Transcript a. Medication Assisted Therapy in Opioid Dependence in Northern

COORDINATION OF
OPIOID DEPENDENCE
TREATMENT:
NORTHERN ONTARIO CONTEXT
Kristen Morin, MPH, PhD Candidate
School of Rural and Northern Health, Laurentian University
Northern Ontario School of Medicine
Outline and learning objectives
•
Understand the provincial context for opioid dependence treatment and examine
current research
•
Express and describe various perspectives on opioid dependence treatment
•
Apply knowledge of opioid dependence and discuss the complexity of the opioid
dependence environment in Ontario
•
Examine an ongoing research project on coordination of care for opioid
dependence in Northern Ontario
Introductions
Role & organization
1.
2.
Patient/person with lived
experience
Direct service provider (nurse,
doctor, counselor, etc.)
3.
Administrator/manager/leadership
4.
Policy/funding/planning
5.
Research/research trainee
6.
Other…
Experience and/or knowledge of opioid
dependence treatment and/or services
1.
No experience/knowledge
2.
I know a little about it
3.
I know a lot about it
4.
I am an expert
Introduction
Kristen Morin MPH, Ph.D. Candidate
PhD student in the School of Rural and Northern Health
Research interests: Coordination of mental health and addiction services, opioid
agonist therapy (methadone / buprenorphine), health equity, rural health
Interdisciplinary research group doing OAT research
Opioids and Opioid Agonist Therapy
•
Opioid: family of drugs intended to
treat pain
•
Opioid agonist therapy (OAT) is a
substitution therapy with the goal of
harm reduction and improved
psychosocial functioning
•
OAT relieves the patient of opioid
withdrawal to allow the patient
return to psychological, physical, and
social functioning
Terminology
•
Methadone Maintenance Therapy (MMT) or Buprenorphine Maintenance Thrapy
(BMT)
•
Medication Assisted Therapy for opioid dependence (MAT)
•
Opioid Agonist Therapy (OAT)
•
Opioid dependence treatment (ODT)
•
Heroin Assisted Treatment (HAT)
DOES ONTARIO HAVE AN
OPIOID DEPENDENCE
CRISIS?
Discussion
In Ontario
In 2014, 12.4% of students in grade 7 to 12 used prescription opioids for non-medical
purposes
An increase from 6,000 to 42,000 patients enrolled in MMT in 10 years
Communities in northern Ontario experience some of the highest rates opioidrelated deaths in the province
In some remote northern Aboriginal communities, 70%-80% of the population
suffers from opioid dependence
In 2005/06 to 2010/11 there was a 250% increase in the number of ER visits related to
opioids
Boak, 2013, , CPSO, 2015, Gomes et al., 2014, Gomes et al., 2011, Addiction, 2012
Other jurisdictions
In Canada:
•
•
•
General population (2013) among opioid users, 2.3% (0.3% of the total population)
reported abusing
Youth (2013)the rate of opioid abuse 5.8%
Students (2012-2013) 1.5% of students grades 7 to 9 and 2.5% of students in grades 10
to 12 reported using pain relievers to get high
United States (2013) - Prevalence of non-medical use of prescription opioids was
4.2% for people ages 12+
Australia (2013) - 3.3% of those ages 14 and older reported misusing prescription
opioids
Canada, 2015; Canada, 2014; Administration, 2014; Welfare, 2014
ARE FATAL OPIOID
OVERDOSES A
PROBLEM IN ONTARIO?
Discussion
Fatal Opioid Overdoses in Ontario
•
Opioid-related deaths
between 1997- 2011
increased from 1.2 per
100,000 to 4.2 per 100,000 (a
350% increase)
•
Leading cause of death for
people aged 18-35 in Ontario
•
12% of deaths in patients
between the ages of 25 and
34 years occur due to opioidrelated overdoes (2014)
Weeks, 2016; Gomes et al., 2014
Geographical Variation
Gomes et al., 2011
Fatal Opioid Overdoses in Other Jurisdictions
British Columbia
•
Opioid-related deaths between 2005‐2010 were 1.1 per 100,000
Québec
•
2000 - 51 fatal OD
•
2011 - 95 fatal OD
•
2016 - projecting triple the fatalities
European union (2014)
•
3.4 % of all deaths among Europeans between the ages of 15 and 39 occur due to opioidrelated overdoes
Gomes et al, 2014; Fischer & Argento, 2012, Carter, 2013; CAMH, 2013; Follett, 2012
Rossen, 2016
Rossen, 2016
WHAT CAN BE SEEN AS THE
MOST EFFECTIVE SOLUTION FOR
OPIOID DEPENDENCE?
Ontario or northern Ontario
•
Abstinence/detox
•
Preventative health
•
Medication assisted therapy (meth/suboxone)
•
Psychosocial
•
Harm reduction strategies
MMT as the Most Effective Solution for
Opioid Dependence?
•
MMT is recommended as the most economical and effective strategy for
managing opioid dependence
•
Ontario clinical practice guidelines state that MMT is the standard of care for
treating patients with opioid dependence
•
Maintenance therapy has been shown effectively improve health and social
outcomes
•
Included on WHO list of essential medicine
Canada, 1973; Canada, 2002; Health, 2009; Herget, 2005
Combination of Programs as a Solution
for Opioid Dependence?
•
Programs offering combination of medication and counselling are associated with better
treatment outcomes
•
Recent systematic review found that a combination of psychosocial interventions and MMT have
positive outcomes on treatment attendance, drug use, drop out rates and opioid use
•
Cochrane review showed that provision of MMT should not be abandoned in the absence of
resources for additional psychosocial treatment
•
Switzerland - estimated that 22-24,000 people areopioid dependent, 16,500 of which are in
treatment and 92% are given daily doses of primarily methadone at conventional clinics
Ball, 1991; Amato, Minozzi, Davoli, & Vecchi, 2011; Dugosh et al., 2016
IS THERE A GAP BETWEEN
OPIOID TREATMENT AND
DEPENDENCE?
Ontario/ in northern Ontario?
Discussion
“Some rivalry, I believe, is going
on between the clinics,”
“There is just not enough demand
there for this kind of operation. We are
not that busy at all.”
Boyle, 2014
“…patients of the Northeastern Manitoulin Family
Health Team (FHT) will be accessing the services
of Dr. Dressler at his Espanola clinic at the
Espanola Family Health Team.”
Church, 2015; Expositor, 2015
Service vs. Need
•
Ontario MMT enrollment - 6,000
(2005) to 42,000 (2015), an increase
of about 70 % and fatal overdoses
have increased by 350%
•
United States MMT enrollment 230,000 (2003) to 340,000 (2011), an
increase of about 50 %
Volkow, Frieden, Hyde, & Cha, 2014; CPSO, 2015; Weeks, 2016
HOW ARE PEOPLE
RECEIVING OPIOID
DEPENDENCE CARE IN
ONTARIO?
Discussion
How are people receiving care in Ontario?
•
Patients receiving MMT often start treatment at a specialized addiction
clinic with the future possibility of treatment in a family physician's office or
community pharmacy following stabilization
•
Currently, 350 physicians are prescribing methadone to 42,000 individuals
in Ontario
•
Access to addiction therapy is not uniformly distributed across all regions of
the province
•
Longer travel distances, less service availability and longer wait times in
some areas of Northern Ontario
Brands, 2000; CPSO, 2015; Strike, 2011
Coordination with other part of the system
There is a disconnect between MAT and Mental health services
OHIP fee-for service clinics
Specialized MH and Addiction Services
■ Pharmacotherapy
■ Psychosocial counseling and treatment
■ Fee-for-service model
■ Accountable to Local Health Integration
Networks (LHINs) through service
agreements and/or other ministries
■ Under the general physician services
agreements
■ Direct link to the Ministry of Health and
Long Term Care (MOHLTC)
■ Physicians not usually affiliated
Weisner, Mertens, Parthasarathy, Moore, & Lu, 2001, Strike, 2011, Lawrinson et al., 2008
DO WE NEED A BETTER
CONTINUUM OF CARE?
Discussion
Current Research Project
1) Compare baseline characteristics of two exposure groups
•
adults in MAT for opioid dependence only
•
adults in MAT for opioid dependence and accessing specialized mental health and addictions
2) Define a relationship between the independent variable coordinated care and treatment outcomes such as:
•
treatment retention for one year
•
incarceration in the last year
•
overdoses in the last year
•
emergency department re-admission for mental health and/or addiction in the last year
3) Identify barriers and enablers to accessing mental health and addiction services in northern Ontario for adults in
MAT for opioid dependence?
References
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Amato, L., S. Minozzi, M. Davoli, and S. Vecchi. 2011. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of
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Association, A.C.H. 2013. National college health assessment II: Canadian reference group data report. , Hanver, MD.
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THANK YOU
Kristen Morin, Mph, PhD Candidate
[email protected]