family Health Team Pharmacology of OxyContin and OxyNeo, equianalgesic dosing of opiates
and constructing a narcotics contract
Dr. Meredith MacKenzie, Street Health Centre, Kingston Substitution therapy and managing opioid withdrawal
Ron Shore, Director, Clinical Services, Kingston Community Health Centres
Dr. Wayne Spotswood, Assistant Professor, Emergency Medicine, Queen’s University
Opioid Management in Times of Change: The Use of Opioids for
Chronic non-Cancer Pain (CNCP)
Dr. Scott Duggan, MSc, FRCPC Assistant Professor – Queen’s University
Department of Anesthesia and Perioperative Medicine
Clinic Fellow – Chronic Pain Clinic
The Ottawa Hospital
Disclosures
2011 Clinical Pain Fellowship Award Canadian Pain Society/Pfizer Canada
Opioid prescribing in the media…
The Pain and Addiction Continuum
Improves Function
Impairs Function (Addiction)
Opioid Effect on the Pain Patient
Opioid Prescribing…Opioid Misuse
• Minimal training for safely prescribing opioids
• Applying the WHO analgesic ladder to non-cancer pain
• The (mis)perception that – “no ceiling dose with
opioids” – physicians should “dose
to effect”
Canadian Guideline for Safe and Effective Use for Opioids for Chronic Non-Cancer Pain
• 2007 – National Opioid Use Guideline Group formed – Aim
• Assist physicians in managing patients with Chronic non-Cancer Pain (CNCP) through safe and effective opioid prescribing
– Principles • Patients deserve to have their chronic pain treated • Best available evidence should be used to create a
national consensus of expert opinion • Collaborative and autonomous effort involving clinician and
patient input • The guideline is an evidence-based resource intended to
educate/inform clinicians and to guide practice decisions
Canadian Guideline for Safe and Effective Use for Opioids for Chronic Non-Cancer Pain
• 6580 studies (184 used) to create 49 draft recommendations
• 24 practice recommendations… – Deciding to initiate opioid therapy – Conducting an opioid trial – Monitoring long term opioid therapy – Treating specific populations – Managing opioid misuse and addiction in CNCP
• Guideline published in 2010
Recommendation Grading
• Grade A: Recommendations are supported by evidence from RCT(s)
• Grade B: Recommendations are supported by: – Evidence from controlled trial(s) without randomization or – Evidence from cohort or case-control analytic studies,
preferably from more than one centre or research group, or – Evidence from comparisons between times or places with or
without the intervention; dramatic results in uncontrolled experiments could be included here
• Grade C: Recommendations are supported by consensus opinion of the National Advisory Panel
Canadian Guideline for Safe and Effective Use of Opioids for CNCP
Cluster 1: Deciding to Initiate Opioid Therapy Recommendations
• Before initatiating opioid therapy.. 1. Conduct comprehensive assessment of patients pain
condition, general medical condition, psychosocial history (Grade C), psychiatric status and substance abuse history (Grade B)
2. Addiction risk screening (Grade B)
Canadian Guideline for Safe and Effective Use of Opioids for CNCP
Brief Pain Inventory
Opioid Risk Tool Designed to predict which patients may develop aberrant, drug related behavior • Low (0-3) • Medium (4-7) • High (≥8) Low risk: 6% chance of developing problematic behaviors High risk: >90% chance of developing problematic behavior
Cluster 1: Deciding to Initiate Opioid Therapy Recommendations
• Before initiatiating opioid therapy.. 1. Conduct comprehensive assessment of patients pain condition,
general medical condition, psychosocial history (Grade C), psychiatric status and substance abuse history (Grade B)
2. Addiction risk screening (Grade B) 3. Urine drug screening for baseline risk and compliance
(Grade C) 4. Consider evidence for opioid efficacy in CNCP (Grade A) 5. Obtain informed consent of benefits risks, adverse
effects and complications (Grade B). Consider treatment agreement? (Grade C)
6. Consider benzodiazepine tapering or slow opioid titration (Grade B&C)
Canadian Guideline for Safe and Effective Use of Opioids for CNCP
Cluster 2: Conducting an Opioid Trial
• During dosage titration 7. Advise patients to avoid driving until stable dosage
(Grade B&C)
8. Select the most appropriate opioid using a stepped approach (Grade C)
9. Start low, increase slow, monitor effectiveness (Grade C)
10. CNCP can be managed effectively in most patients with dosages ≤ 200 mg/day of morphine or equivalent (Grade A)
11. For high risk patients prescribe for only well-defined somatic or neuropathic pain conditions…start low, increase slow, and monitor for signs of aberrancy (Grade A,B,C)
Canadian Guideline for Safe and Effective Use of Opioids for CNCP
Cluster 3: Monitoring Long-Term Opioid Therapy
12.Assess opioid effectiveness, adverse effects, complications or aberrancy (Grade C)
13.Switch or discontinue if unacceptable or insufficient effectiveness (Grade B)
14.Consider factors that impair driving safety – severe pain rating, sleep disorders, sedating medication (Grade C)
15.Ensure long term therapy is warranted - revisit opioid trial steps (Grade C)
16. If employing collaborative care, communicate and clarify roles to ensure opioid effectiveness and safety (Grade C)
Canadian Guideline for Safe and Effective Use of Opioids for CNCP
Cluster 4: Treating Specific Populations with Long-Term Opioid Therapy
17.Start lower, titrate slower, longer dosing, frequent monitoring and taper benzodiazepines for elderly patients (Grade B)
18.Adolescent patients present a hazard (Grade B&C)
19.Pregnant patients should be tapered to lowest effective dose and tapered slowly to avoid withdrawal symptoms (Grade B)
20.Co-morbid pyschiatric diagnoses are greater risk for adverse effects (Grade B)
Canadian Guideline for Safe and Effective Use of Opioids for CNCP
Cluster 5: Managing Opioid Misuse and Addiction in CNCP Patients Recommendations
21.CNCP patient addiction treatment options – Methadone or buprenorphine (Grade A)
– Structured opioid therapy (Grade B)
– Abstinence-based therapy (Grade C)
22.Reduce prescription fraud (Grade C)
23.Prepare an approach for Patient unacceptable behaviour (Grade C)
24.Develop policies to avoid opioid misuse or diversion (Grade C)
Canadian Guideline for Safe and Effective Use of Opioids for CNCP
Canadian Guideline for Safe and Effective Use of Opioids for CNCP
Canadian Guideline for Safe and Effective Use of Opioids for CNCP
Universal Precautions in Pain Medicine: Minimizing Risk – Maximizing Relief
1. Make a diagnosis with appropriate differential 2. Psychological assessment, including risk of addictive
disorders 3. Informed consent 4. Treatment agreement 5. Pre-/post intervention assessment of pain level and function 6. Appropriate trial of opioid therapy ± adjunctive medication 7. Reassessment of pain scores and level of function 8. Regularly assess the “Four As” of pain medicine (Analgesia,
Activities, Adverse Effects and Aberrant Behaviour) 9. Periodically review pain diagnosis and comorbid conditions,
including addictive disorders 10. Document in the medical records
Gourlay DL, Heit HA et al. Pain Med. 2005;6:107-12
Pain and Addiction Continuum
• Pain and addiction may exist as co-morbid conditions but can also present as a dynamic continuum
• The treatment can be both the problem and the solution
• Important to identify which factor is dominant
• Many experts feel that chronic pain can not be effectively treated until the addiction issue is first addressed
Gourlay DL and Heit HA. J Add Dis. 2008;27:23-30.
Take home points
• Before prescribing opioids… – Do a comprehensive assessment of the pain problem – Assess for addiction risk – Set goals and patient expectations – Review with the patients – opioid adverse effects;
complications and risks (informed consent) – Document, Document, Document
• The Canadian Opioid Guideline
– http://nationalpaincentre.mcmaster.ca/opioid
Canadian Guideline for Safe and Effective Use of Opioids for CNCP
Some good advice from one of my Ottawa mentors
The approach to the Chronic Pain Patient is a mixture of…
Science
Placebo
Voodoo
It’s alright to use any of these approaches as long as you remember
which is which…
Pharmacology of
OxyContin and OxyNEO,
Equianalgesic Doses of Opioids and
Constructing a Narcotic Contract
Sherri Elms RPh ACPR
Out with the old, in with the new
Why?
To reduce abuse
◦ Harder to break
◦ Forms a gummy gel with water or alcohol –
cannot be drawn into a syringe or snorted
BUT …
◦ Not all abuse is snorting or injecting
◦ Reports of choking in patients with
swallowing difficulties
Pharmacists Letter Jan 2012 (28)
Pharmacokinetics
Bioequivalent – meaning the same amount
of drug is absorbed
BUT
◦ Peak is delayed (perceived as less effective?)
◦ Peak is slightly higher (more adverse effects?)
Availability
OxyContin OxyNEO
5mg -
10mg 10mg
15mg 15mg
20mg 20mg
30mg 30mg
40mg 40mg
60mg 60mg – not covered by ODB
80mg 80mg – only covered for palliative patients
Equianalgesic Doses
670mg
• Codeine
100mg • Morphine
75mg • Oxycodone
20mg • Hydromorphone
25mcg * • Fentanyl
Incre
asing P
ote
ncy
* topically/24hrs
Equivalences
http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b08.html#table_b_app_b01_01
Easier Way
Convert oxycodone 24 hour dose to another
agent
◦ Oxycodone (mg) x 0.3 = hydromorphone (mg)
◦ Oxycodone (mg) x 1.5 = morphine (mg)
Reduce dose by 25-50% for incomplete cross-
tolerance
Breakthrough? If any – 10% of the 24 hour dose
– more for planned incident pain
Policy at Queen’s
OPIOID TREATMENT AGREEMENT
Written, signed, dated
Only one prescriber, one pharmacy
Consequences to early or replaced prescriptions
Regular follow-up
Drug testing as required
Open communication with others including family, other doctors and pharmacy
Dr Ruth Dubin - Universal Precautions for Opioid Prescribing July 2011
Useful References
Canadian Guideline for Safe and Effective
Use of Opioids for Chronic Non-Cancer
Pain
www.nationalpaincentre.mcmaster.ca/opioid/
• Urine Drug Testing in Clinical Practice www.familydocs.org/files/UDTMonograph_for_web.pdf
Opioid Dependency Treatment Options
KFLA March 22, 2012
Meredith MacKenzie
Physician, Street Health Centre
Kingston, ON
Conflicts: NONE
DSM 4 Definitions: Opioid Abuse
1 or more in a 12 month period:
Recurrent use resulting in failure to fulfill major roles in work, school or home
Recurrent use in physically hazardous situations
Recurrent substance related legal problems
Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by substance
Opioid Dependence: 3 or more in a 12 month period:
Tolerance (marked increase in amount; marked decrease in effect)
Characteristic withdrawal symptoms; substance taken to relieve withdrawal
Substance taken in larger amounts and for longer period than intended
Persistent desire or repeated unsuccessful attempts to quit
Treatment Options: Abstinence
Psychosocial Treatment Programs
Medical Detoxification
Opioid Agonist Therapies
Opioid Antagonist Therapy
Abstinence: Consider this option when:
Highly motivated
Good existing supports in place
Medical Detoxification: Consider this in patients who:
Are dependent only on opioids and in particular, ORAL users
Have a brief duration of dependence (ie less than one year)
Are younger
Have no major psychiatric comorbidity
Are socially stable with a supportive network
Withdrawal Management: Clonidine 0.1 mg 1-2 tabs po bid-qid prn agitation,
diaphoresis, and sympathetic overdrive
Dimenhydrinate 50 mg po or pr; prn nausea
Ibuprofen 200 mg 1-2 tabs tid prn myalgia
Loperamide 2 mg po prn (max of 6/day) prn diarrhea
Trazodone 50-100 mg po qhs prn insomnia
Clonidine Precautions: Do not prescribe clonidine if BP < 90/60, patient is pregnant, on antihypertensives or has
heart disease
Warn patients about postural symptoms and drowsiness. Postural symptoms are dose-related.
Warn about mixing with opioids, or having prolonged hot baths (both lead to hypotension).
Keep prescription to less than 14 days (rebound HTN).
Warn about risk of overdose if they relapse (loss of tolerance).
Always use clonidine in conjunction with treatment plan.
Buprenorphine/naloxone Management of Acute Withdrawal:
Initial dose is similar to maintenance protocol (4-8 mg per day)
Increase dose by 2-4 mg daily until therapeutic dose achieved (usually 8-16 mg)
Reduce dose by 2 mg every week
Use adjuvant medications as necessary (anti-inflam/anti-diarrheals etc.).
Psychosocial Treatment Programs:
Inpatient and outpatient programs have similar results.
Offer comprehensive assessment, group and individual therapy, patient education and long-term follow-up.
www.drugandalcoholhotline.ca
Agonist Therapy: MMT and Suboxone
Agonist therapy results in improved treatment retention and decreased substance use compared to all forms of acute opioid detoxification.
Agonist therapy reduces mortality and drug use and retains patients in treatment.
Methadone Maintenance: Prescription opioids in varying forms have become
the predominant form of illicit opioid use (Fisher et al. 2005)
Prescription opioid users can be treated at least as effectively as heroin users (Banta-Green et al. 2009).
Methadone Eligibility: Meet DSM 4 criteria for opioid dependency for at least
one year (or intermittent use for longer periods).
Physical signs of chronic drug use (eg. Track marks).
Physical signs of withdrawal.
Recently released from incarceration (relapse prevention).
Age 18 or above (with exceptions).
MMT Pharmacology (BRIEF): Long acting, pure mu-agonist
Half life 22 hours (huge variability)
Peaks at 4 hours
SE similar to opioids
Prolongs QT interval
Risk of death is highest in the first TWO weeks of treatment
Avoid prescribing BDZ or let MMT provider know
Indications for MMT in Opioid Dependency:
Pregnancy
Where withdrawal during induction is clinically dangerous
Failure of Suboxone
History of injecting buprenorphine
SE or allergy to buprenorphine
Xerostomia
Past history of success with MMT
MMT Precautions: Recent benzodiazepine use or use of other sedating
drugs
Respiratory illnesses
Alcohol dependent patients
Over 60 years old
Respiratory Illness
Taking drugs that inhibit methadone metabolism
Lower opioid tolerance
Decompensated liver disease
Suboxone: Buprenorphine + naloxone
Partial opiate agonist (mu) + opiate antagonist (K)
Naloxone addition intended to reduce IV misuse.
Suboxone Pharmacology: Very high affinity for mu-receptor and will displace
methadone, morphine and other full opioid agonists...sits at the receptor site for a long time (binds tightly but only partially stimulates).
Partial agonist activity means better safety profile; limited ability to cause respiratory depression.
Withdrawal syndrome milder, therefore easier to taper off
Suboxone Pharmacology: Starts to work within 30-60 minutes
Peaks 1-4 hours
Max plasma concentration after SL ranges from 40 min to 3.5 hours.
Elimination ½ life 24-36 hours
Duration of action dose dependent
Maximum daily dose 24 mg
Probably less effective than MMT at doses above 60-80 mg.
Indications for Suboxone in Opioid Dependency:
Good prognosticators
Prior addiction treatment
Those who have not done well on MMT
Those with significant SE to MMT
MMT contraindicated
Patient choice
Access (drug plans and geography)
Suboxone Contraindications: Pregnancy
Allergy
Severe liver dysfunction
Acute severe respiratory illness
Decreased level of consciousness
Paralytic ileus
Inability to provide informed consent
Elevated transaminases (>3-5 x ULN)
Suboxone vs Methadone:
Antagonist Therapy: Naltrexone
Resources: ConnexOntario Health Services Information (drugandalcoholhelpline.ca)
DART
ACCS 1-888-720-2227
Suboxone and MMT guidelines available online: www.cpso.on.ca
CAMH “toolkit” for MMT and buprenorphine providers www.camh.net
Canadian guideline for safe and effective use of opioids for CNCP: http://nationalpaincentre.mcmaster.ca/opioid