Transcript Emergent opioid trends

Emergent opioid trends
The influences, the
availability and the impacts
www.matuaraki.org.nz
www.tepou.co.nz
“Among the remedies
which it has pleased
Almighty God to give
to man to relieve his
sufferings, non is so
universal and so
efficacious as opium”
Sir Thomas Sydenham, 1680
Inspired by
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Historical use of opioids
Supply sources
Communication channels
Adjunctive use-over and above maintenance doses
Desire to ‘have some control’ over use
Users resourfulness
Desire to ‘not do harm’
NZ context
• Dominated by use of pharmaceuticals:
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Morphine and methadone as the ‘mainstays’ (Robinson et al, 2011)
Cough syrups (Griffiths et al, 1982)
Homebake (Bedford et al, 1987)
Opium poppy heads (Dore et al, 1997)
Poppy seed tea (Braye et al, 2007)
Over the counter codeine analgesics (Robinson et al 2010)
Oxycodone (BPJ, 2011)
Objectives
• To explore service users and service
providers understandings of:
◦ patterns of new and emerging opioid drug
use (trends)
◦ the mechanisms that influence these trends
(availability)
◦ the impacts of these on opioid users
(impacts)
Mindful that:
‘each kind of analysis and way of presenting
the data, both simultaneously reveals and
conceals…however rich one analysis is, it is
inevitably incomplete, partial, tentative,
emergent, open and uncertain’ (Finlay, 2008)
Methodology
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Qualitative
Husserlian phenomenology
Understanding of participants perspective
Role of the researcher
Method
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Self reflection- bracketing
Ethical challenges
Purposeful sampling
In depth interviews
Reflection
Analysis-(Giorgi; N-vivo)
Iterative process
Participants
• Service Users
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n=9
CADS, OST, DHDP
Age 35-56; 10-30+ years use
7 male; 2 female
NZ Euro, Māori, British, Aus, Jewish
• Service Providers
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◦ 10-35 years working in addiction
◦ Range of services, roles, ethnicity, gender
Findings
• Emergent trends
• Availability and accessibility
• Impacts
Trends
Emergent trends
• “what is reported is that morphine and
methadone is used predominantly, but
then that’s because they ask about
morphine and methadone. They don’t
actually ask about the more OTCs or...”
(SP)
Localised trends, susceptible to change
• “There is always something that will replace
something that goes” (SU)
• “…it’s a comparatively small market and, you
know, it only needs one dealer to get put in jail
and you know, the whole thing changes, and one
big bust and there will be a recalibration of what
people use and what is available” (SP)
Availability and Accessibility
The business of pharmaceutical companies
• “They keep supplying and supplying, and keep the opiate users
going...”(SU)
• “Growing market share is what they do” (SP)
• “You know, these drug companies are quite cunning, you know.
They put a hell of a lot of, a lot of thought, they know that’s
addictive...and there is a lot of money involved. You know, they
don’t put silly people in charge of getting these things out there
and I think people have to be aware of that” (SU)
• “marketing programmes…including
direct to the public marketing” (SP)
Prescribed opioids-a primary supply source
‘aroha’, ‘ignorance’ or ‘arrogance’
• “Yeah. Well, I have always been really lucky, I have always found
drug doctors…”(SU)
• “A lot of the discharge prescribing, discharge scripts, discharge
summaries etc. are done by junior doctors, who aren’t
sufficiently aware of these sorts of issues. So I think there is a
problem with hospitals in particular… “(SP)
• “The surgeons, you could just get anything you want off them
really, and I used to think, can I get anything off these
guys…”(SU)
Users as creative, flexible people
‘The art of lying, cheating and manipulation’
• “you’ve got to think about what they’re going to come
back at you with to turn you down so you’ve got to work it
out, so you’ve closed up all the loopholes so they can’t say
no” (SU)
‘Deterrents, potentiators and precursors’
• “they are not deterrents, yeah. To an addict there is
always a way, there is always a way...” (SU)
• “...they’ll say we’ll put that in, that will stop them. But if
they knew the client that wouldn’t bloody stop them” (SP)
Information sharing
• “I guess when you look way back at opiate use, it was
very much like an apprenticeship in a way, you know,
the elders taught the younger ones, and it came
through. I don’t get a sense that that is happening so
much anymore. There’s not those tight communities
of drug users” (SP)
• “I don’t know if that is because there is more
availability of other stuff or maybe the new
generation just doesn’t have that kind of chemistry
knowledge” (SU)
Systemic considerations
• “Guidelines exist- but are not necessarily
adhered to” (SP)
• The role of PHARMAC and MoH
• Pharmacists role◦ the friendly pharmacists
◦ the regulated pharmacist
◦ The supportive/accessible pharmacist
Border controls
• “Small country. Small market. Island. Good border
control. Lots of sea, no warring countries on our borders”
Legislation enforcement
• Fairly lax re opioids
• ‘Focus on methamphetamines as part of govt policy’
• Precursor restrictions used in baking processes
Unsanctioned controls
• OST-restricting availability, ‘labeling’, stigma
• Retail restrictions
Impacts
Associated harms
• harms of opioids generally
• some emergent trends more harmful-particularly
to the uninitiated user
• abuse deterrent formulations (ADFs)
• dependence cycle
• displacement
• Criminalisation
“Or they would get it off the black market, which is
actually going to be worse, …Then they would be
involved in crime and things like that” (SU)
Considered approaches to minimising harm
• ‘Carefully considered and executed exercise to maximise
effect and minimise harm’
• Stabilising effect of some opioids
• “I don’t know. On one hand I want to get my drugs and
on the other hand I know that it’s not good for too many
people to have those drugs. Some people are just going
to do what they are going to do. No matter how much
you educate them or lecture them and that. It’s
probably better that they don’t restrict the access but
don’t make it so liberal that anyone can just go in and
get it as well” (SU)
Recommendations
Considerations-opioid dependant population
• Unintended consequences:
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lifestyle and wellbeing
accessibility (price, dosing, formulations)
criminalisation
stigma and discrimination
displacement (substance, geographical)
‘Metered’ doses/low harm options
Abuse deterrent formulations
Access to harm reduction info and interventions
Treatment delivery to be ‘recovery’ focused
Considerations-wider population
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Abuse, misuse and dependence potential
Impact on uninitiated users
Training AND monitoring for ALL prescribers
Networking opportunities
‘Atypical’ or hidden populations
Roles across agencies: prescribers pharmacists, DHDP/NEP
National prescribing and monitoring platform
Direct to public advertising (DTPA)
Shared responsibility
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prescribers
users
treatment providers
pharmaceutical industry
Ministry/Government
legislation
Consideration of
“the public good”
The effect of drug policy options on the public good and
individuals, (Strang et al., 2012, p79)
Closing thoughts
“There has never been a time,
place or culture where some
psychoactive drug
has not been
used, and it’s
highly unlikely
that there
ever will be”
(Ryder, Salmon & Walker, 2006)