OPIOID BASICS For RNAO - IntNSA · Resources mentioned in this tutorial: Brochures About Percs, Oxys and other Pain Pills:

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Copyright © CAMH 2011Copyright © CAMH 2011

OPIOID BASICSFor RNAO

October 24, 2013Lori Naylor, RSW

Developed in collaboration with the Centre for Addiction and Mental Health,

Timiskaming Addictions and Mental Health, Sandy Hill Community Health Centre Oasis Program


Learning Objectives

Increase knowledge and understanding about:• What opioids are

• Problematic use

• Who is using opioids

• Risk and protective factors

• Health promotion

• Opioids and pregnancy

• Treatment approaches

• Overdose prevention

• Supporting Full Recovery

• Opiate Substitution Therapies2


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What are Opioids?

?

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Opioids:

• Are psychoactive chemicals that work by binding to our natural opioid receptors.

• Are types of painkillers, or analgesics, that are sometimes called “narcotic pain relievers.”

• Have positive effects associated with their analgesic qualities.

• Have risks associated with misuse and with the drug’s depressant qualities.

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“Opiate” is a synonym for “opioid.” True / False


Four Classes of Opioids Naturally produced in the body

Opiates, derived from opium poppy

Fully synthetic Semi-synthetic

HeroinPercocet

Oxycodone

DilaudidOxyNeo

PercodanFentanyl

Suboxone

Methadone

Demerol

Endorphins

Morphine

Codeine


Common Prescription Opioids and Their Ingredients

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Tylenol #2, #3, #4

Codeine with acetaminophen

Percocet Oxycodone with acetaminophen

OxyNeo

OxyContinOxycodone in a time-released formula

Dilaudid Hydromorphone

Since a common sign of acetaminophen toxicity is vomiting, it is not possible to be seriously harmed from taking too much Tylenol or Percocet. True / False

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Other Prescription Opioids and Their Ingredients

MS Contin, M-Eslon Morphine

Duragesic patch Fentanyl

Talwin Pentazocine

Demerol Meperidine

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Intended Use of Opioids:

1) Physical pain management

2) Treatment of addiction to other opioids

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Understanding Pain: What to do about it in less than five minutes? (5 min) http://www.youtube.com/watch?v=4b8oB757DKc

More resources about pain:

Non-pharmacologic Therapy and Chronic Pain (54 min)https://camh.adobeconnect.com/_a829238269/p41da49y1da/?launcher=false&fcsContent=true&pbMode=normal

Chronic Pain and Treatment (51 min) https://camh.adobeconnect.com/_a829238269/p2z32qxd7w7/?launcher=false&fcsContent=true&pbMode=normal

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Problematic Use

Photo credit: http://www.flickr.com/photos/robbrucker/


“There is a relationship between the amount of opioid medicine prescribed in Canada and the increasing level of opioid abuse and opioid-related deaths among youth in Ontario.”

(Dhalla, Mamdani, Sivilotte, Kopp, Qureshi & Juurlink, 2009)

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What are the risks of opioid use/abuse?

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• Dependence

• Addiction

• Overdose

• Withdrawal

• Health risks

• Diversion

Most people who use opioids go on to develop dependence or addiction. True / False

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Substance Use Continuum

Individuals move up and down this continuum at any timeNo use Dependence / Addiction

Occasional use / Circumstantial use /Experimentation

Regular use / Longer-term use / Problematic use Tolerance


Why are opioids prone to abuse?

To numb physical pain

To numb emotional pain

For the euphoric effect

For relaxation

To avoid withdrawal: Sudden cessation results in uncomfortable/painful withdrawal symptoms

Everyone is different. Reasons for using may vary.


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What are the Warning Signs of a Problem?

• Early renewal of prescriptions

• Double-doctoring

• Diversion

• New pain symptoms

Photo credit: Alex E. Proimos

http://www.globalhealthcheck.org/?p=505

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Diarrhea

InsomniaExhaustion

Chills, shivering, clammy skin Muscle cramps and spasms /Body aches / Bone aches

Sweating

Anxiety / restlessness / agitationDepression / hopelessness

What are the Withdrawal Effects?

• They are uncomfortable but not life threatening.

• They usually subside after a week.

• They often drive people to use again.

• They can occur even after first use.

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What is Tolerance?

• It’s the need for higher doses for the same effect.

• Tolerance increases the risk of physical and psychological dependence.

Note: Since tolerance for euphoria increases more rapidly than respiratory depression, individuals may continue to seek the euphoria of the drug while ignoring overdose cues (i.e. slowed breathing). This puts them at risk of overdose.


What does Addiction Impact?

Leisure

Emotional health

Physical health

Family relationships

Social relationships

Legal status

Education

Employment

Finances

Determining whether drug use is a problem isn’t always about how often or how much it is used but more about how it is negatively impacting various life areas.

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Who Is Using Opioids?

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“Ontario is in the midst of a public health crisis—a crisis stemming from the inappropriate prescribing, dispensing and illicit use of opioids and other narcotics."

- Dr. Jack Mandel, PresidentCollege of Physicians and Surgeons of Ontario(September 2010)


Opioid Use in Ontario

Between 1991 and 2009, the number of prescriptions in Ontario for oxycodone drugs rose by 850%.*

Between 1991 and 2004, deaths in Ontario from opioid use doubled from 13.7 deaths per million residents to 27.2 deaths per million.*

In 2009–2010, MOHLTC spent $156 million on narcotics for Ontario Drug Benefit Program recipients, $54 million on OxyContin alone.**

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$*(Dhalla, I., et al, 2009)**CBC investigative report (CBC Radio 1, 1730 hour News, June 2, 2009)

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Opioid Use in Ontario

Between 2000 and 2004, controlled‐release oxycodone increased from 3.8% to 55.4% of the total opioid admissions.

Long‐acting oxycodone was associated with a five‐fold increase in oxycodone‐related mortality.

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Note: Since March 2012, OxyContin began being removed from the market in Ontario and has been delisted from the Ontario Drug Benefit Program.


Prescription Opioid Misuse

Prescriptions opioid misuse has been Ontario’s fastest‐growing problem substance, and the third top presenting problem substance for new admissions (DATIS, 2012).

Due to discontinuing OxyContin in 2012, DATIS expects to be observing a different trend.

Image: http://www.datis.ca/newsarchive.php#27


Entering Treatment

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Opioid misuse among general population in Ontario

(Lalomiteanu et al,2012)

Mouse-over this text for analysis


Reported Use among Youth (Ages 19-24)

Therefore, when assessing and treating, it is important to speak to females about the nature of their drug use.


Ontario Student Drug Use and Health Survey

Past Year Use 2011

Alcohol 55%

Cannabis 22%

Opioid pain relievers (NM) 14%

Cigarettes 9%

Stimulants (NM) 4%

Sedatives (NM) 2%

www.camh.net

NM = non-medical

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Ontario Student Drug Use and Health Survey 2011

• Approximately 14% of Ontario students in Grades 7–12 report using prescription opioid pain relievers such as Tylenol #3 and Percocet for non-medical purposes

• Almost 67% report obtaining the drugs from home

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Resources For Parents

Key messages on

how to prevent problems:1) Build healthy relationships

2) Clear rules – never take someone’s else’s medicine

3) Store opioids in safe secure place and keep track of pills

4) Clean out medicine cabinet at least once a year

5) Get help early – call Drug and Alcohol Helpline 1.800.565.8603

Youth and prescription painkillers: What parents need to knowhttp://knowledgex.camh.net/amhspecialists/resources_families/Documents/YouthandMisuse%20E.pdf


About Percs, Oxys and other Pain Pillshttp://knowledgex.camh.net/amhspecialists/resources_families/Documents/about_percs_oxys.pdf

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Risk and ProtectiveFactors*

*Remember, these don’t have a simple cause-and-effect relationship.


Risk Factors

• Life events / environmental stressors

• Psychological vulnerabilities (personality traits)

• Other illness and medications

Note: If we are aware of risk factors we can target prevention and education specifically to these areas.


Protective Factors

• Personal and social competence

• Feeling in control of one’s life

• Optimism

• Ability to detach from conflict

• Willingness to seek support

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Populations at greater risk

• Adolescents

• Older adults

• People with a family history or personal history of substance use issues

• People with a personal history of mood or anxiety disorders

(Kahan et al, 2011)


Concurrent Disorders

From Ontario data, non‐medical prescription opioid use has been reported to be significantly higher among those reporting elevated psychological distress (Shield et al., 2011)

Mental health problems

Substance use problems

(Shield et al., 2011)


Health Promotion

Aimed at empowering individuals

to improve their health

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Health Promotion Strategies

Strengthening community

actions

Developing personal skills

Reorienting health services

Creating supportive

environments

Building healthy public policy


Social Determinants of Health

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What Works?• Building resiliency and protective factors

• Balancing health and safety

• Setting goals based on evidence / best practices

• Using a comprehensive approach (a range of strategies)

• Supporting collaborations (sectors, governments, NGOs)

• Addressing the determinants of health

• Using a population health approach

Opioid Basics: Health Promotion, Prevention and Harm Reduction Approacheshttp://camh.adobeconnect.com/p9j5z4mefu5/

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Opioids and Pregnancy

Note: Opioids cross the placenta.


Risks of Withdrawal

Risks to fetuses and infants:• Withdrawal has the same physical

effects on the fetus as it does on the woman.

• Neonatal Abstinence Syndrome (NAS) – occurring in some infants born to mothers who are dependent on opioids

Risks to the mother:• Withdrawal is also associated with

placental abruption and could be life-threatening for the mother.

Opioids in Pregnancy

If tapering has to be done:

• The safest time is between 14 and 32 weeks*

• The dose should be tapered at a rate of:

• No more than 10% reduction per day*

• No more than 5-10 mg per week as an outpatient, or

• No more than 1-2 mg per day as an inpatient

• Switch to an immediate release preparation at the end of the taper to allow for finer titration*

Prenatal

Monitor closely and stop tapering if any adverse consequences are reported!

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During Pregnancy

Minimize withdrawal

Prevent relapses

Use maintenance medications


Safety Considerations

Provide prenatal care and psychosocial treatment

Monitor for partner’s use of drugs and/or violence in the relationship

Consider taking action if the child is at risk under the Child and Family Services Act

Poly-drug use and tobacco (high risk for SIDS)


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For more information and resources on opioids and pregnancy, visit: https://knowledgex.camh.net/opioid_alert/2012/Pages/pregnancy_pro_april32012.aspx

Management of Perinatal Opioid Addictionhttp://camh.adobeconnect.com/p3uznlolk6k/

Resources on Treating Pregnant Clients with Opiate

Addictions

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Treating Opioid Dependence

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(Prochaska JO, DiClemente CC, & Norcross JC, 1992)

Stages of Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

RelapseTermination


What is the Overall Goal of Harm Reduction?

To increase awareness of the risks of behaviour and provide people with tools and resources they can use to decrease

the risk of harm to themselves and/or others.

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How does Harm Reduction relate to Substance Use?

• Harm Reduction is considered the “best practice” approach to addiction.

• It takes into account individual preference.

• It can include – but is not limited to – abstinence.

“Harm reduction means focussing on the most immediate and achievable changes that can reduce the threat to the health and well-being of the user and of society.”

(Substance Abuse Network of Ontario)


What are the Core Principles of Harm Reduction?

Attitude

Autonomy Pragmatism

Focus on harms

Emphasis on goals

Flexibility in treatment options

Redirection

Broad perspective

Evaluation Address stigma,

prejudice & discrimination

(Adapted from CAMH, 2002, 2005)


Why Take a Harm Reduction Approach?

Harm Reduction

Harm Reduction

More positive relationshipsMore positive relationships

Less isolationLess isolation

Addresses personal prioritiesAddresses personal priorities

More stabilityMore stability

More hopeMore hope

Helps avoid crisesHelps avoid crisesLess costly to societyLess costly to society

Start where a person’s at, NOWStart where a person’s at, NOW

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Overdose Prevention / What is Naloxone?

• It can prevent death in the case of an opioid overdose.

• It acts as an opioid inverse agonist.

• It is commonly administered/self-administered intravenously.

Note: While Naloxone was included in overdose prevention kits distributed to agencies in Ontario in 2012-13 by the Ontario Harm Reduction Distribution Program (OHRDP), the MOHLTC is now looking into alternative Naloxone delivery models for Ontario due to regulatory issues.

Photo credit: Toronto Public Health


What are Some Treatment Approaches?

• Controlled use

• Tapering

• Withdrawal management (residential or community)

• Opiate Substitution therapies (ie. Methadone and Suboxone)

• Alternative Therapies

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Supporting Opioid Addiction Through Adjunct Therapieshttp://camh.adobeconnect.com/p1920sa9u9f/


Controlled Use

• Taking drugs “as prescribed”

• Involves some tapering

• Makes use of alternative pain management strategies, such as

– Acupuncture, TENS

– hot/cold compresses

– physical activity

– relaxation

– distraction

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Supported Tapering/Withdrawal

• Slowly decreasing opioid use with the intent to quit

• The ideal approach includes planning with the client, the service provider/physician, and a support person

• The client is monitored closely throughout the tapering process and meets frequently with the service provider

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Preparing for Withdrawal

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Supports

Consider the “whole person”when putting supports in place

(E.g. Does the person need mental health supports,

spiritual supports, physical supports?)

Explore self-help options, peer support and family/friend

support

Education

Ensure the client knows that there’s a high risk of overdose if the person relapses to the original dose (due to there being a loss of tolerance

following withdrawal).

Educate client about the withdrawal process, and prepare an “at home kit” of what might be

helpful for them.

Develop a solid practical plan based on resources available to the person, including:


Other Strategies for Successful Withdrawal

• Prepare a safe and comfortable environment

• Ensure access to a support person

• Get lots of rest

• Decrease noise levels

• Cool clothing

• Warm compresses

• Baths

• Stay hydrated by drinking water

• Consult with a physician about medications that can support withdrawal symptoms

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Supporting Full Recovery

Full recovery requires a continuum of care including:

•Initial contact

•Stabilization

•Withdrawal Management

•Treatment (in or out-patient)

•After care

•Relapse prevention

•Education and on-going support

•Alternatives for pain management if necessary

•Adjunct Therapy support

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3 Common Substitution Treatment Options

1. Methadone

2. Buprenorphine

3. Suboxone


What is METHADONE?

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Methadone

• A long-acting oral opiate analgesic

• Given in the appropriate dose to opioid-dependent patients

– Dose is usually once daily

– Suppresses symptoms of opioid withdrawal for 24-36 hours

– Reduces cravings

– Does not induce sedation, intoxication or euphoria at the correct dose

– Reduces pain for short periods of time

– Cross-tolerance to other opiates61


Components of a Successful MMT Program

• MMT = Methadone Maintenance Treatment

• Counselling which involves education and support for both the client and his/her family

• Urine drug screens

• Integrated medical, counselling and administrative services

• Availability of a variety of psychosocial services if required

• Highly trained staff and involvement of support people

• Long term involvement from clients(Methadone Research Drug Guide, 2006) 62


Benefits of MMT

• Decreased illicit drug use

• Decreased criminal activity

• Improved employment rates

• Improved psychological status

• Decreased mortality (11x less)

• Suppression of withdrawal symptoms

• Reduced craving for opiates

• Does not induce sedation or euphoria

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Who is Methadone helpful for?

• Those who have tried other treatment options who may be more motivated to try MMT because of past failings

• Those with persistent pain who are able to commit to the treatment regime *

• Individuals with a safe stable living environment

• Individuals who able to get to the clinic or pharmacy without difficulty

• Individuals who are motivated to commit to a long term program **

• Individuals who have support from a family member or case manager

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Methadone Dispensing

• Daily oral dose is administered at a pharmacy

• Administration is supervised by a nurse or a pharmacist

• Policies and professional/client contracts are in place to ensure safety and adherence to program

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What is a “Carry” and what are the general guidelines?

• A ‘carry’ is a take-home dose of methadone

• Not recommended in first 2 months of treatment

• Client will receive 1 extra carry/week for each month of the program if there are no issues

• Maximum 6 carries/week

(Methadone Maintenance Treatment Program Standards and Guidelines, 2011)

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How does MMT help improve lives?

• More effective in retaining client in treatment

• More effective in the suppression of opioid use

• Reduced drug-related criminal behaviours

• Reduced mortality rates among individuals receiving treatment

• Improved physical and mental health

• Reduced risk behaviours for HIV, HCV, and STI’s

• Improved pregnancy outcomes

• Improved social functioning and quality of life

(Health Canada, 2013, Mattick et. Al., 2003)

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Methadone Summary

Methadone is effective

It is a long-acting opioid agonist that is administered daily

Treatment is very specific to the individual

There is a high risk of relapse if treatment is discontinued, and withdrawal symptoms can be severe

The induction period is a particularly dangerous time

With long term supports in place, treatment outcomes are very good

Some individuals will use methadone for the rest of their lives


What is BUPRENORPHINE?

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Buprenorphine

• Buprenorphine is a partial agonist

• Alternative to Methadone

• Blocks effects of opioids to help reduce cravings

• Suppresses withdrawal symptoms for a duration of approximately 6-12 hours with relief in about 15 minutes

• Lower potential for abuse/overdose risk

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What is SUBOXONE?

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Suboxone

• Suboxone is a partial opioid agonist• Contains naloxone to deter injection• Theoretically, less severe withdrawal than

methadone• Clients often state that suboxone feels less

emotionally addictive than methadone• There is a ceiling on Suboxone activity making it

safer• Not suitable for those who need a high dose to

avoid withdrawal

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Resources mentioned in this tutorial:

Brochures

About Percs, Oxys and other Pain Pills: http://knowledgex.camh.net/amhspecialists/resources_families/Documents/about_percs_oxys.pdf

Youth and prescription painkillers: What parents need to know: http://knowledgex.camh.net/amhspecialists/resources_families/Documents/YouthandMisuse%20E.pdf

Videos

Prescription for Addiction: https://knowledgex.camh.net/videos/Pages/prescription_addiction.aspx

Understanding Pain: What to do about it in less than five minutes? http://www.youtube.com/watch?v=4b8oB757DKc

Webinars

Management of Perinatal Addiction: http://camh.adobeconnect.com/p3uznlolk6k

Supporting Opioid Recovery with Adjunct Therapies: http://camh.adobeconnect.com/p1920sa9u9f/Chronic Pain and Treatment:

https://camh.adobeconnect.com/_a829238269/p2z32qxd7w7/?launcher=false&fcsContent=true&pbMode=normal

Management of Perinatal Opioid Addiction: http://camh.adobeconnect.com/p3uznlolk6k/


References

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CAMH. CAMH and Harm Reduction. 2002. Available at: http://knowledgex.camh.net/amhspecialists/resources_families/Pages/harm_reduction.aspx

CAMH. Fundamentals of Addiction On-line course, Characteristics of Harm Reduction. 2005. Available at: http://www.camh.net/education/online_courses_webinars/mha101/introtoaddiction/Introduction_to_Addiction.htm

Canadian Guideline for Safe and Effective Use of Opioids for chronic non-cancerous pain: http://nationalpaincentre.mcmaster.ca/opioid

College of Physicians and Surgeons of Ontario. Avoiding Abuse, Achieving a Balance: Tackling the Opioid Public Health Crisis. 2010. Available at: http://www.cpso.on.ca/uploadedFiles/policies/positions/Opioid%20report%20final.pdf

Dhalla IA, Mamdani MM, Sivilotte ML, Kopp A, Qureshi O, Juurlink DN. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMJ 2009; 181:891-6.

Drug and Alcohol Treatment Information System (DATIS) – CAMH. Substance Abuse Statistical Tables - Fiscal Year 2007/2008 To Fiscal Year 2011/2012. 2012. Available at: http://www.datis.ca/pub/reports/DATIS%20Substance%20Abuse%20Statistical%20Tables%20FY200708%20to%20FY201112.pdf


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ReferencesFischer G, et al. (2000). Treatment of opioid-dependent pregnant women with buprenorphine. Addiction. 95(2): 239-244

Fishbain, D.A., Cole B, Lewis J., Rosomoff HL., Rosomoff RS What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review Pain Med2008 May-Jun;9(4):444-59.

Harrison, Susan, Carver, Virginia Eds.(2004) Alcohol and Drug Problems: A Practical Guide for Counsellors 3rd Edition. Toronto: Centre for Addiction and Mental Health 2004

Health Canada, Retrieved from website May 2013 from Literature Review – Methadone Maintenance Treatment: http://www.hc-sc.gc.ca/hc-ps/pubs/adp-apd/methadone/effectiveness-efficacite-eng.php

Ialomiteanu AR, Adlaf EM, Hamilton H & Mann RE. CAMH Monitor eReport: Addiction and Mental Health Indicators Among Ontario Adults, 1977-2011 CAMH Research Document Series No. 35. 2012. Toronto: Centre for Addiction and Mental Health.

Johnson R, et al. (2003). Use of buprenorphine in pregnancy: patient management and effects on the neonate. Drug Alcohol Depend. 70(2 Suppl): S87-S101

Kahan M, Wilson L, Mailis-Gagnon A, Srivastava A. Canadian guideline for safe and effective use of opioids for chronic noncancer pain. Clinical summary for family physicians. Part 2: special populations. Can Fam Physician. 2011; 57:1269–76.

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Lacroix L, et al. (2004). Buprenorphine in pregnant opioid dependent women: first results of a prospective study. Addiction. 99: 209-214

Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews 2008;CD002207(April 16). Johnson RE, et al. (2001) Buprenorphine treatment of pregnant opioid-dependent women: maternal and neonatal outcomes. Drug Alcohol Depend.; 63: 97- 103

Methadone Maintenance Treatment, Client Handbook, Centre for Addiction and mental Health 2003

Methadone Maintenance Treatment: Program Standards and Clinical Guidelines, February 2011. Retrieved from the College of Physicians and and Surgeons Website: http://www.cpso.on.ca/uploadedFiles/members/MMT-Guidelines.pdf

Methadone Research Web Guide December 2006. Revised from: Methadone Maintenance Treatment: Translating Research Into Policy (1995) prepared by the National Institute on Drug Abuse (NIDA) International Program.

Ottawa Charter,http://health.qld.gov.au/atod/documents/atod_prev_statement.pdf 2009Paglia-Boak A, Adlaf EM, Mann RE. Drug use among Ontario students, 1977-2011: Detailed OSDUHS findings. CAMH Research Document Series No. 32. 2011. Toronto, ON: Centre for Addiction and Mental Health.

Prochaska JO, DiClemente CC & Norcross JC. In search of how people change: Applications to addictive behaviors. American Psychologist. 1992; 47(9), 1102-1114

References


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Queensland Health Population Health Plan 2007–2012) Prevention Statement: December 2009Selby, P. & Kahan, M. (2008). Methadone Maintenance: A Physician's Guide to Treatment (2nd ed.). Toronto: Centre for Addiction and Mental Health.

Shield KD, Ialomiteanu A, Fischer B, Mann RE, Rehm J: Non-medical use of prescription opioids among Ontario adults: data from the 2008/2009 CAMH monitor. Can J Public Health 2011, 102(5):330-335.

Whitehead M & Dahlgren G. What can we do about inequalities in health? Lancet, 1991; 338: 1059-1063.

References