five things the family physician needs to know …...deaths due to prescription opioids has...
TRANSCRIPT
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Five Things the Family Physician Needs to Know about
Addiction and Harm Reduction
Dr. Sharon Koivu Palliative Care Physician Consultant,
London Health Sciences Centre, Department of Family Medicine,
Western University
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Presenter Disclosure:
Sharon Koivu has no potential for conflict of interest with this presentation
Five Things the Family Physician Needs to Know about Addiction and Harm Reduction
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1) Most Common Drugs Abused IV London, Ontario, 2013
1. Opioids
2. Methamphetamine (Crystal Meth)
3. Methylphenidate (Ritalin)
4. Cocaine
All are contributing to premature deaths of young people
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2) Misguided Physician Prescribing Habits has Contributed to the Problem
• Almost all opioids on the street are prescribed drugs that have been diverted,
• The age group most likely to divert their drugs is:
60-75
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Deaths due to Prescription Opioids has Surpassed Illicit Street Drugs!
• ~60% of all drug overdoses were due to
opioids (2006-2008)
• Death by drug overdose is equal to motor vehicle crashes as a cause of unintentional deaths, (as of 2006)
• Deaths from infections related to IV drug use are not captured in the statistics (therefore overall deaths surpass MVC)
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Canada now has the highest opioid use per capita in the world!
• USA 2nd
• Norway 3rd @ 40% lower
• 50% lower: Switzerland, Austria, Germany, Australia, UK, Belgium, New Zealand, Spain, Iceland
• 66% lower: France, Sweden, Netherlands, Finland
• 70% lower: Japan
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Ontario has the Highest Rate of Opioid Prescribing in Canada!
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London Middlesex Data
• 7,399 annual opioid prescriptions per 1,000 people aged 15-64 eligible for publicly funded drug coverage (top 40% in ON)
• 7.5 deaths per 100,000 from opioid overdose,
(fourth highest amongst all health units)
(2004-2006)
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Misguided Physician Prescribing habits has Contributed to the Problem
• 14 % of adolescents say they have used prescription opioids recreationally
• 75% got them from the medicine cupboard in their own home
(OSDUHS 2011)
Tell all your patients to lock up their opioids
Opioids kill more people than loaded guns
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Misguides Physician Prescribing habits has Contributed to the Problem
• Pain does not mask the euphoric effect of drugs
• People in pain can become addicted to opioids
• Susceptible people who would never have taken illicit drugs may be legally exposed to opioids by their physician
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Misguides Physician Prescribing habits has Contributed to the Problem
There is a ceiling on opioids!
• higher than 100mg morphine equivalent per day increases the risk of unintentional death
• higher than 200mg morphine equivalent per day increases the risk of hyperalgesia
• CPSO, Canadian Guidelines recommend a maximum of 200mg morphine equivalent per day in CNCP unless really good evidence that function is improving
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Misguides Physician Prescribing habits has Contributed to the Problem
• Purdue lost a $600 million lawsuit in 2007 for deceptive marketing about the addiction risk of OxyContin yet many physicians are still influenced by their message
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Misguided Physician Prescribing habits has Contributed to the Problem
• Prescribing opioids too often, too much and too little have all been shown to increase the risk of addiction
• Stopping opioids too quickly increases the risk of street use
• We need to prescribe wisely
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3)Harm Reduction Strategies Save Lives
• Over 2 million needles were exchanged in London (2013)
• We need to enhance our message
• Many IV drugs users do not understand the risk
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Infections Associated with IV drug use Can be Fatal
• Infective endocarditis
• Sepsis
• Respiratory
• Abscesses: lungs, spine
• HIV
• Hep C
• STD’s
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Infections Associated with IV drug use Can be Fatal
• 33% of patients admitted to LHSC with endocarditis die within 1 year regardless of treatment
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Harm Reduction Strategies
Do not share needles
prevents spread of HIV
Do not share spoons, cookers or washes
Prevents spread of Hep C
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Harm Reduction Strategies
What else do you need to tell your patients to prevent other infections?
• Do not reuse your own needles
• Do not be 2nd on the needle
• Do not use tap water
• Use sterile water only
• Do not use saliva
• Do not use corrosives to dissolve drugs
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Sterile Not for Injection
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Harm Reduction Strategies
What else do you need to tell your patients to prevent other infections?
• Use a filter each time you inject
• Do not reuse filters
• Use a proper filter not a cotton ball, tampon or cigarette filter
• Use the filter properly, Do not let the needle poke through the filter
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Try using this filter properly after a night of call
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Harm Reduction Strategies
What else do you need to tell your patients to prevent other infections?
• Use sterile technique to inject
• Find a safe injection site when and where possible
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Harm Reduction Strategies
What else do you need to tell your patients to prevent other infections? • Let your patients know that IV drug use can lead
to fatal infections such as infections of the heart valve
• Even if they do everything properly they cannot dissolve all the filler in prescription drugs
• These undissolved particles damage blood vessels and can lead to serious infections
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Harm Reduction Strategies
What else do you need to tell your patients to prevent other infections?
• Tampering with a PICC line increases the risk of fatal infections
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What is this?
You call this a PICC Line, I call this a trigger.
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4) Addiction Treatment Programs Do Work
Family physician is key to success
• Non-judgemental Support
• Recognize the patient may now be in a different stage of change in addiction
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Addiction Treatment Programs Do Work
Family physician is key to success
SBIRT: Screening
Brief Intervention
Referral to treatment
• Motivational Interviewing
• Celebrate successes
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Addiction Treatment Programs
Abstinence:
Withdrawal/De-tox
Out-patient counseling
In-patient residential
AA-NA
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Addiction Treatment Programs
Harm Reduction: Opioid Maintenance Programs: opioid agonist : Methadone Buprenorphine/Naloxone Opioid agonists are the only prescription medications approved for addiction treatment Prescribing opioids for addiction is NOT approved by CPSO
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Addiction Treatment Programs
Most successful:
Opioid Maintenance Programs in the context of an interprofessional team
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5) Opioid Overdose Prevention Strategies Save Lives
• As much as two-thirds of witnessed overdose deaths might be prevented if basic life support and the drug naloxone were given at the time of overdose.
• The training of drug users constitutes an essential resource in the management of opioid overdoses.
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5) Opioid Overdose Prevention Strategy
• There is identified and underused potential for peer education and intervention where significant others are trained in overdose recognition and management.
• Friends, family members and carers are often the ones to encounter someone overdosing on opioids and should be offered overdose training.
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Opioid Overdose Prevention Strategy
Starting Spring 2014 MLHU will be:
• Offering overdose training to IV drug users, peers, friends, family and caregivers
• Trained people will be provided with Naloxone Kits
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THANK YOU