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Genera&on O How did we get here? What can we do?
Melanie Willows B.Sc. M.D. C.C.F.P. C.A.S.A.M. C.C.S.A.M.
Clinical Director, Substance Use and Concurrent Disorders Program
Mano&ck Public Informa&on Mee&ng On Fentanyl November 14, 2012
Discussion Points
• Current paOerns of substance use in youth • What is an addic&on and what is experimental • Risk Factors and Protec&ve Factors for Addic&on • What is an opioid? Why are opioids so addic&ve?
Discussion Points cont’d
• What makes fentanyl so dangerous?
• Signs and symptoms of opioid intoxica&on and withdrawal
• Preven&on and Treatment of opioid addic&on in youth
A Genera&on Exposed…
• Although experimenta&on with alcohol and other drugs is a natural part of adolescence, experimenta&on involving opioids is high risk as addic&on occurs much more rapidly than with other drugs
» Na&onal Ins&tute of Drug Addic&on (NIDA)
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
CigareOes 8.7 9.3 8.2 2.8 3.7 10.3 14.5 14.4
What is Addic&on?
• Chronic disease of brain reward circuitry • Addic&on is characterized by inability to consistently abstain, impairment in behavioural control, craving, diminished recogniMon of significant problems with one’s behaviours and interpersonal relaMonships, and a dysfuncMonal emoMonal response.
» Excerpt from American Society of Addic&on Medicine (ASAM) defini&on
Risk Factors for Addic&on • Environment
– culture and society (e.g., laws and availability of substances)
– peers and family including actudes
– early/persistent behavioural problems
– poor school performance, rebelliousness
– early onset of substance use
• Drug – cost – availability – rapidity with which the agent
reaches the brain – efficacy of the agent as a tranquilizer
• Host – inherited suscep&bility – psychophysiologic vulnerability
to the effects of substances – mental health disorders
Protec&ve Factors
• Posi&ve temperament/self‐acceptance • Intellectual ability/academic performance
• Suppor&ve family/home environment
• Caring rela&onship with at least one adult • External support system (e.g. Religion/church) that encourages prosocial values
• Law abidance/avoidance of delinquent peer friendships
What is an Opioid?
• Opioids belong to the drug classifica&on depressants (as do alcohol and benzodiazepines)
• Opioids are referred to as narco&cs (sleep inducing) • Opioids are effec&ve pain killers
Common Abused Prescrip&on Opioids Drug Name AcMve Ingredients
Tylenol #1,2, 3 Codeine with acetaminophen
M‐Eslon, MS Con&n Morphine
Percocet Oxycodone with acetaminophen
OxyNeo, Oxycon&n Oxycodone
Dilaudid Hydromorphone
Duragesic patch Fentanyl
Why Opioids? Why now?
• Increasing availability of prescrip&on opioids – 1977 Oxycodone/Acetaminophen (Percocet) – 1989 Hydromorphone Hydrochloride (Dilaudid)
– 1991 Morphine (MS IR)
– 1992 Duragesic patch (fentanyl) – 1993 Morphine (MS Con&n)
– 1996 Oxycodone Hydrochloride CR (Oxycon&n) – 1996 Duragesic patch added to Ontario Drug Benefits Formulary
Why Opioids? Why now? cont’d
– 2000 Oxycodone IR (Oxycon&n IR) – 2000 Oxycodone Hydrochloride CR (OxyconMn) added to
Ontario Drug Benefits Formulary
– 2001 Hydromorphone Hydrochloride (Hydromorph Con&n CR)
– 2002 Hydromorphone Hydrochloride (Hydromorph IR) – 2006 RanFentanyl Patch (generic) added to Ontario Drug
Benefits Formulary
Fentanyl
• First synthesized by Paul Jannsen in 1959 • Synthe&c potent opioid, rapid onset, short dura&on of ac&on
• Said to be 80 to 100 &mes more potent than morphine
• 1960’s introduced as an intravenous anesthe&c Sublimaze
Fentanyl cont’d
• Illicit use of pharmaceu&cal fentanyl first appeared in the mid‐1970s in the medical community
• First Durogesic patch was approved by the US FDA in 1990, marketed in Canada in 1992
• Effec&ve pain medica&on for chronic moderate to severe pain when used properly
Fentanyl cont’d
• Possible to interfere with transdermal delivery system thereby delivering larger doses of drug more rapidly to the brain (increases addic&ve poten&al of this drug)
• Difficult for user to determine dose (overdose risk)
• Depending on dose and delivery, physical withdrawal symptoms may be felt aler several days or weeks of fentanyl use
Why Prescrip&on Opioids? Why Now? Why Fentanyl?
• Perceived safety because it is a pharmaceu&cal
• More socially acceptable than heroin • Purity • Potent opioid (euphoria effects)
Why Prescrip&on Opioids? Why Now? Why Fentanyl? cont’d
• Easy access (inadequate monitoring of prescrip&on narco&cs)
• High dose • Possible to circumvent delivery system: chew, suck, snort, smoke, inject
Opioids Intoxica&on: What do others observe?
• Drowsiness or “the Nod” • Constricted or pinpoint pupils • Slurred speech • Impairment in aOen&on or memory
Risks of Opioid Intoxica&on
• Overdose (especially if new user, unknown dose, or combined with alcohol and/or benzodiazepines)
• Tolerance for euphoria increases more rapidly than tolerance to respiratory depression
• High risk for overdose if relapses aler a period of abs&nence
• Accidents • Addic&on
Opioids Withdrawal: What can you observe?
• Dilated pupils • Anxiety, irritability, anger (drug craving) • Agita&on (cannot sit s&ll) • Appears to be ill: nausea, vomi&ng,
diarrhea, sweats and chills, watery eyes, runny nose • Yawning and Insomnia
Preven&on of Opioid Dependence
• Delaying onset of all substance use • Treatment of any underlying mental health issues • Protec&ve factors previously discussed • Safe and secure dispensing, storage and disposal measures of opioids must be reinforced for pa&ents, pharmacists and physicians.
Treatment Op&ons
• Abs&nence following withdrawal management: stop using opioids completely
• Opioid subs&tu&on therapy: receive daily dose of long‐ac&ng approved and controlled opioid such as methadone or Suboxone (buprenorphine/naloxone)
Op&ons for Treatment of Opioid Dependence
• Abs&nence Based – Pa&ent preference – Has not tried abs&nence based – Prior sustained response to abs&nence based treatment
– Are a younger age – Are dependent only on opioids and in par&cular oral opioids
Op&ons for Treatment of Opioid Dependence cont’d
• Abs&nence Based – Good prognos&c factors
• Socially stable • Suppor&ve social network • Short dura&on of addic&on • No major psychiatric comorbidity
Methadone Maintenance Treatment Program Standards and Clinical Guidelines 4th Edi&on February 2011 Buprenorphine/Naloxone for Opioid Dependence: Clinical Prac&ce Guideline CAMH 2011
Non‐Opioid Management of Opioid Withdrawal
• Clonidine ini&a&ng at 0.05mg TID, check BP if less than 90/60 then hold; dosing of up to 0.1mg‐0.2mg po TID‐QID
• An&diarrheals :loperamide(Immodium) • An&nauseants : dimenhydrinate (Gravol)
Non‐Opioid Management of Opioid Withdrawal cont’d
• Analgesics for myalgias: ibuprofen
• Night‐&me seda&on: Trazodone, Seroquel, or Benzodiazepine (but only for short term)
Residen&al Withdrawal Management Centre ‐ Level 2
• Supervision by trained but non‐medical staff
• May bring prescribed medica&ons • Loca&ons
– OOawa 613.241.1525
– Cornwall 613.938.8506 – Kingston 613.549.6461 or toll free 1.888.795.6688
Substance Use and Concurrent Disorders Program Assessment and Stabiliza&on Unit
• Within SUCD program have one of three residen&al withdrawal management level 3 centres according to CONNEX
• 24/7 medical/psychiatric monitored detoxifica&on • ASU ROMHC 12 beds (CAMH 18 beds, Humber Regional Hospital 4 beds) TOTAL 34 BEDS FOR ALL OF ONTARIO
Substance Use and Concurrent Disorders Program Assessment and Stabiliza&on Unit
• Medical detoxifica&on with
– Buprenorphine/Naloxone – Methadone – Clonidine, Diazepam
• Detoxifica&on followed by 28 day residen&al treatment program
Opioid Subs&tu&on Therapy for Opioid Dependency
• Long‐ac&ng medica&ons can be used for detoxifica&on (inpa&ent or outpa&ent) or for maintenance – Methadone – Buprenorphine/Naloxone (Suboxone)
Methadone
• Synthe&c opioid that relieves drug cravings and withdrawal symptoms for 24 hr without inducing seda&on or euphoria
• Methadone has been extensively researched for safety and its effec&veness to reduce morbidity and mortality in intravenous heroin users.
Methadone cont’d
• Regulated, physician requires a methadone exemp&on
• Requirements of observed dosing, limits on ini&al dosing, weekly urine screens
Youth and Methadone
• Pa&ents under 18 years of age may be considered for MMT, however abs&nence based treatment and/or opioid subs&tu&on tapering should also be considered for adolescents, par&cularly those with a shorter dura&on of opioid dependence
Youth and Methadone cont’d
• The MMT physician should ensure that there has been a discussion with the adolescent (and other family members where possible) about poten&al issues with methadone including side effects, risks and difficulty of tapering off.
Methadone Maintenance Treatment Program Standards and Clinical Guidelines 4th Edi&on February 2011
Availability of Methadone Maintenance Services
• Ontario currently has 37 000 people receiving methadone
• Several days to 2 week wait to be ini&ated onto methadone currently in OOawa
• Covered by for those with Ontario Drug Benefits or a private drug plan, otherwise cost is $6 per day
Buprenorphine/Naloxone
• Is a par&al opioid agonist • Approved in Canada in November 2007 • Tablet taken sublingually under supervision at a pharmacy for at least the first 2 months
Buprenorphine/Naloxone cont’d
• More rapid &tra&on to stabiliza&on than methadone
• May be easier to taper off this medica&on than methadone
• Risk of precipitated withdrawal if taken when not in significant withdrawal
Other Treatment Resources for Youth
• Rideauwood • Dave Smith Youth Treatment Centre (residen&al treatment program ages 13‐21)
• Connex Ontario Health Services Informa&on • Youth Services Bureau
Treatment Outcomes for Youth
• High rate of treatment dropout is greater than that seen in adults and is likely related to the adolescents’ typically low mo&va&on for treatment and the absence of perceiving their substance use as a problem
• Adolescents most commonly report a social situa&on or peer influence such as socializing with pretreatment friends as the context for ini&al relapse
Post‐treatment factors
• Par&cipa&on in alercare treatment
• Peer/parental social support • Prosocial ac&vi&es • Post‐treatment factors have been found to be the most important determinant of clinical outcomes
References
• Methadone Maintenance Treatment Program Standards and Clinical Guidelines, 4th edi&on February 2011 CPSO
• Buprenorphine/Naloxone for Opioid Dependence: Clinical Prac&ce 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 Addic&on and Mental Health.
• NIDA Na&onal Ins&tute on Drug Abuse
References
• Lowinson & Ruiz’s Substance Abuse: A Comprehensive Textbook Filh Edi&on Chapter 57 Adolescent Substance Abuse R. Milin and S. Walker. Editors Pedro Ruiz &Eric Strain. LippincoO Williams & Wilkins, Philadelphia, PA, 2011
• Substance Abuse: A Comprehensive Textbook 4th Ed. Lewinson et al. 2005
• Principles of Addic&on Medicine 4th ed., American Society of Addic&on Medicine. 2009
Websites
• www.theroyal.ca • www.connexontario.ca • www.davesmithcentre.org • www.rideauwood.org • www.cahm.net • www.asam.org • www.nida.nhi.gov