Transcript Opioids: A Review – Meldon Kahan PDF - CSAM

CSAM-SCAM
Fundamentals
Opioids – A
Review
Presentation provided by
Meldon Kahan, MD
Family & Community Medicine
University of Toronto
Fundamentals: Opioid Addiction
Conflict of interest statement
Dr. Christy Sutherland - none
Dr. Elena Zoe Paraskevopoulos - none
Fundamentals: Opioid Addiction
Outline:
 Context:
Canada’s opioid crisis
 Prescription opioids: a major source of the
epidemic
 Family physician perspectives
 Prevention of opioid use disorders
 Diagnosis/Detection
 Management of opioid use disorder
Fundamentals: Opioid Addiction
Opioids:
Overview of the The National
Crisis
Fundamentals: Opioid Addiction
The Opioid Crisis
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Canada, US, heaviest opioid users
Relentless pharmaceutical pressure
0.5 - 3% of Canadians are currently using
opioids
April 14, 2016, British Columbia declares a
public health emergency
BC, overdose deaths will surpass deaths from
motor vehicle collisions this year. Estimated
800 deaths in BC in 2016
Fundamentals: Opioid Addiction
The Opioid Crisis
 In
2014, 700 opioid overdose deaths, ON
 ON, opioid overdose the #1 cause of
death 24 – 35
 50 000 individuals in OST tx in Ontario
 Only 12% of SUD receive tx
Fundamentals: Opioid Addiction
Opioids - America
 2015,
NIH estimates
9.4 million Americans
take chronic opioids
for “long term pain”
(3% of population)
 Estimate 2.1 million
have an opioid use
disorder
Fundamentals: Opioid Addiction
The Opioid Crisis
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
These deaths are
preventable
Iatrogenic: MD
prescriptions are the
major source of
opioids, directly or
through diversion
Number of opioid
deaths is very well
aligned with the
number of opioids
dispensed to the
population
Fundamentals: Opioid Addiction
Case: Anna
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22 yo female
Suffers from social anxiety
disorder, panic disorder,
severe
ASI
Prescribed opioids X 2 years
Hydromorphone 40 mg PO
(200 MED)
Clonazepam 1 mg BID PO
IVDU
Supplements with street
hydromorphone
Fundamentals: Opioid Addiction
Prescription Opioids
 1991
– 2007 annual prescriptions of opioids
increased from 458 – 591 per 1000
individuals
 Prescriptions of oxycodone increased by
850% between 1991 and 2007
Fundamentals: Opioid Addiction
9x increase in oxycodone-related deaths
14.00
Before addition of
OxyContin onto public
drug formulary
After addition of
OxyContin onto public
drug formulary
Number of deaths per 1 000 000 per year
12.00
12.93
11.24
10.00
8.40
8.00
7.17
5.78
6.00
4.03
4.00
2.91
1.64
2.00
0.76
0.65
1.71
1.02
1.94
1.51
1.39
0.10
0.00
1991 1992 1993* 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Dhalla et al CMAJ 2009
Fundamentals: Opioid Addiction
Most deaths occur in people who were
prescribed opioids

56% dispensed an opioid in the 4 weeks prior to death

82% dispensed an opioid in the year prior to death

Median number of opioid prescriptions in year prior to
death
 10 prescriptions
Fundamentals: Opioid Addiction
Opioids: Physician
Perspectives
Fundamentals: Opioid Addiction
Number of patients on opioids causing
concerns
Wenghofer 2010
Number of Patients Causing
Concerns for FP
None
Percent of FPs
(%)
15.1
1 – 3
47.9
4 – 6
23.4
7 – 9
6.4
10 or more
7.2
Fundamentals: Opioid Addiction
FPs very concerned about…
Concerns
Running out early, demanding fit-in
appointments, lost scripts
Lack of specialized pain clinics
Very concerned
(%)
44.8
42.2
Getting patient addicted (n=641)
38.4
Patients getting high doses
28.0
Lack of addiction treatment resources
26.4
Disagreements with patients about opioids
22.0
Fundamentals: Opioid Addiction
Opioids:
Tolerance & Withdrawal
Fundamentals: Opioid Addiction
Opioid Addiction:
 Repeated
drug positive reinforcement
leads to dysfunction of the pain and
reward pathways
 Opioids & all drugs act on ‘reward centre’
Tolerance and withdrawal develop
Fundamentals: Opioid Addiction
Tolerance

Neurobehavioural adaptation

Tolerance to analgesic effects
develops slowly

Rapid tolerance to psychoactive
effects

Tolerance disappears within days
Fundamentals: Opioid Addiction
Withdrawal: Symptoms
Psychological:
 Intense anxiety
 Craving for opiates
 Restlessness, insomnia, fatigue
Physical:
 Myalgias
 Nausea, vomiting, cramps, diarrhea, sweating
 Agitation, dilated pupils, chills, goosebumps
Fundamentals: Opioid Addiction
Withdrawal: Time Course
 Begins
 Peaks
1- 2 half lives after administration
at 2-3 days
 Physical
days
symptoms largely resolve by 5-10
 Insomnia
months
and dysphoria can last weeks to
 Symptoms
quickly relieved with opioid use
Fundamentals: Opioid Addiction
Withdrawal
 Usually
mild, transient in patients taking
low to moderate doses for analgesia
 More
severe in patients taking higher
doses for psychoactive effects
Fundamentals: Opioid Addiction
Opioid Use Disorder:
PREVENTION
Fundamentals: Opioid Addiction
Major cause of the increase…
 Prescribing
higher doses of opioids to
greater numbers of high risk people
 High risk patients more likely to experience
euphoria or anxiety relief with opioids

This may lead to tolerance, dose
escalation, withdrawal and addiction
Fundamentals: Opioid Addiction
Prevention
 Risk
stratify
 Use as trial only, limited evidence
 Use only in conjunction with strong non
opioid pain management plan
 Opioid contract
 Provincial pharmacy databases,
(Pharmanet, DSQ)
 UDS
 Monitor aberrant drug behaviour
Fundamentals: Opioid Addiction
When to taper
 Severe
pain and poor function despite
high dose
 Complications: Depression, fatigue, sleep
apnea, sexual dysfunction, falls,
osteoporosis, constipation, cognitive
dulling, opioid induced hyperalgesia,
overdose
Fundamentals: Opioid Addiction
How to taper
 Explain
that tapering improves pain,
mood and function

During taper, ask about positive effects not
just withdrawal
 Use

scheduled doses
Frequent dispensing with no early refills
 Taper
by no more than 10% of dose q
2 weeks
 Also taper benzodiazepines
Fundamentals: Opioid Addiction
Opioid Use Disorder:
DIAGNOSIS
Fundamentals: Opioid Addiction
Opioid Use Disorder: History
 Tolerance
 Withdrawal
 Cravings
 Use
under hazardous circumstances
 Failure to meet obligations: work and
family
 Failed attempts to cut back
 Ongoing use despite negative
consequences
Fundamentals: Opioid Addiction
Laboratory Work
 Elevated
AST, ALT (viral or alcoholic
hepatitis)
 Gamma GT, MCV (alcohol)
 Hepatitis B, C
 HIV
Fundamentals: Opioid Addiction
Other Sources of Information
 Addiction
is chronic relapsing remitting
disease
 It is beneficial to obtain collateral
information to make the diagnosis
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Other physicians
Spouse, family
Urine drug screen history
Fundamentals: Opioid Addiction
Red Flags for addiction
 Binge
use (“unsanctioned dose
escalations”)
 Early refills
 “lost” medications
 Alters route of entry

chew, crush, snort, inject
 Accesses

opioids from other sources
Other doctors, the street
Fundamentals: Opioid Addiction
Why do patients do this?
 Overcome
tolerance
 Achieve psychoactive effect of euphoria
 Avoid withdrawal
 Financial gain
Fundamentals: Opioid Addiction
Limitations of behaviour
monitoring
 Patients
will hide these behaviours
 These behaviours not always seen if
physician prescribes higher doses
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Some patients take oral opioids without
running out early yet experience
psychoactive effects, withdrawal,
dysphoria and decreased function
Fundamentals: Opioid Addiction
Urine Drug Screening
 Used
for detection of:
 Diversion
and non-compliance
 Use of other drugs such as cocaine,
benzodiazepines
 Chronic
Pain patients have high
prevalence of unauthorized drug
use on UDS, or absence of the drug
they are prescribed
Fundamentals: Opioid Addiction
Types of UDS: Immunoassay
 Opioids,
cocaine, benzodiazepines etc.
 Detects use for up to five days
 False positive and False negative are rare
as the immunoassays become more
sensitive and specific
 Some brands do not test for synthetic
opioids
 Remember that heroin and codiene will
show as morphine
Fundamentals: Opioid Addiction
Chromatography
 Depending
on your lab, you have to
specifically ask for synthetic opioids such
as:
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Oxycontin
Hydromorphone
Fentanyl
Buprenorpine
Methadone
Fundamentals: Opioid Addiction
Opioid Use Disorder:
TREATMENT
Fundamentals: Opioid Addiction
Management of Suspected
Opioid Addiction
 Buprenorphine
 Methadone
Fundamentals: Opioid Addiction
Methadone treatment:
Indications
 Opioid
Use Disorder
 Patients with untreated opioid use
disorder are at high risk of death, HIV,
Hepatitis C, and crime
 Methadone decreases all of these
negative outcomes
Fundamentals: Opioid Addiction
Methadone treatment
 Slow
onset, long duration of action
 Relieves withdrawal, cravings without
sedation or euphoria
 Can be monitored with UDS
Fundamentals: Opioid Addiction
Methadone
 Three
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components:
Daily dispensing with gradual introduction
of take-home doses
Regular UDS
Counselling and medical care
 Provincial
College guidelines about
methadone Rx

who prescribes & how
Fundamentals: Opioid Addiction
Limitations of methadone
treatment
 High

risk of overdose early in treatment
Optimal candidate is highly tolerant to
opioids
 Not
all communities have methadone
providers
 Major commitment of time for patient
and provider
Fundamentals: Opioid Addiction
Buprenorphine
 Suboxone
(buprenorphine + naloxone)
 Sublingual partial opioid agonist
 Long duration of action
 As effective as methadone at doses
above 16mg
 Lower risk of overdose than methadone
(ceiling effect because partial agonist)
Fundamentals: Opioid Addiction
Abstinence-based treatments
 Medical

detoxification
Detox alone has been shown to increase
mortality and increase HIV seroconversion
NA, AA, and counseling have no evidence
for benefit for Opioid Use Disorder
Fundamentals: Opioid Addiction
Addiction and pain: Paradigm shift
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MDs see pain treatment in opposition to
addiction treatment
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‘Patient is addicted but also has severe pain – if
I stop opioids his/her pain will be unbearable’
Yet evidence shows this is false:
Opioid addiction increases pain perception
and depression, worsens function
Patient’s pain, mood and functioning
improves with treatment, by resolving
withdrawal-mediated pain and opioidinduced depression
Conclusion
 Chronic
non-cancer pain does not
generally benefit from opioids
 Patients with Opioid Use Disorder should
be treated with Buprenorphine, or
Methadone
 It can be hard to tell these two
populations apart – it takes time, urine
testing, and clinical acumen