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Opioids – A Review

Opioids – A Review. Presentation provided by Meldon Kahan , MD Family & Community Medicine University of T oronto. Fundamentals: Opioid Addiction. Conflict of interest statement. Dr. Christy Sutherland - none Dr. Elena Zoe Paraskevopoulos - none. Fundamentals: Opioid Addiction.

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Opioids – A Review

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  1. Opioids – A Review Presentation provided by MeldonKahan, MD Family & Community Medicine University of Toronto

  2. Fundamentals: Opioid Addiction Conflict of interest statement Dr. Christy Sutherland - none Dr. Elena Zoe Paraskevopoulos - none

  3. 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

  4. Fundamentals: Opioid Addiction Opioids: Overview of the The National Crisis

  5. Fundamentals: Opioid Addiction The Opioid Crisis • 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

  6. 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

  7. 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

  8. Fundamentals: Opioid Addiction The Opioid Crisis • 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

  9. Fundamentals: Opioid Addiction Case: Anna • 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

  10. 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

  11. Fundamentals: Opioid Addiction 9x increase in oxycodone-related deaths Dhalla et al CMAJ 2009

  12. 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

  13. Fundamentals: Opioid Addiction Opioids: Physician Perspectives

  14. Number of patients on opioids causing concernsWenghofer 2010 Fundamentals: Opioid Addiction

  15. Fundamentals: Opioid Addiction FPs very concerned about…

  16. Fundamentals: Opioid Addiction Opioids:Tolerance & Withdrawal

  17. 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

  18. Fundamentals: Opioid Addiction Tolerance • Neurobehavioural adaptation • Tolerance to analgesic effects develops slowly • Rapid tolerance to psychoactive effects • Tolerance disappears within days

  19. 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

  20. Fundamentals: Opioid Addiction Withdrawal: Time Course • Begins 1- 2 half lives after administration • Peaks at 2-3 days • Physical symptoms largely resolve by 5-10 days • Insomnia and dysphoria can last weeks to months • Symptoms quickly relieved with opioid use

  21. 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

  22. Fundamentals: Opioid Addiction Opioid Use Disorder: PREVENTION

  23. 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

  24. 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

  25. 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

  26. 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

  27. Fundamentals: Opioid Addiction Opioid Use Disorder: DIAGNOSIS

  28. 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

  29. Fundamentals: Opioid Addiction Laboratory Work • Elevated AST, ALT (viral or alcoholic hepatitis) • Gamma GT, MCV (alcohol) • Hepatitis B, C • HIV

  30. Fundamentals: Opioid Addiction Other Sources of Information • Addiction is chronic relapsing remitting disease • It is beneficial to obtain collateral information to make the diagnosis • Other physicians • Spouse, family • Urine drug screen history

  31. 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

  32. Fundamentals: Opioid Addiction Why do patients do this? • Overcome tolerance • Achieve psychoactive effect of euphoria • Avoid withdrawal • Financial gain

  33. Fundamentals: Opioid Addiction Limitations of behaviour monitoring • Patients will hide these behaviours • These behaviours not always seen if physician prescribes higher doses • Some patients take oral opioids without running out early yet experience psychoactive effects, withdrawal, dysphoria and decreased function

  34. 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

  35. Fundamentals: Opioid Addiction Types of UDS: Immunoassay • Opioids, cocaine, benzodiazepines etc. • Detects use for up to five days • False positive and False negativeare 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

  36. Fundamentals: Opioid Addiction Chromatography • Depending on your lab, you have to specifically ask for synthetic opioids such as: • Oxycontin • Hydromorphone • Fentanyl • Buprenorpine • Methadone

  37. Fundamentals: Opioid Addiction Opioid Use Disorder: TREATMENT

  38. Fundamentals: Opioid Addiction Management of Suspected Opioid Addiction • Buprenorphine • Methadone

  39. 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

  40. Fundamentals: Opioid Addiction Methadone treatment • Slow onset, long duration of action • Relieves withdrawal, cravings without sedation or euphoria • Can be monitored with UDS

  41. Fundamentals: Opioid Addiction Methadone • Three 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

  42. 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

  43. 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)

  44. 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

  45. Fundamentals: Opioid Addiction Addiction and pain: Paradigm shift • MDs see pain treatment in opposition to addiction treatment • ‘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 opioid-induced depression

  46. 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

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