Something for your pleasure - IntNSA › ... › conference › 2016 › handout › 169.pdf · 2018-12-06 · • 2001 shortage of heroin on illegal drug market in Europe resulted

Something for your pleasure

• https://www.youtube.com/watch?v=FqQ-

JuRDkl8

Making Health Choices Parody

• https://youtu.be/Lp3pFjKoZl8

Poly pharmacy Parody

The Panel

Moderator: Dr Carmel Clancy (UK)[email protected]

•Dr Divane Vargas (Brazil)[email protected]

•Dr Stephen Strobbe (USA)[email protected]

•Adam Searby (Australia)[email protected]

•Emma Garrod (Canada)[email protected]

•Miriyam Farkash (Israel)[email protected]

Opioids are a class of drugs chemically similar to alkaloids found in opium poppies. Historically they have been used as painkillers, but they also have great potential for misuse. Repeated use of opioids greatly increases the risk of developing an opioid use disorder. The use of illegal opiate drugs such as heroin and the misuse of legally available pain relievers such as oxycodone and hydrocodone can have serious negative health effects.

Separating out the issue –

it is different globally

Trends in prescription opioid abuse

vs

Trends in heroin use

UNODC estimates indicate that the global

number of opiate users (i.e., users of opium,

morphine and heroin) has changed little in

recent years and that opiates continued to

affect some 17 million people in 2014.

World Drug Report 2016 http://www.unodc.org/doc/wdr2016/WDR_2016_ExSum_english.pdf

Regional Trends

North America Past decade – increase in use resulting in

increase in heroin-related deaths

Western & Central

Europe

Although long-term trends have been

stable or declining, early signs indicate a

surge in heroin market in parts of Europe

Africa Trend perceptions report the use of

opioids may have grown

Asia Reported by experts to have remained

largely unchanged

Oceania Opiate use is considered to have declined

World Drug Report 2016 http://www.unodc.org/doc/wdr2016/WDR_2016_ExSum_english.pdf

Mean availability of opioids for pain management

2001-03

Mean availability of opioids for pain management

20011-13

So…Magnitude of prescription opioid abuse

varies among nations

• USA at the forefront in terms of prescription opioid consumption. 2009 USA consumed 99% of the world’s hydrocodone, 60% of world’s hydromorphone; 81% of world’s oxycodene

• Rising trend found in Canada, Australia and Europe

• Of concern global trend may be underestimated due to absence of data

And we know…

• Consumption of opioid pain relievers is closely tied to the availability of heroin

• 2001 shortage of heroin on illegal drug market in Europe resulted in increase in abuse of illegally produced fentanyl in Estonia

• Heroin shortage linked to rise of illicit buprenorphine use in Finland

• Relationship between abuse of prescription opioids being tackled and increase in illicit heroin distribution and abuse in USA has been made

USA – country profile

Dr Stephen Strobbe

State of the Nation

• Epicenter of the opioid epidemic

• Contributing factors– Lack of adequate training to health care

providers: pain, addictions

– Marketing• Pharma to physicians: promotion of opioid

medications as safe, non-addictive if used for pain

• Unscrupulous “pill mills”

• “Black tar” heroin

• Conversion from opioid medications (licit or illicit) to use of heroin

– Pain as the 5th vital sign• Patient satisfaction surveys

• Lack of support for research for non-opioid pain relief

– Sociocultural factors

Drug-Related Deaths (CDC)

Drug-Related Deaths (CDC)

• Opioid overdose deaths– A function of Rx opioid sales

– Quadrupled from 1999 to 2014

– More than 28,000 in 2014

– Exceeded motor vehicle fatalities

– Enough prescriptions written in the US for every adult to have received a bottle of opioid pain medications

– More recent estimates of opioid overdose deaths in US approaching 150 day

• > 6 per hour

• One every 10 minutes

– Increased numbers, percentages involve fentanyl, now carfentanil

Drug-Related Deaths (CDC)

Key Policies and Actions

• Mental Health Parity and Addiction Equity Act of 2008– Requires payers to provide similar

coverage for mental health and substance use disorders as other medical benefits

• Affordable Care Act– Substance use treatment becomes one

of 10 essential benefits

– Federal government offers States opportunity to expand Medicaid programs

• Comprehensive Addiction and Recovery Act of 2016– Expands prescriptive authority to Nurse

Practitioners and Physician Assistants

• CDC Opioid Prescribing Guidelines

Principles [Controversies] of

Treatment

• To be added • Philosophies

– Pain management

– Addiction Treatment

• Abstinence-based

• Harm-reduction

• Medication-assisted

treatment (MAT)

– naloxone

– naltrexone

– buprenorphine

– methadone

[Addictions] Nurses’ Roles

• IntNSA’s Vision: To be a global leader in addictions nursing.

• IntNSA’s Mission: To advance excellence in nursing care for the prevention and treatment of addictions for diverse populations across all practice settings through advocacy, collaboration, education, research and policy development.

Australia – country profile

Adam Searby

The Australian Situation

• For the period 1979-1995, overdose deaths were primarily

due to heroin (Hall & Darke, 1998)

• 2011-2013 saw polysubstance use prevalent in non-fatal

overdose of PWID, predominantly oxycodone and

methamphetamine (Betts et al, 2015)

• Victorian Coroners Court data (2014) for overdose deaths

shows:

– 384 overdoses, 315 involving pharmaceutical drugs

Do we have a problem Down Under?

• Leong, Murnion and Haber (2009) found an increase in opiate

prescribing:

– From 2,397,006 in 1992

– To 6,998,556 in 2007

• Blanch, Pearson and Haber (2014) reported opioid related

hospitalizations increased from 605 cases in 1998 to 1464 in

2009, which have outnumbered heroin related cases since

2001

• Mars et al (2014) found a significant number of heroin users

started out using prescription opiates (although that was in Philadelphia and San

Francisco)

Trends in heroin use

• Shameless self promotion: see Searby, Maude &

McGrath (2015) An Ageing methadone population: A

challenge to older adult mental health services?

• Our methadone maintenance population is aging, living

longer and continuing to use drugs while carrying a high

degree of psychiatric and physical comorbidity

• And, according to Degenhardt et al (2013) heroin users

"had far higher rates of prescription opioid consumption

than the general population…" But were estimated to

use only 5% of oxycodone

Codeine: the forgotten pill

• Available over the counter, cheaply and easily

• Often in ibuprofen or paracetamol (sorry,

acetaminophen!), resulting in liver and gastrointestinal

damage

• In 2013, 27,780,234 packs of codeine were sold in

Australia (Gisev et al, 2016)

• "Easy" to obtain with "standard questioning" and "only

occasional refusal to supply" (Nielsen, Cameron and

Pahoki, 2013)

• An emerging face of the opiate epidemic?

Clinicians are struggling!

• "I prefer, probably the substance, like alcohol as a drug rather

than the prescription ones. And most of the prescription ones

in elderly are hard, because most of the people that are on

them don’t think they’ve got a problem because the GP gives

it to them, so they’re not addicted."

• "My concern is more abuse of prescription drugs… and drugs

like, you know, I think we are going to see that more and

more. We’ve had a few with heroin addiction. These I would

have no idea how to deal with. Alcohol I have been exposed to

in my clinical work, but prescription drugs, I find that harder

to manage, I find that they have a lot of other issues that

make it a lot more complex."

So what are we doing about this?

• There is repeated talk about real time

prescribing and monitoring, however little has

progressed beyond talk

• Plans to reschedule codeine have been met

with resistance

• Screening remains poor

• Clinicians struggle with assessing and

managing prescription opiate dependence

Canada – country profile

Emma Garrod

Canadian Data

• The Canadian Tobacco, Alcohol and Drugs Survey (CTADS) is a biennial general population survey of tobacco, alcohol and illicit drug use among Canadians aged 15 years and older.

• The results for 2013 are based on telephone interviews with 14,565 respondents across all 10 provinces, representing 29,043,889 Canadian residents aged 15 years and older.

CTADS results

High Risk Population Study

Provincial Opioid Related Mortality

data• There are currently no national-level data available for

prescription opioid-related mortality in Canada.

• Alberta: Deaths attributable to poisoning from narcotics or psychodysleptics 3.8 per 100,000 between 2003 and 2006

• British Columbia: Between 2005 and 2009, there were 815 deaths related to fentanyl, hydromorphone, morphine and oxycodone in British Columbia.

• Ontario: Data from the Office of the Chief Coroner show that opioid-related deaths in Ontario increasing, in particular, deaths related to oxycodone increased from less than 60 in 2004 to 160 in 2011. Deaths related to fentanyl also increased substantially over this period

Treatment for Opioid Addiction

• Currently no national-level data available for

prescription drug-related treatment in Canada.

• Ontario: prescription opioid-related admissions

to substance use treatment programs doubled

from 2004 to 2009. In 2005–2006, prescription

opioids were identified as the presenting

problem substance by 10.6% of individuals

seeking addiction treatment in that province. By

2012–2013, the numbers had increased to 18.2%.

Public Health Emergency

• Declared on April 14 by Dr. Perry Kendall (PHO)

• First declaration of a provincial public health

emergency under the BC Public Health Act

• Allows PHO or Minister additional powers, including:

– Powers respecting reporting

– Powers to make regulations

– Implementation of emergency measures

• >170 OD deaths in Jan and Feb2016

• If we continue, > 1,000 in 2016

400

>1000

http://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-

investigation/statistical/illicit-drug.pdf

Fentanyl Detected Deaths (BC)

Responses

• Harm Reduction: Supervised Injection Sites

and naloxone distribution

• Treatment: development of guidelines

• Positions on prescribing opioids

• Research and information sharing

Supervised Injection

Insite Evaluation

• Insite has reduced HIV risk behaviour

• Insite promotes uptake of addiction treatment

• Insite offers medical care for injection-related

infections

• Insite provides safety for women who inject drugs

• Insite does not lead to increased drug use or

increased crime

• Insite has improved public order

Naloxone Distribution in Canada

•Provincial:

– Ontario Ministry of Health 2012

– THN-BC August 2012

•Local

– Edmonton (Streetworks) 2005

– Toronto (POINT) 2011

– Ottawa (POPP) 2012

– Thunder Bay 2013

Take Home Naloxone

Source: Towardstheheart.com

Nov 3, 2015

MMT vs. Bup/Nx

• Patient choice and

shared decision

making with health

care providers

• Buprenorphine/nalox

one as first line

therapy

Diacetylmorphine

Heroin maintenance for chronic heroin-

dependent individuals (Ferri et al., Cochrane review 2011)

•Supportive review but expensive treatment not

presently widely available

•Cost effective

•Hydromorphone and SALOME study

Nursing Roles

• Leaders in harm reduction

• Naloxone distribution

• Many hours of patient contact in front line

settings- teaching, interpretation, therapeutic

relationships

• Interdisciplinary collaboration and advocacy

• Future: improved nursing education

Canadian Nurse, 2002

Nurses can prescribe Naloxone in BC!

Israel – country profile

Miriyam Farkash

Population of Israel 2016

State of the Nation

• The Health Ministry does not know how many

addicts there are

• The amount of prescription drugs that are

sold is not tracked

• Prescription drugs are being diverted into the

black market and their trade is increasing

The survey was carried out among three groups:

- Students aged 12-18

- Adults aged 18-40.

- Youngsters aged 12-18 that are not enrolled in

any formal educational

The Seventh National Epidemiological Survey of

Illegal use of Drugs and Alcohol in Israel, 2009,

Israel Anti-Drug Authority

* Illegal drug includes pills without a doctor’s prescription

Key Findings

6.85 % reported using medications without a

doctor’s prescription.

Associated drug profile within this group

indicated greater use of tranquilizers and

sleeping pills compared to stimulants.

Key policies and actions The Addiction Treatment Department, which

belongs to the Division of Mental Health Services

at the Ministry of Health is responsible for:

•Developing general guidelines

•Licensing supervision and control institutions for

addiction Treatment

•Development of interventions guidelines

•Training of practitioners (predominately Medics)

in the field of addictions

Principles of Treatment

• It is recommended to treat opiate addicts over

an extended period with personal, oral doses of

methadone hydrochloride or buprenorphine.

• Opiate addicts may be treated only in clinics or

government centers, either private or public,

which have a license issued by the Government

Addiction Treatment Department.

• Addicts who live far from treatment centers are

treated by mobile units.

Nurses role

• Overall the nursing role is limited

• Nurses work under the direct supervision of doctors

• Israel’s educational nursing system does have registered nurses, and registered nurses with an academic degree(e.g. BA, MA, PHD).

• All nursing students must pass a standard government licensing exam that authorizes them to work as nurses.

• Based on the current regulations it is difficult to define the range of nursing/medical actions that they are legally permitted to perform.

• In the course of their work, nurses may choose from a large array of advanced courses in different fields including: obstetrics, emergency care, intensive care, midwifery etc..

• There are no advanced courses for addictions.

Brazil covers approximately half of South America.

Has borders with all South America Countries except Chile and Equador.

Brazil – country profile

Dr Divane Vargas

• Population (2016) – 206 millions (mostly urban)

• Federative Republic, 5 regions, 26 States

• (01 FD)

• Municipalities - 5,598

• Territory: 8.5 mln sq km (aprox. 22 inh/sqkm)

• Per capita GNP (2015) - US$ 8.000-16.000

•

Sao Paulo City�Is the largest city

in South America

(and the Southern

Hemisphere).

�Is ranked seventh

among the largest

Cities on the

planet and and

its metropolitan

area, with

20 935 204 inhabit

ants (2014).

�Is also the 7th

biggest in the

world.

Brazil has one of the lowest rates of prescribing

opioids in the world.

Consumption is estimated to be 7.8 mg opioids

(such as morphine) per person per year.

The Brazil is the largest consumer of opioid

analgesics of South America.

The most prevalent problems are associated

with heroín.

Barbieri, 2014.

In 2005 the second household survey carried

out in 108 largest cities (more them 200,000

inhabitants) showed that 1.3% of the population

report using opioids.

The biggest use is among women, between 18

and 34 years.

CEBRID, 2005

The incidence of heroin use is 0.09% and

codeine syrups, 1.9%.

Brazilian health facilities rarely deal with people

who are morphine or heroin dependent; most

of the time these people have returned from

Europe or United States.

The risk of use and reliance on other opioids is

limited to people who have developed

dependency in the course of medical treatment

and health professionals who have access to

opioids.

Alves et al, 2005

It is estimated, that in Brazil, the rate of harmful

use among physicians is 4% and opioid

addiction, 22.7%. (Tabu)

Alves et al, 2005

Explanations

Among others

• Bureaucracy for the prescription of these drugs.

• High price to buy it.

• The familiar and patient prejudice.

• Lack of security of the physician to diagnose the patient's suffering and deal with the pain.

• Lack of hability of the nurses in how to assess the degree of pain.

Bureaucracy

To prescribe opioids are starting with getting

the prescription pad yellow (type A). To get it,

the professional (physician) must go personally

to the State Department of Health to make a

record.

Prejudice

The patient and family members think that the

use of these medicines is restricted to terminally

ill patients and reject using it.

Outcomes

Low problems with opioids dependency.

Chronic pain is undertreated.

Many times, the terminally patient dies with pain in Brazil.

Pondé, 2014

Problem is starting

Heroin Trafficking and Opioid Abuse

Heroin Trafficking and Opioid Abuse

5 to 10% of the price

Europe5%

Cracolândia/Cracoland

Apprehensions

2003 – 49g

April 2016- 182g

UK – country profile

Dr Carmel Clancy

State of the Nation.• 2012, ten million people

were prescribed an OP compared to France (4 million) its closest EU neighbour

• 2013, highest sales of morphine and codeine by volume than any other country in the EU

• Between 2010-2013 the UK had a 6% growth in sales, against the next largest margin increase in the EU.

• Between 2001-2011, prescriptions for co-codamol almost doubled from 8.8 million to 15 million

• In the period 1994-2009, Tramadol prescribing increased tenfold and all OP showed significant increases in level of prescribing during this period with the exception of dihydrocodeine.

• Just in England, the number of prescriptions rose from around three million in 1991 to 23 million by 2014.

• Defined Daily Doses (DDD) for Tramadol in England have increased from 5.9 million in 2005 to 11.1 million in 2012.

Drug related Deaths

• A key measurable harm from the rising number of

OP prescriptions and volume of OTC sales is the

concomitant increase in the overdose statistics

• E.g Tramadol deaths (England & Wales)

1996 2011 2014

1 154 240

Key policies and actions

• Guidelines for the use of opioids in pain

management have been available in the UK

and elsewhere for a number of years but have

made no impact on the increasing use of

opioids, particularly for persistent pain.

• Excellent report written for the All-Party

Parliamentary Group on Prescribed Medicine

Dependency by Harry Shapiro (2015)

Key points

• “The subject of OP dependency is chronically under-researched. Despite having some of the highest levels of OP use and sales in the EU and a wealth of anecdotal evidence from individuals, patient group representatives and clinicians about OP dependence, the estimate of those who might be OP dependent varies wildly from tens of thousands to nearly a million. But whatever the figure, it is clear that a significant number of people in the UK are battling with an OP dependency while being ‘hidden in plain sight.”

• Until the publication of the All-Party Parliamentary Group on Drugs report An inquiry into physical dependence and addiction to prescription and over-the counter medication in 2009, little interest was shown in this issue either from government or professional medical organisations. This has begun to change with, for example, guidelines from the RCGP, the development of assessment tools, professional calls for regular reviews on repeat prescriptions and reductions in packet size for OTC painkillers with additional patient health warnings.

Principles of Treatment

• In the main, those suffering from OP dependency are not willing to attend established community drug treatment centres, but find that there are few specialist treatment options.

• The British Paid Society in partnership with Royal College of General Practitioners have produced guidelines

Nurses role

• Main challenge is lack of education – role

adequacy, role legitimacy and role support

issues (alive and well!!)

• Addiction nurses specialists do have a role

working in partnership with generalists

• Much more to offer and do

• Questions