Opioids: the latest battle in the War on Drugs Mark Yarema, MD - - PowerPoint PPT Presentation

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Opioids: the latest battle in the War on Drugs Mark Yarema, MD FRCPC Poison and Drug Information Service Alberta Health Services Alberta Adolescent Recovery Centre Workshop November 17, 2016 Disclosure I have no conflicts of interest.

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Opioids: the latest battle in the War on Drugs

Mark Yarema, MD FRCPC Poison and Drug Information Service Alberta Health Services Alberta Adolescent Recovery Centre Workshop November 17, 2016

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Disclosure

  • I have no conflicts of interest.
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Objectives

  • Review the following:

– Opioids and opioid receptors – Fentanyl / Carfentanil / W18 facts – Clinical features of opioid poisoning – Management of opioid poisoning – Take home naloxone program – Addiction primer – Resources – Summary

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2016 EU Drug Markets Report, April 2016

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Opioid Receptors

  • There are three main opioid receptor

subtypes:

– Mu (µ) – Kappa (κ) – Delta (δ)

  • Each major opioid receptor has a unique

anatomical distribution in the brain, spinal cord, and the periphery

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µ -Receptor Effects

  • Analgesia (supraspinal, spinal, peripheral)
  • Euphoria
  • Respiratory depression
  • Bradycardia
  • Gastrointestinal dysmotility
  • Physical dependence
  • Pruritus
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κ Receptor Effects

  • Analgesia (spinal)
  • Miosis
  • Dysphoric and psychotomimetic effects
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δ Receptor Effects

  • Analgesia (supraspinal and spinal)
  • Cough suppression
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Opioid prescriptions

  • Canada: 2nd largest per capita consumer
  • f prescription opioids
  • Ontario, 1991-2007: oxycodone

prescriptions increased 850%

  • USA, 1997-2007: opioid prescriptions

increased 700%

  • USA, 1997-2007: number of grams of

methadone prescribed increased by 1200%

Dhalla et al. CMAJ 2009 Dec 8;181: 891-896

  • Boyer. NEJM 2012;367:146-55
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Dart et al, NEJM Jan 15, 2015

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What The Fentanyl?

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Fentanyl fatalities in Alberta

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Background

  • Opioid analgesic
  • 100 times more toxic than morphine

– 100 mcg = 10 mg morphine

  • Abused as heroin substitute
  • Controlled substance most often abused

by anesthetists

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Kinetics

  • Absorbed IM, IV, PO, intrathecally,

intranasally or transdermally

  • Rapid onset of action (seconds-minutes)
  • Duration of action 0.5- 2.0 hours (IV)
  • Available forms (pharmaceutical): lozenge,

patch, IV

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The patch

  • For chronic pain
  • Abused by eating, smoking, injecting
  • Substantial amounts of drug remain on

used patches (50% after 72 hours)

  • Case reports of drug abusers removing

patches from dead bodies

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The pill

  • Green (primarily), sometimes white or pink
  • CDN 80 markings
  • Made to look like oxycodone 80 mg tablets
  • Sources in Calgary

– Fentanyl powder imported from China – Domestic clandestine labs (Lower Mainland BC, Calgary)

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Street names

  • Greenies
  • Green beans
  • Beans
  • Green apples
  • Apples
  • Shady 80’s
  • Fake oxy
  • Oxy
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Other Fentanyls

  • There are over 12 different analogues of fentanyl that

have been produced in clandestine labs; they include: – Carfentanil – Acetylfentanyl – 6 butyrfentanyl – 3-methylfentanyl – Furanylfentanyl – Alfentanil – Sufentanil

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Carfentanil

  • 100 times more toxic than fentanyl
  • RCMP state one kilogram of carfentanil

can produce approximately 50 million fatal doses

  • It is available commercially in the

veterinary industry as a tranquilizer for large animals

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W-18

  • Although W-18 was initially developed for its analgesic (pain killing)

potential, there are no published studies or case reports regarding its use for this

  • Although W-18 and W-15 have been suggested to be potent opioids,

investigators in North Carolina found them to be without detectible

  • pioid activity at μ, δ, κ and nociception opioid receptors in a variety
  • f assays
  • Lack of data about toxicity, bioavailability, tolerance, half-life and
  • nset of effects for W-18 could lead users to rely on self-reported

experiences and other information from user web forums

  • Counterfeit tablets containing W-18 have been made to appear like

prescription oxycodone tablets

  • Bottom line: does not appear to be an opioid, at least in research

studies

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Opioid overdose: Clinical features

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www.drugsfool.ca

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Management

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ABCDEFG’s of toxicology

  • Airway
  • Breathing
  • Circulation
  • Decontamination
  • Elimination
  • Find an antidote
  • General management
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Naloxone

  • Opioid antagonist
  • IM, IV, SC, endotracheal, intralingual,

inhalational

  • Only 10% absorbed via PO / SL routes
  • Dose: 0.04 to 0.4 mg IV in adult, 0.1 mg/kg

IV in peds

– May repeat Q 2-4 min up to max. 10 mg – If no response after 10 mg, search for alternative diagnosis

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Naloxone

  • Reverses effects at opioid receptors
  • Duration of action 20-90 minutes
  • May need repeat dosing as naloxone

wears off before most opioids do

  • Continuous infusion may be preferred to
  • ngoing repeat bolus dosing
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Take home Naloxone (THN) program

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Responding to an opioid overdose

Stimulate – call 911 Airway Ventilation (rescue breathing) Evaluate the situation Muscular injection of Naloxone Evaluate again (continue rescue breathing)

If you ever have to leave the person alone, put them in the recovery position

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THN in Alberta: Update

  • Virtual ECC developed October 2015

– Converted to Harm Redn Cmte February 2016

  • January 25, 26, 27, 29: AHS-sponsored Fentanyl/THN

learning sessions for AHS employees

  • As of Sep 30 2016, 6,450 THN kits distributed with 472

reversals reported

  • As of Oct 17 2016 almost 900 sites have been registered

to distributed THN kits, including 722 community pharmacies

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Looking beyond the drug: the disease of addiction

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Addiction is…

  • A primary, chronic brain disease of brain reward,

motivation, memory and related circuitry

  • Dysfunction in these circuits leads to

characteristic biological, psychological, social and spiritual manifestations

  • This is reflected in an individual pathologically

pursuing reward and/or relief by substance use and other behaviors

http://www.asam.org/quality-practice/definition-of-addiction

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Addiction is…

  • Characterized by:

– Inability to consistently Abstain – Impairment in Behavioral control – Cravings – Diminished recognition of problems with behaviors and interpersonal relationships – Dysfunctional Emotional response

http://www.asam.org/quality-practice/definition-of-addiction

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Addiction thrives on…

  • Fear
  • Isolation
  • Loneliness
  • Low self-esteem
  • Shame

– “I am bad.”

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Contributors

  • Genetics
  • Environment
  • Disruption of healthy social supports
  • Trauma/stressors that overwhelm an

individual’s coping abilities

  • Co-occurring psychiatric disorders
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Words of wisdom

  • “We can’t arrest our way out of this

problem.”

  • “Addiction should not be treated as a
  • crime. It should be treated as a disease.”
  • “When it comes to treating a person with

addiction, see that person as a person.”

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Ways forward

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Children

  • You Have a Unique Voice - Use It!
  • Trust your instincts
  • Know the facts
  • Talk to an adult
  • Choose your role model(s) wisely
  • Hang with "supporters”
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Parents

  • Stay involved
  • Use the news
  • Just the facts
  • Side by side
  • Spot the signs
  • Tell them you care
  • Be honest
  • Consistent boundaries
  • Have the talk more than once
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Protective factors

  • Individual

– High self esteem, confident, positive outlook – Good communication and social skills (assertiveness)

  • Friends

– Positive peer group activities

  • Family

– Good relationship, strong bond, parents involved

  • Community

– Supportive, caring – Opportunities for involvement

  • School

– Supportive, caring – Clear standards and rules – Opportunities for involvement

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Prevention

  • Physicians

– Responsible prescribing – Prescription monitoring programs – “Opioids to go” - ED/Urgent Care universal policy – http://nationalpaincentre.mcmaster.ca/opioid/ – Opioid substitution therapy

  • Manufacturers

– Honest marketing – Fund objective prescribing information programs

  • Patients

– Education about effects of opioids

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Methadone clinics in Alberta

  • CALGARY

– AHS Opioid Dependency Program Phone 403-297-5118 – Second Chance Recovery Phone 403-232-6990

  • EDMONTON

– AHS Opioid Dependency Program Phone: 780-422-1302 – Metro City Medical Clinic Phone: 780-429-3991 – Panorama Medical Clinic Phone 780-471-4434

  • LETHBRIDGE

– North Side Medical Clinic Phone 403-942-3003

  • MEDICINE HAT

– Chinook Alberta Methadone Program Phone: 403-504-1874 – Medicine Hat Addiction Clinic Phone: 403-487-3944

  • RED DEER

– Central Alberta Methadone Program Phone: 403-309-3652

http://www.cpsa.ca/physician-prescribing-practices/methadone-program/methadone-clinics-alberta/

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Resources

  • Alberta Health Services

– www.drugsfool.ca (for info on fentanyl and THN kits)

  • Government of Canada National Anti-Drug Strategy

– http://www.healthycanadians.gc.ca/anti-drug-antidrogue/index-eng.php

  • Canadian Centre on Substance Abuse

– http://www.ccsa.ca/Pages/default.aspx

  • Addiction: The next step

– addictionthenextstep.com – “Wasted” – documentary on The Nature of Things Jan 21, 2016

  • Addiction & Mental Health 24 Hour Helpline

– 1-866-332-2322

  • Partnership for a Drug Free Canada

– http://www.canadadrugfree.org/

  • Poison and Drug Information Service

– 1-800-332-1414 – www.padis.ca

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Take home points

  • Variable content of non-pharmaceutical fentanyl
  • Fentanyl and other opioids: small pupils,

decreased respiratory rate, decreased level of consciousness

  • Treatment: ABCDEFG / SAVE ME
  • There will be more “fentanyls” in the future
  • Understand addiction as a primary brain disease
  • Have “the talk” (more than once)
  • “See that person as a person.”
  • Help is available
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www.padis.ca

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If you tweet…

  • AARC: @helpteenaddicts
  • Dr. David Juurlink: @DavidJuurlink
  • Dr. Hakique Virani: @hakique
  • Dr. Mark Yarema: @mcyarema