1. Overview of Opiate Addiction

2. Conflict of interest – 2 talks for Purdue about dangers of opioid addiction Bias – support patients in both abstinence and methadone – but seeing more stability on MMT

3. Opioid Addiction in Canada Until 1990’s, heroin was the major opiate – mainly in coastal cities At the same time - Pain clinics were gaining acceptance for more opioid prescribing for pain Shortage of physicians – no longer one physician who knew his patients well over years of service

4. Then…. Mid 1990’s – oxycontin produced, with major marketing campaign Newfoundland had major “epidemic” of oxycontin addiction, which travelled westward – also widespread abuse of other prescription opioids In Ontario, aboriginal communities were particularly affected

5. Canada - World Leader

6. Where Are These Drugs Going?

7. Sad but True Physicians and prescriptions are part of the problem! Prescription opioids have surpassed heroin as the primary narcotic of abuse….Canadian Opioid Guideline

8. Opioid Addiction in Winnipeg Rare – some T & R addiction in the inner city – and codeine addiction 2005 – assessed ~20 patients with opioid addiction 2009 – assessed over 300 patients

9. Methadone Resources Until summer 2008, no wait list Now wait list at AFM methadone clinic is over 150 patients – wait time is months 2 other clinics providing services

10. Access to Methadone Brandon – wait list, new doctor starting Rural Manitoba – no MMT providers Comparisons MMT in Manitoba ~ 700 MMT in Saskatchewan ~ 2000 MMT in Ontario ~ 24,000

11. Does Access Matter? Patients in treatment often improve dramatically Patients on wait lists deteriorate (health and social consequences) and may die Crime decreases with treatment access

12. Typical Patient in 2007- 2008 Wave 1 – Suburban Middle-class male aged 17-30, with supports in regards to family, education, work, finances – using oxycontin, usually snorting - in significant trouble after 6-24 months of use with debt, some crime, estranged family, failing at school or work

13. Most stabilize rapidly They become tax-payers!

14. Demographics Evolve Wave 2 – inner city – more use of morphine and dilaudid - more injection use – multiple family members may use together (high rates of Hep C, some HIV)

15. Family Tree 2414201722 1 1

16. Treatment is more difficult because of chaotic lives The opioid addiction responds but many are repeatedly “knocked down by life” Past trauma issues resurface

17. Northern Ontario Reserves “I just admitted two young oxy- mothers…….the opioid wave has hit these communities like a tsunami” Dr M.D What’s going to happen in Manitoba? Who’s doing prevention?.

18. And in 2010… Ongoing oxycontin – now progressing to fentanyl with several deaths More rural patients More chronic pain patients with addiction More Women....and more babies More aboriginal patients

19. Harm and Injection Use Increasing rates of HIV in Manitoba IV drug use is a factor

20. Harm- Pregnancy and Families Increasing numbers of addicted mothers- diagnosed on the labor floor Babies require many days of care – and most are apprehended

21. Codeine Canada is the only developed country to sell over the counter codeine 80% of those addicted are female with a history of early life difficulties In their teens or twenties, they try T1’s or T3’s, and get a feeling of positivity and energy

22. Codeine After about 10 years, patients face increasing consequences – increasing dysfunction When we see them, they are using: 50-100 tylenol 1’s per day 20-50 tylenol 3’s per day adding benzo’s or gravol

23. Talwin Poor analgesic – T’s and R’s are a problem only in the prairie cities – “poor man’s speedball” Slow death from talc lung This is a combined stimulant/opioid addiction – methadone might bring stability

24. Percocet 5 mg oxycodone – widely available Oxycodone has surpassed marijuana as teenagers’ experimental drug of choice in the U.S. Swallow, chew, or snort – gateway to oxycontin

25. Oxycontin Oxycontin: comes in 10, 20, 40, 80 mg strengths. It can be chewed, snorted, or injected – then it is a rapid intense high “ Safe and fun”

26. Oxycontin…. Often minimal alcohol or cocaine – only the oxy matters Street benzo’s help withdrawal "I don’t even get high anymore..” Use ranges from 80-600 mg/day Costs 50 cents or more per milligram

27. Morphine and Dilaudid Injection use is more common with these Not much dilaudid use in Winnipeg, but increasing

28. Fentanyl Often cut up into “chiclets” and used orally Many reports of respiratory arrest and several deaths after injection use

29. Benzodiazepines Benzo’s are a problem too – widely sold Ashton manual – how to get people off (download from internet)

30. Abstinence and Success Rates Doctors – 90% abstinent Long term, street-hardened – 3% abstinent In Winnipeg – only a few successfully abstinent – over 90% relapse

31. Relapse is the Norm The death rate is higher in abstinence- based treatment, because tolerance is lost and accidental (or deliberate) overdose occurs Drugs are so available on the street – or by prescription - relapse is easy “my best friend is my neighbor – and my dealer!” Currently no long-term follow-up program to support abstinence

32. Methadone Reasonable to use as first treatment approach, especially in unstable lives

33. Methadone - Goals 1. Survival and stability 2. Stop opioids, stop injecting 3. Stop other drugs 4. Grow emotionally, develop success in life 5. Consider weaning off, ONLY if appropriate

34. It’s Not Just a Substitute Drug 1. They feel normal – energy goes into creating a life 2. Tight rules and consequences = structure 3. Relationships with staff promote maturity and emotional skills The patient is still on an opioid but the addictive behaviour lessens or disappears.

35. Methadone - Outcomes 30% do very well 30% markedly improved, still problems 30% somewhat improved 10% wean off or leave yearly

36. Methadone – if not done well… Death Diversion Dispensing errors Inappropriate patients in treatment Physician norms can change Education, support of colleagues, College oversight are all necessary

37. Suboxone ( a “milder” methadone) SUBOXONE - It has less side effects, and is much safer - and it’s easier to wean off In use in Europe for 10 years – too expensive for Canada? If you do the online course at www.suboxonecme.ca you can apply for a combined methadone/suboxone exemption www.suboxonecme

38. Financial Impact Cost of treatment – in methadone clinic, about $3000 per patient per year – in “methadone only clinic” about $1,000 per year Cost of an untreated heroin addict - $44,000 per year – costs include health, family services, incarceration, crime

39. Human Impact Most patients in methadone programs “get their life back” – almost all of my “young suburban” patients are back at school or work within a few months Patients not in treatment suffer financially and socially - risk of legal consequences and debt and family breakdown are huge

40. Challenge Stigma Preconceived ideas about addicts, treatment, hopelessness Methadone - Hard Work and Good Outcomes Go Unrecognized

41. So…. Support methadone clinics and patients in your community or hospital Consider becoming part of the prescribing network -full clinic -general practice following stable patients -hospitalist

42. Methadone Saves Lives