Ge#ng the Low Down On Prescrip4on Opioids: How to recognize the signs and seek help Dr. Melanie Willows Clinical Director Substance Use and Concurrent Disorders Program Dr. Kim Corace Project Director, Regional Opioid Intervention Service Substance Use and Concurrent Disorders Program January 17, 2013 Learning points •  •  •  The current state of prescrip4on opioid abuse and addic4on in Ontario How to recognize when you or someone you love is in trouble with prescrip4on opioids The Royal's new Regional Opioid Interven4on Service to treat opioid addic4on and related mental health issues What is an Opioid? •  Opioids are depressants‐‐ they slow down certain brain func4ons •  Opioids are also referred to as narco4cs •  Opioids can be eﬀec4ve painkillers •  Some opioids are prescrip4on medica4ons (like oxys, fentanyl) and others are not (ie., heroin) Prescrip4on Opioid Abuse •  Opioid abuse is a growing problem •  Canada is the world’s third largest per capita consumer of opioids. Ontario tops the list in Canada •  Prescrip4on opioids has become the predominant form of illicit opioid use (rather than heroin) Prescrip4on Opioid Abuse cont’d •  Increase in number of individuals seeking treatment for opioid dependence in the last 10 years •  Opioids are a commonly abused substance by youth and young adults Why Opioids, Why now? •  Increasing availability of prescrip4on opioids –  –  –  –  –  –  –  1977 Oxycodone/Acetaminophen (Percocet) 1989 Hydromorphone Hydrochloride (Dilaudid) 1991 Morphine (MS IR) 1992 Duragesic patch (fentanyl) 1993 Morphine (MS Con4n) 1996 Oxycodone Hydrochloride CR (Oxycon4n) 1996 Duragesic patch added to Ontario Drug Beneﬁts Formulary Why Opioids, Why now? cont’d •  Increasing availability of prescrip4on opioids –  2000 Oxycodone IR (Oxycon4n IR) –  2000 Oxycodone Hydrochloride CR (OxyconCn) added to Ontario Drug Beneﬁts Formulary –  2001 Hydromorphone Hydrochloride (Hydromorph Con4n CR) –  2002 Hydromorphone Hydrochloride (Hydromorph IR) –  2006 RanFentanyl Patch (generic) added to Ontario Drug Beneﬁts Formulary Why Prescrip4on Opioids? Why now? •  •  •  •  •  •  Think it’s safe because it’s a prescrip4on More socially acceptable than heroin Purity Strong opioid Easy access Possible to alter how you use it: chew, suck, snort, smoke, inject Commonly Abused Prescrip4on Opioids Drug Name AcCve Ingredients Tylenol #1,2, 3 Codeine with acetaminophen M‐Eslon, MS Con4n Morphine Percocet Oxycodone with acetaminophen OxyNeo, Oxycon4n Oxycodone Dilaudid Hydromorphone Duragesic patch Fentanyl Table 1. Past Year Drug Use (%) for the Total Sample, and by Sex and Grade, 2011 OSHUHS (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 Cigarehes 8.7 9.3 8.2 2.8 3.7 10.3 14.5 14.4 A Genera4on Exposed… •  Although experimenta4on with alcohol and other drugs is a natural part of adolescence, experimenta4on involving opioids is high risk as addic4on occurs much more rapidly than with other drugs »  Na4onal Ins4tute of Drug Addic4on (NIDA) Risks of Opioid Misuse •  Overdose (high risk new users, unknown dose, combined with alcohol and/or benzodiazepines, amer a period of stopping opioids) •  Death •  Accidents •  Addic4on •  Infec4ous diseases from intravenous use and sharing drug equipment (Hepa44s C, HIV) Opioid Intoxica4on: What do others observe? •  •  •  •  Drowsiness or “the Nod” Constricted or pinpoint pupils Slurred speech Impairment in ahen4on or memory Opioid Intoxica4on: What do others observe? •  Dilated pupils •  Anxiety, irritability, anger (drug craving) •  Agita4on & Restlessness (cannot sit s4ll) •  Appears to be ill: nausea, vomi4ng, diarrhea, sweats and chills, watery eyes, runny nose •  Yawning •  Insomnia Not everyone who takes prescribed opioids has a problem.... •  Prescrip4on opioids are eﬀec4ve pain relievers •  Some people require long‐term prescrip4on opioids for chronic pain •  Many people take their opioids as prescribed •  Experiencing withdrawal symptoms if you stop your prescrip4on opioids abruptly would be expected How do you know you may have a problem? (Drug Abuse Screening Test‐10*) 1.  Have you used drugs other than those required for medical reasons? 2.  Do you abuse more than one drug at a 4me? 3.  Are you able to stop abusing drugs when you want to? * DAST‐10; H.A. Skinner, 1982 How do you know you may have a problem? (Drug Abuse Screening Test‐10) cont’d 4. Have you ever experienced black‐outs or ﬂashbacks as a result of your drug use? 5.  Do you ever feel bad or guilty about your drug use? 6.  Does your spouse (or parents) ever complain about your involvement with drugs? 7.  Have you neglected your family because of your use of drugs? How do you know you may have a problem? (Drug Abuse Screening Test‐10) cont’d 8. Have you engaged in illegal ac4vi4es in order to obtain drugs? 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepa44s, convulsions, bleeding)? What are the warning sign that your loved one may have a problem? •  Missing school or work, change in performance in school or work •  Change in peer group •  Money issues, possessions are lost/missing •  Irritability, mood swings, secre4ve, isola4on •  Finding drug paraphernalia: 4n foil, needles, straws, empty pens Preven4ng of Opioid Use Problems •  Delaying onset of all substance use •  Safe storage of opioids in the home and disposal of opioids once no longer required •  Treatment of any underlying mental health issues Mental Health and Substance Use •  People with substance use problems have higher rates of mental health problems than the general popula4on •  People with mental health problems have higher rates of substance use problems than the general popula4on Mental Health and Substance Use cont’d •  Young people age 15‐24 are more likely to report mental health and/or substance use problems than other age groups •  Concurrent Disorders = condi4on in which a person struggles with both a mental health and a substance use problem Rates of Concurrent Disorders •  40‐70% of people with substance use problems have mental health issues •  Most common combina4ons: –  Substance use problems + Anxiety disorder –  Substance use problems + Mood disorder Concurrent Treatment is Key •  Trea4ng both mental health and substance use problems together = Greater chance of success •  If mental health and substance use problems are caught and treated early, people have a beher chance of a quicker and fuller recovery Stages of Change Model* Maintenan ce: Change ≥6 months AcCon: Change <6 months *Prochaska & DiClemente ContemplaCo n: Change date <6 months PreparaCo n: Change date <1 month Regional Opioid Interven4on Service •  We are one of the ﬁrst of it’s kind in Ontario •  We provide early interven4on for opioid addic4on on an outpa4ent basis alongside trea4ng mental health problems •  Our team has many types of health professionals Regional Opioid Interven4on Service cont’d •  We partner with community and hospital service providers to oﬀer a full spectrum of care •  We provide training and educa4on to health care providers to build capacity to treat opioid addic4on Hub and Spoke Partnership Model Why did we develop the Regional Opioid Interven4on Service? •  More young people and those using for shorter periods of 4me are seeking treatment •  Very long wait 4mes for inpa4ent medical detox •  High rates of concurrent mental health and substance use problems issues, which need to be treated together Why did we develop the Regional Opioid Interven4on Service? •  Experience/exper4se with the use of opioid subs4tu4on medica4on [Buprenorphine/Naloxone (Suboxone)] •  Buprenorphine/Naloxone (Suboxone) is an appropriate oﬃce based treatment for use by family doctors with training Buprenorphine/Naloxone (Suboxone) •  •  •  •  Approved in Canada in November 2007 Is a par4al opioid agonist Long ac4ng Tablet taken sublingually under the tongue Buprenorphine/Naloxone (Suboxone) •  May be safer in overdose than methadone* •  May be easier to taper oﬀ this medica4on than methadone* •  May be beher for youth, young adults and for early interven4on** •  High risk of precipitated withdrawal discourages ongoing opioid use *Methadone Maintenance Treatment Program Standards and Clinical Guidelines, 4th edi4on February 2011 CPSO **Buprenorphine/Naloxone for Opioid Dependence: Clinical Prac4ce Guideline CAMH 2011 Regional Opioid Interven4on Service •  We mainly serve people who are under 30 years old or who have been using opioids for less than ﬁve years. •  Treatments based on your unique needs: –  Outpa4ent opioid detoxiﬁca4on and maintenance •  Detox lasts about 3 weeks, and requires you to ahend the program almost every day –  Mental health assessment and treatment –  Counseling and case management supports –  Follow up services How can you par4cipate in the Regional Opioid Interven4on Service? •  First step is to register and ahend one of our monthly orienta4on sessions OR •  Contact our addic4on counsellor •  Family members are encouraged to ahend the orienta4on session. We will provide informa4on on support for family members What happens next? •  A team member will contact you by phone to ask you some more ques4ons to see if this treatment is a good ﬁt for you •  If this program does not meet your needs, then we will discuss alterna4ves and help you to access other treatments either here at the Royal or with one of our partners Treatment doesn’t end here….. You will need ongoing support to maintain the gains you’ve made……. •  Con4nued counseling and support •  Referral to programs for addic4on and mental health treatment within The Royal and with our community partners What if the treatment doesn’t work? •  Relapse in addic4on is common and does not mean that you should give up •  Your team will work with you to help determine what the best next step might be What does this new ini4a4ve mean for pa4ents and families? •  No more knocking on the wrong door, if this service is not a good ﬁt we will help you ﬁnd the right door in the SUCD program at The Royal or in a community program •  Customized treatment based on your addic4on and mental health picture •  Educa4on and support for pa4ents and families What will this mean for the community? •  Further linkages of community agencies •  Forma4on of links between family doctors and community addic4on and mental health agencies •  Increased capacity of the region to iden4fy and treat opioid addic4on and mental health problems •  Increased access to addic4on and mental health care for opioid users where they live References •  Methadone Maintenance Treatment Program Standards and Clinical Guidelines, 4th edi4on February 2011 CPSO •  Buprenorphine/Naloxone for Opioid Dependence: Clinical Prac4ce 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 Addic4on and Mental Health. •  NIDA Na4onal Ins4tute on Drug Abuse •  Substance Abuse: A Comprehensive Textbook 4th Ed. Lewinson et al. 2005 References •  Principles of Addic4on Medicine 4th ed. , American Society of Addic4on Medicine. 2009 •  Lowinson & Ruiz’s Substance Abuse: A Comprehensive Textbook Fimh Edi4on Chapter 57 Adolescent Substance Abuse R. Milin and S. Walker. Editors Pedro Ruiz &Eric Strain. Lippincoh Williams & Wilkins, Philadelphia, PA, 2011 •  Skinner, H.A. (1982). The Drug Abuse Screening Test. Addic4ve Behaviors, 7, 363‐371. The DAST‐10 was developed and copyrighted by Dr. Harvey A. Skinner, PhD, Department of Public Health Services at the University of Toronto, and the Centre for Addic4on and Mental Health, Toronto, Canada.