Addiction by Prescription Opiates Helping Your kid in Trouble

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1 Addiction by Prescription Opiates Helping Your kid in Trouble Dr. Lindy Lee, M.I.N.E. Program, AFM Talia Weisz, Clinical Liaison, Opiate Assessment Unit

2 Who am I? - emergency physician for twenty years at HSC 2003 addiction unit in Winnipeg 2005 oxycontin arrived Started doing detailed assessments and treatment planning with Talia Weisz development of Opiate Assessment Team HSC worked to increase methadone resources

3 Son Daughter Aware of easy access to drugs in society today

4 Rx Opiates & Opioids Codeine (Tylenol 1, 2, 3, 4) Morphine Hydromorphone (dilaudid) Oxycodone (percocet, oxycontin) Fentanyl patches Methadone

5 Illegal opioids. Opium products fentanyl powder heroin

6 What do Opioids Do? 1. they treat acute pain 2. they help some people with chronic pain 3. they make some people feel very good addiction 4. they can cause sleepiness/coma/death

7 Contin = long acting Oxycontin long-acting oxycodone But if crushed, snorted, injected it becomes high-dose, fast-acting opiate

8 History Lessons Opium has been found back to 4000 B.C. Physicians frequently prescribed opium for physical or emotional distress

9 Eras of Increased Use Laudanum and Victorian England Opium in China British desire for trade/money 1920 s Vietnam

10 Fixing the Problem. 1. A crime approach lock them up 2. Social philosophy just say no! 3. Abstinence-based addiction care 4. Medication-assisted recovery (methadone)

11 Opioid Addiction in Canada Until 1990 s, heroin was the major opiate mainly in coastal cities Around Pain clinics were gaining acceptance for more opioid prescribing for pain

12 Then. Mid 1990 s oxycontin produced, with major marketing campaign Newfoundland had major epidemic of oxycontin addiction, which travelled westward Many aboriginal communities were particularly affected

13 Canada - World Leader

14 Canada/US More opioids prescribed per person than anywhere else in the world!!! England ½ our use Japan 1/30 our use Cuba 1/300 our use

15 Where Are These Drugs Going? A significant amount is doing to abuse and diversion

16 New England Journal of Medicine A Flood of Opioids, a Rising Tide of Deaths Nov 18, 2010

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19 Expensive Complications IV use can lead to - deep body infections (endocarditis) - HIV - Hepatitis C

20 Different Opioids - Distinct Patterns Addicts often have a drug of choice

21 Codeine Canada sells over the counter codeine (Tylenol 1) Usually women with difficult early life try T1 s or T3 s and get more energy, and less anxiety After 5-10 years, using T1 s a day, increasing dysfunction at work and home

22 Percocet 5 mg oxycodone Swallow, chew, or snort use tabs/day Gateway to oxycontin

23 Oxycontin Oxycontin: comes in 10, 20, 40, 80 mg strengths. Meant to be long-acting, however it can be chewed, snorted, or injected then it is a high-dose, rapid acting drug hillbilly heroin Addicts use mg/day Cost $1 per mg stealing, dealing, prostitution

24 Is Oxycontin More Addictive? It is more appealing to new users because it is snorted (not injected) Less sedation/ more energy so work and family don t notice

25 Oxy-Neo to decrease abuse Hard shell is difficult to crush If crushed and snorted.. jellynose Not popular with addicts

26 When oxycontin was taken away More IV drug use - dilaudid, fentanyl, increased deaths, more medical illness More heroin use in some communities (oxycontin is back..cheaper than before)

27 Morphine and Dilaudid Injection use is more common with these

28 Fentanyl patches (meant to last 3 days) Often cut up into chiclets and used orally Or, to inject, extract the gel by mixing with vinegar or acetic acid Many patients report near-deaths or knowing of friends who died

29 Street Methadone Bought to experiment or to treat withdrawal Can be lethal - someone tries methadone, falls asleep, found dead in the morning

30 Where do people get their drugs? Local prescribers I rolled my truck I didn t break anything but talked my doctor into 600 mg oxy a day I think one couple was making $14,000 month selling their opiates I gave my friend $150 and he came back with an oxycontin script for me

31 Addicts Seeking Treatment

32 It s the only treatment option he has under his current health plan.

33 Opioid Addiction in Winnipeg Manitoba traditionally used abstinence-based treatment small methadone program 2005 assessed about 10 patients with opioid problems 2009 assessed over 300 patients with prescription opioid addiction

34 Typical Patient in Wave 1 Suburban Middle-class male age 17-30, support from family, educated, social skills Using oxycontin, snorting - in trouble after 6-24 months with debt, crime, furious family, failing at school or work

35 What Happened?

36 10% - experimenters 30% - significant trauma or psych illness 60% - sad, stressed, family or school difficulties Often family history of addiction

37 Risk Different Response to Opioids Many people dull response to opioids dislike the side effects Our opioid patients confidence, relief of anxiety, energy

38 The sensible adult. Doctor: I got 2 T3 s for my episiotomy pain I loved it! I was floating away..i knew I really had to avoid them in the future.

39 The Teenager - Oxy Fixed Me I was a nerdy procrastinator in a family of achievers. I was fourteen and found a percocet in the medicine cabinet I took it and went to a party I was funny, danced with any girl I liked, and felt high, confident and energetic. I knew I had found the answer to my problems. 4 years later debt, crime, despair

40 a professional rx oxy I loved my job, my family, sports. Then I had a car accident and hurt my foot These drugs do so much for me, I can t believe that everyone who uses them doesn t get addicted..

41 If Opioids Make Them Feel Better Intermittent use becomes daily use They want higher doses They start to experience withdrawal Now they have to use drugs just to feel normal and try to keep going drug-sick, draggy They hate their habit but can t stop all that matters is opiates and money for opiates

42 Demographics Evolve Wave 2 inner city more use of morphine and dilaudid - more injection use multiple family members may use together

43 Family Tree

44 Treatment.everyone wanted abstinence Over 90% relapsed within 6 months Serious overdoses; deaths; health problems; legal issues What to do?

45 Methadone Traditionally used for longterm addicts who had failed abstinence treatment Is it reasonable to use for young prescriptionopioid addicts?

46 Abstinence It s the obvious solution! Is it? Success rates are problematic and death rates are higher Ontario most of the young addicts going on to methadone

47 Abstinence and Success Rates Doctors 90% abstinent Long term, street-hardened 3% The new wave of 1-2 years prescription opioid abuse minimal success in Manitoba with abstinence

48 Hazeldon Program Major abstinence-based program in Minnesota Looked at their relapse and death statistics in their opioid-addicted patients Now offering suboxone

49 Relapse is the Norm Drugs are so available friends are users There may be months of feeling flat and sad and facing consequences Many are reluctant to get involved with AA or NA

50 Planning Treatment Detailed assessment build trust and rapport Abstinence and methadone options discussed Treatment for abstinence withdrawal management, residential treatment, NA or AA OR Methadone read, visit a clinic, start outpatient treatment

51 Treatment not just detox! It s a combination of -medication -emotional and cognitive skill building -new values, new friends, new activities -living a meaningful, responsible connected life -relapse and learning -AA or NA support

52 Nichole wants abstinence Pretty, well-spoken, intelligent hx of early childhood trauma, raised by relatives, good student planned to do medicine or nursing Age 19 addiction to percocet, T1 s, T3 s adept at doctor-duping Overdose truth comes out admitted to ward relapses day of discharge another overdose

53 Nichole More serious attempt detox, women s treatment program, goes to NA daily for months, sees counsellor At 6 months: I am just having some mornings where I don t wake up and think about pills first thing..i m starting to have more hope Stayed clean, in university

54 Pathway to Abstinence Plan and book treatment go through withdrawal (alternative try taper with a doctor) Make major life changes with help such as AA. NA, treatment programs Is there medical or psychiatric illness that needs treatment? It takes time (months off work, school)

55 Going Through Withdrawal Physical severe for about a week ache all over, headaches, sweats, restless arms and legs, nausea, vomiting, diarrhoea Emotional agitation, can t sleep, craving, compulsive thoughts about drugs, may lie to sneak drugs Prolonged period no joy, no energy, craving

56 Detox Cold-turkey in safe setting Or, medical support in safe setting Significant risk of relapse/death after detox Detox is not treatment!!!! Just a first step

57 Taper With a Doctor It rarely works if the patients are addicted and can return to street access of drugs It keeps it a secret it has no recovery work attached They often try to get extra to sell they start street use again they manipulate the doctor tight contract and daily dispensing!

58 ? Private Residential Program Great programs Ontario and BC cost about $30,000 for a month Family week Patient comes back to same life/same friends/debt to parents

59 Georgia choosing methadone 17 lives with disabled mother in 1 bedroom apartment was good student but isolated and sad started THC school work failing found oxycontin dropped out of school to work & pay for oxycontin often no money, in and out of withdrawal - hopeless, 2 overdoses Wanted methadone mom and grandma came in to discuss it

60 Georgia Adolescent - needed psych consult, second opinion GP did daily dispensed low dose oxycontin for 2 months immediate stability Started methadone, stopped using oxycontin - one brief relapse with friend at one year Finished grade 12, now in university Weaned off methadone in 3 years

61 Bobby and Sandy Ran away from home and difficult lives at age 15 and 13 survived with minimal income raising two kids alcohol, crack, anxiety-pills used a lot Oxycontin severe debt within months, lost housing, couldn t feed kids, begging for treatment but no spots for 6 months Kids taken into care by C&FS

62 Bobby and Sandy Started methadone within 6 months had stopped opiates, crack, benzodiazepines, alcohol Bobby had jail time, drug court, went back to school for his Grade 12 Sandy had baby, responsible parent Methadone doses weaned down from 160 to 80 Still trying to get their older kids back after 4 years in care 4 visits a year!

63 How Does Methadone Work? Long-acting drug makes you feel normal - with no craving and no sedation gives you back the time & energy to have a life Rules & consequences Relationships with clinic staff honesty, hope, humor - longterm program, time to grow up

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65 Methadone Clinic Models - methadone only -methadone with counselling - methadone with comprehensive health care Opioid use decreases by 50-90% depending on clinic model and severity of social problems

66 Suboxone (Buprenorphine/Naloxone) milder methadone It has less side effects, and has a lower mortality rate, easier to taper off Widely used in Europe and United States too expensive for Canada? Allowed for a few.

67 Methadone - Goals 1. Survival and stability 2. Stop opioids, stop injecting 3. Stop other drugs 4. Grow emotionally, develop success with work, family, school, life 5. Consider weaning off, if appropriate

68 Methadone - Outcomes Almost all stop opioids. Most stop other drugs (except marijuana). Most return to productive lives. They keep their treatment a secret. Stigma and social judgment are big problems Some wean off after 2-5 years.

69 pa Dad will the heroine go into rehab?

70 Family Facing The Problem

71

72 Recognizing Opioid Addiction Is it obvious? Might be sedated, with small pupils Withdrawal bad flu with big pupils Often hide the problem for months family not aware until person is desperate, moody and irritable, legal issues arise, or money is stolen

73 Family No Idea I was sixteen and addicted to oxycontin. My family didn t have a clue. We took the family dream vacation to Disney World and I spent the whole time lying in bed and puking. No one had a clue I was in withdrawal. I thought at least I d be clean but as soon as we got back to Winnipeg I started using again.

74 Lana University student, 21 she and her boyfriend addicted to oxy/fentanyl for 2 years 2 episodes of resuscitation after accidental overdose On methadone for 2 years, doing well Family completely unaware of addiction, of near-death overdoses, or of treatment

75 Family Finds Out Jump to control and police Want a fast fix secret Reactive emotions and actions, anger and tears Shame, guilt, shock, fear Be tough or be kind? All energy is sucked up by the kid in trouble for months.

76 Moving Ahead Listen, how big is the problem? Assess safety your kid your family Work as partners work to keep a positive life Find out about help for your kid Find out about help for you You cannot dictate or control what your kid will do

77 Help for your Kid Addiction Foundation of Manitoba Multiple other programs centralized intake with options at Riverview (open in May) Check out AA and NA Check out abstinence and methadone/suboxone Visit the family doctor (?brief opioid rx to stabilize) he can refer to HSC Opiate Team

78 Help for You AFM family program Al-anon or Families Anonymous Keep a positive life with partner, other kids, life in general Some parents face their own addiction issues and get help

79 What Do We Need to Do? Fight stigma make treatment available - celebrate success Change attitudes towards addictive prescription drugs physicians and society

80 Solutions Multiple task-force reports since 2004 Change physician prescribing Change attitudes of public towards these drugs Increase treatment availability Decrease stigma

81 Major reports/taskforces 2013: First Do No Harm (federal, CCSA) 2011:Avoiding Abuse, Achieving a Balance (Ontario) 2007:Methadone Maintenance Treatment Practices Task Forces (Ontario) 2004:Oxycontin Task Force (Newfouindland)

82 Allow Both Treatment Options Methadone and abstinence based programs both need support and to respect each other Recovery & life-skills are essential for real progress whatever treatment you follow

83

84 The 4 C s CONTROL is lost or one is struggling for control CRAVING (drug-hunger) COMPULSION (constant preoccupation) Negative CONSEQUENCES ensue but one can t stop using

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