1 / 46

Opioids – A Review

Learn about the opioid crisis, prescription opioids, prevention strategies, and management of opioid use disorder in this informative presentation by Dr. Meldon Kahan, MD. Understand the impact of opioids, case studies, physician perspectives, tolerance and withdrawal symptoms, and strategies for prevention and tapering.

rthomason
Download Presentation

Opioids – A Review

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related