Category: Overdose

Dr Wood tells the forum recipe for research-centre success

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In a talk at the 2017 National Institute of Drug Abuse meeting on June 17th, Dr Evan Wood pondered lessons learned and success tips derived from his team’s experiences of building an International centre on substance use. The key ingredients in the recipe for success of research centre on substance use were:

Emphasize research productivity. Integrate educational opportunities and mentorship at every step. Use interdisciplinary approach wherever possible. Integrate research alongside clinical care.

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From AIDS to opioids

Historically, the new BC Centre on Substance Use grew out of HIV research centre for excellence. The emergence of powder cocaine in 1990’s led to an HIV outbreak in needle exchange when it was believed to be under control. This helped the team to make a compelling case about their unique situation for funders like the National Institute for Drug Abuse. Next, a centralized database of people treated on anti-retroviral treatment (ART) contains all data on everybody living with HIV in the province. This database enables longitudinal survival analysis of HIV outcomes. Using this data, another prospective cohort study of injecting drug users has demonstrated how the viral load went down between 1996-2004. Furthermore, the first supervised injection facility in North America – Insight – has led to about a dozen of supervised injecting facilities in the area nowadays. In sum, the evolution of the centre from HIV treatment to HIV prevention and now to addiction treatment (because of the population of study) is a result of concentrated efforts by researchers, providers and the community.

Current priorities

The centre’s mission is to provide provincial leadership in substance use and addiction research, education and clinical care guidance and to seamlessly integrate these pillars to help shape a comprehensive, connected system of treatment and care that reaches all British Columbians. (taken from www.bccsu.ca)

Co-speaker presentations

International sites with rapidly evolving HIV epidemics in patients with substance use disorder present an opportunity for rapid scale-up of interventions once proven efficacious with a promise of large public health impact (text taken from www.drugabuse.gov). The three speakers in this session moderated by Petra Jacobs, entitled “Research on HIV and Substance Use Disorder: International Perspectives,” including Drs Wood and Korthuis, have presented several research projects supported by NIDA and other institutions. I have attended the session. The discussant, Dr Metzger, closed the session with concluding remarks.

Does alcohol use change after shift to Methadose?

alcohol drink, methadose
Do people drink more when they switch to Methadose? It is 10 times more concentrated than methadone –  proven treatment of opioid use disorder. We did not find more drinking after the switch. But others found changes in opioid use patterns coinciding with the change.

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We talked to 787 people receiving methadone for opioid use disorder in Vancouver, Canada.  Our new study followed them as they switched from methadone (1mg/mL) to Methadose (10mg/mL). We asked whether their drinking has changed after the switch – between 2013 and 2015. 16% said they drank too much at least once in the last six months. Those who drank too much were not more likely to do so after the shift to Methadose. The Substance Use& Misuse journal has published the study this week. 
Persons on methadone for opioid use disorder may report going through opioid withdrawal and increasing their illicit opioid use when switched to Methadose. We need to understand impacts of these changes on other forms of drug use. Careful and planned information about upcoming changes may help people cope with the potential risks better.

Conclusion

In sum, change is the law of life. Those who do not change do not survive in nature. For complex systems, such as health care, change management is the key to success. Healthy, happy and satisfied patients are healthcare’s success best proof. If they self-report negative experiences following methadone changes, their opinions should inform change management in order to build a better, patient-centered care. Their opinions, together with our findings, could help future formulary decisions in addiction treatment. Various methadone formulations may have little short-term impact on heavy alcohol use. Let’s evaluate the long-term impact.

Double trouble: opioids and pain among people with substance use disorders

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Against the use of opioids for chronic non-cancer pain to people who have active substance use disorders advises the third recommendation in the new opioid therapy guidelines (May 8th, 2017).

However, this “strong” recommendation is based on low quality of evidence from studies that rarely involve people with active substance use disorders (SUD).

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Here, we first highlight the main caveats in the research of pain treatment among people with SUDs, why this has been the case and then we offer potential solutions for overcoming the obstacles in clinical research and policy.

Most clinical trials of pain medications exclude people with SUDs. Denying treatment of pain with opioids to people with active SUDs in the absence of evidence, based on a presumed potential for “more” addiction and documented adverse side effects (overdose), is cautious. However, it is also likely influenced by stereotypes and stigma towards people who use drugs and it further discriminates people with SUDs. Instead of stigma, the society should seek better ways of increasing rapid access to evidence-based opioid agonist therapy for prescription opioid use disorders (see Ahamad & Socias, 2016).

Moreover, this approach can lead to unanticipated consequences, such as seeking illicit drugs (see Voon et al, 2015). It is clear that we need more research to better understand pain treatment among people with SUDs and to give better recommendations to clinicians. But what kind of further research? Firstly, we need clinical trials that specifically include people with SUDs, such as people receiving opioid agonist treatment (Ti et al., 2015). If trialists refuse to include people with pain and concurrent SUDs into pain trials, presumably because of their high-risk for more SUDs, this obstacle can be overcome by including a standardized measure of pain, like the VAS, into every pharmacotherapy trial of SUD treatment.

Which pain patient treated with opioids will develop opioid use disorder?

Secondly, we still don’t know which pain patient treated with opioids will develop opioid use disorder (OUD). Despite the typical occurrence of OUDs among approximately 5.5% of the study populations in pain trials, there is no evidence for a reliable predictor of who will develop OUD. We need to find valid risk indicators.

Finally, the current opioid overdose crisis in many countries is primarily driven by not-as-prescribed-use of fentanyl – an anesthetic used to tranquilize elephants. What if people with opioid use disorders self-medicated their pain with fentanyl (see Voon et al., 2015)? What if their pain, both emotional and physical, was as big as elephants and we had nothing for them? What we offer to them is suspicion, exclusion, denial and mistrust. We should offer compassion and fairness.

Cited sources:

  • Busse, J. W., et al. (2017). “Guideline for opioid therapy and chronic noncancer pain.” Canadian Medical Association Journal 189(18): E659-E666.
  • Socias, M. E. and K. Ahamad (2016). “An urgent call to increase access to evidence-based opioid agonist therapy for prescription opioid use disorders.” Canadian Medical Association Journal 188(17/18): 1208.
  • Ti, L., et al. (2015). “Denial of pain medication by health care providers predicts in-hospital illicit drug use among individuals who use illicit drugs.” Pain Research & Management 20(2): 84-88.
  • Voon, P., et al. (2015). “Pain among high-risk patients on methadone maintenance treatment.” The journal of pain 16(9): 887-894.

Bring Audrey back: Teaching medical students about substance disorders

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When is the best time to teach medical students about substance related disorders?  In a new commentary published online in Annals of Internal Medicine, we bring Audrey’s story and call for better addiction medicine education for physicians.

For over 20 years at the University of British Columbia, the first year medical students have had 20 hours of teaching on the theme Addiction Medicine and Inter-collegial Responsibility which has been both highly rated by medical students and has improved their motivational interviewing.  (more…)

Naloxone and Irish Primary Care Practitioners

We wanted to know what General Practitioners’ (GP) views and experiences of opioid addiction, overdose care and naloxone provision are. Naloxone is an antidote to opioid overdose, also known as Narcan.

How was the study done?
We sent 448 GPs an anonymous postal survey.
They all had students on placements from University College Dublin in Ireland.
Over 75% of GPs had patients who used illicit opiates, and 25% prescribed methadone to treat opioid use disorders.



What did the study find?
We found that two thirds of GPs were in favour of a project to increase naloxone availability in the community; almost one third would take part in such a scheme. Intranasal naloxone was much preferred to single, or multiple dose, intramuscular naloxone.  Few GPs objected to wider naloxone availability.
Irish primary care doctors are keen to distribute Naloxone in the community.
Why is the study important?
Every year, more people die in Ireland due to opioid overdoses than in car accidents.
Over 200 overdose deaths occur annually in Ireland.  Overdose prevention and management, including naloxone provision, should be a priority for healthcare services.   Naloxone is an effective treatment and is now being considered for wider lay use. This study showed that general practitioners commonly provide healthcare for patients with opiate use disorder and want more naloxone in this setting.

Reference:
Barry, T., Klimas, J., Tobin, H., Egan, M., Bury, G. (2017) Opiate Addiction and Overdose: Experiences, Attitudes and Appetite for Community Naloxone Provision. British Journal of General Practice. In press  http://bjgp.org/content/early/2017/02/27/bjgp17X689857/tab-article-info