The opioids and addiction mismatch

hammer and spanner mismatch

Will an increasing pressure on prescribers curb the rising opioid overdose rates?

With only 0.5% of patients prescribed opioids reportedly developing addictions, there must be something else going on that’s making people overdose. A mismatch. Research on this topic is messy and patchy–– simply put, the large correlational research and incidence studies of addiction do not match up. In a recent commentary, we outline how prescription opioids might indirectly influence the rising overdose and addiction rates.

Mismatch: Why Correlation and Incidence Might Not Match Up

First, diversion gets medically prescribed opioids (MPOs) to those who are not prescribed the medication. Diverted MPOs can be sold, gifted (mostly to family members or friends), stolen, or sometimes obtained through “doctor shopping”, where patients get the same prescription from multiple physicians. But we don’t know how much diversion is due to sold, gifted or stolen medicines. How much do the different diversion types contribute to addiction and overdose? And for that matter, how much is diversion occurring, and to what extent is it contributing to national opioid crises?

We need to start accepting that biological factors are a part of this picture

Second, because overdose is often preceded by addiction, many researchers have focused on the persons who develop an addiction when prescribed opioids. However, if addiction doesn’t come before overdose, some high-risk patients go unstudied, and thus unreported. This has been shown in some states, such as West Virginia, where prescription opioids contributed to 93% of overdose deaths and very few of the deceased had iatrogenic addiction. So, some people might be at risk of sudden overdose but are missed in research studies that focus on medical diagnoses of addiction. This gap in the research is likely due the difficulty of studying overdose risk without the presence of addiction.

Polydrug use and overdose

Third, polydrug use may lead to overdose in people who use prescription opioids but do not specifically have addiction to their MPO. Here benzodiazepines are a big issue. It is important to note that many studies of addiction to MPOs do account for polydrug use by incorporating urine drug screens; however, positive results are often lumped together with other “aberrant” behaviours such as failed pill counts or requesting opioids from multiple doctors. Ultimately,  we can’t tell how much polydrug use is really leading to addiction or overdose in this context.

Finally, it is possible that incidence studies to date could be misrepresenting the true risk of addiction to MPOs. Studies of OUD incidence in pain care use definitions of addiction that range from very broad to highly specific, mixing up terms like “dependence”, “abuse”, “misuse”, or “problematic use”. This could make it so our guesses about the risk of addiction to MPOs are muddled, leading to skewed results.

We need to understand better if reduced opioid prescriptions can reduce the opioid crisis. Then we can make the change happen.

To read the whole commentary, please visit the journal website www.canadianjournalofaddiction.org or lookup the paper using the following citation:

Gorfinkel, L., Wood, E., Klimas, J. (In Press) Prescription opioids, opioid use disorder, and Overdose Crisis: Current Dilemmas and Remaining Questions. (Published ahead of Print, June 4th) Canadian Journal on Addiction

I thank Lauren Gorfinkel for feedback on this post.

If you enjoyed reading this post, you may also like my poem about pain. See link below:

Place matters, teachers and learners #CCME18

mountain climber

We learn best in places that support our learning and our bio psycho socio spiritual development – from toddlers to elders, reports Jan Klimas from the Canadian Medical Education conference #CCME18.

Starting in Toronto, Justin Hsu and colleagues from University of Toronto described how they improved spaces for communities in teaching ambulatory care, or the so called Medical Education Teaching Clinics (METC). They plan to evaluate METC clinics via audit of referrals to the teaching clinic and the learner satisfaction survey.
Presentation title: Creating unique spaces to support community-based ambulatory care education: the E3 experience.
Presentation authors: Jerry Maniate, Elizabeth Wooster, Douglas Wooster, Justin Hsu

British Columbia quality matters

Jan Klimas’ team from University of British Columbia evaluated hospital as a place of learning about substance use disorders. Who learns most about addictions in hospitals? Using mixed-methods approach, this team showed that medical students get more out of a rotation in hospital than residents or senior learners. Especially in the areas of safe prescribing, screening and withdrawal management. Why is that? Do residents know more or are they more resistant to new learning? For many medical students, hospital could be the first place where they see someone with addiction and that could be why they learn more in this setting.
Presentation title: Who learns most about addiction in the hospitals? A mixed methods study.
Presentation authors: Jan Klimas, Evan Wood, Walter Cullen, Will Small, Seonaid Nolan, Annabel Mead, Mark McLean, Christophe Fairgrieve, Keith Ahamad, Huiru Dong, Breanne Reel, Lauren Gorfinkel, Nadia Fairbairn

Derek Wilson and colleagues from the same university focused on the quality of health education learning environment (HELES study). HELES survey tool looked at relationship, personal development and program culture as the key parts of the learning environment at the faculty of medicine. For example, the evaluation asked whether the learners have developed a strong sense of community.
Presentation title: Evaluating the Quality of Health Professions Learning Environments: Validation of the Health Education Learning Environment Survey (HELES).
Presentation authors: Derek Wilson, Shayna Rusticus, Derek Wilson, Oscar Casiro, Kevin Eva, Lisa Hazlett, Chris Lovato

Calgary explores and experiences

Maureen Topps and collaborators from University of Calgary, Cumming School of Medicine, asked whether in addition to focusing on the deficiencies and gaps in education, whether we could research the successful activities related to professionalism. The postgraduate education is a key stage in training the next generation of competent and professional clinicians. Professionalism is hard to define and to define it may “limit it,” as Dr Barnhoorn writes in the Academic Medicine journal (2006, Vol. 91, No. 9). But how does the place of learning make for more professional doctors? Slowing down and taking time to plan interactions appears to foster professionalism among other factors such as communication training.
Presentation title: Contexts and Experiences of Postgraduate Residents that support successfully meeting professionalism challenges.
Presentation authors: Janet de Groot, Maureen Topps, Aliya Kassam, Maureen Topps

Nicole Delaloye and colleagues from the same university presented results from her Masters research of the MSc/MD program. Clinicians should be both polite and respective, but not overly submissive. Why do we follow orders? Resuscitation requires wise action, not passive deference. What happens when learners hold back too much and how does the place of learning impact submissiveness? Mechanisms that underly submission in the moment of revival include learner’s mental state, what was going on inside and outside the room, team and motivation.
Presentation title: An Exploration of Deference Behaviours Exhibited within the Paediatric Resuscitation Environment and the Educational Implications.
Presentation authors: Nicole Delaloye, Elaine Gilfoyle, Rachel Ellaway, Aliya Kassam, Elizabeth Oddone Paolucci

In summary, the best learning places not only support our learning, but also challenge us to learn knew knowledge, adopt the discipline’s values, overcome deference and become successful professionals in our own right.

The opinions and views in this article present the views of the author and not the named persons or the #CCME18 conference organisers.

Farewell Thursdays Writing Collective

Thursdays

With the end of the Thursdays Writing Collective coming soon in April 2018, I’ve decided to re-post my earlier blog from 2016 about this unique collective.

Discovering Thursdays Writing Collective

During each session, we spend half the time writing in response to prompts and the other half, especially before group performances, workshopping pieces and instructing fellow writers about time, place, format, and so on. However, I quickly found out that the collective is so much more than a writing group. It’s a true creative hub. Published authors visit frequently. Kate Braid, the poet, and her friend, Clyde Reed, a jazz musician, came to read us their poetry and improvised with a double bass on the spot. Clyde allowed us to read our own pieces while he played his mesmerising bass to accompany our words.

At most meetings, we share books and poems by authors we revere and it always serves to be an enlightening experience. For example, we discussed the Devil in Deerskins, by Katherine Swarthile, whose work is among the earliest published mementos on the first nations’ themes. Katherine Swarthile, the daughter of Anahareao, actually visited us. Her environmental message to the group gave further impetus and context to her book, which we all read in anticipation of her visit.

We also receive regular invitations to read poetry at spoken word events around town, including the Verses Festival and the Vancouver Poetry Slam. The Vancouver Co-op radio offered us spots on their poetry show Wax Poetix. Pamela Post, a journalist from the CBC national radio show, The Current, visited several times. She recorded hours of readings, including a story by one of our own, Henry Doyle, that documented our premiere concerts at University of British Columbia School of Music and the first encounter of Henry with composer Lucas Oickle.

Over time, I began to understand what it was that I couldn’t find anywhere else when I was searching for a writing group. The Collective acts as a single soul. My previous writing groups were wonderful places of exploration and were right for me at the time, but we rarely got together outside of class. This made it feel more like a language course where people mind their own business and go about their lives. However, Thursday’s Collective is a community. We chat during breaks, nibbling at fruit and veggies. The volunteers work hard in the background and keep us informed on new developments. Thanks to fees from the paid classes, they are able to do unpaid classes for people in shelters, prisons, or treatment centres. The members of the Collective have input into the decisions about the performances that we take part in, cash for readers, and choice of projects. Democratic votes about these decisions follow after group discussions. If someone read at a recent event, another writer is encouraged to read next. It reminds me of one of those artist collectives one might read about from the past, where creatives managed their own promotions and shared the same building, using it for studios and shows.

The Collective is a unified community of creative minds.

We are like a band with a leader who sets the tone, direction, and vision. Elee Kralji Gardiner—writer and editor—was this leader until 2016. Elee was our facilitator, manager, and director. Elee unified the Collective at the meetings and did a tremendous amount of work in the background, outside the meetings, to help us grow our work and allow the collective to thrive. With Elee at the helm, every year, the Collective also publishes an anthology. Last year’s (2014) theme was Music and Art Song.

In the history of music, Art Song played an important role. Loosely defined as a musicalized poem, typically performed by a singer and a piano, this form of music combines the work of a poet, composer, singer, and pianist into a stand-alone artistic statement. UBC graduate composers have set eleven of our poems to music, and their fellow student singers and pianists performed them at two April premieres in the UBC Roy Barnett Hall and St James Anglican Church at Cordova Street. The poets introduced their work and read the text before each performance.

We launched the “Voice to Voice” – our art song anthology – at the end of June 2015 in the Lost & Found Café. The book contained not only art songs, but also poems, stories, songs, and memoirs by our writers. An Indiegogo campaign funded the book and others supported it in many ways, including the Canada Council for the Arts, UBC School of Music, Peter Wall Centre, Instruments of Change, Carnegie Community Centre and SFU’s Writer’s Studio. Dwayne Woloshyn painted the book cover praised in the Keremeos Review magazine.

From September 2016, we launched a year of Visualizing the Word, which means writing about visual art, inspiring it and getting inspiration from it, under the new director, Amber Dawn – our alumni – and co-facilitators Curtis and Cara.

 

If you liked reading this blog, you may also like to read the following posts about:

Thank you all Thursday-ers.

Correct dose keeps treatment going, study finds

dose

We wanted to find out whether continued use of drugs or alcohol impedes addiction treatment with methadone. We looked at the dose and things that make people stop treatment.

How was the study done?

Between 2005 and 2015, we talked to 823 people receiving methadone who said they used alcohol at least once. We asked about their experiences with interrupting methadone treatment and their drug use.

The VIDUS study involves people who use illicit drugs. The ACCESS study involves people living with HIV who use illicit drugs, mostly living in Vancouver’s Downtown Eastside neighbourhood. Researchers work with participants to look at how social, economic, physical, policy, and individual factors impact the health and well-being of HIV-positive illicit drug users. All participants do an interviewer-administered survey, and a clinic visit with a study nurse, every 6 months. (text taken from: http://www.bccsu.ca/access/ and http://www.bccsu.ca/vidus/)

What did the study find?

48% said they had stopped methadone treatment. Those who were homeless, or injected heroin daily, were more likely to stop methadone treatment. Those who also received other addiction treatment, received doses of at least 60 ml of methadone, or had Hepatitis C, were less likely to stop methadone treatment.

Heavy alcohol use was not linked to treatment discontinuation.

Why is continuous methadone treatment useful?

People who enroll in methadone treatment may continue to use illicit drugs and alcohol. There is a need to understand how to manage continuous drug use while receiving methadone treatment. Receiving therapeutic doses of methadone and also additional addiction treatment may reduce treatment interruption.

Study: Klimas, J., Nosova, E., Socías, E., Nolan, S., Brar, R., Hayashi, K., Milloy, M., Kerr, T., Wood, E. (2018) Factors associated with discontinuation of methadone maintenance therapy (MMT) among persons who also use alcohol in Vancouver, Canada. Drug and Alcohol Dependence, May 1, Volume 186, Pages 182–186

Read about other similar research here.

20 per cent heroin eligible, study finds

medical heroin

This study looked at how many, and what types of people who inject drugs (PWID), in the AIDS Care Cohort to evaluate Exposure to Survival Services Study (ACCESS), would be eligible for medical heroin in Vancouver, Canada.

Medical heroin could possibly help people who have treatment resistant opioid use disorder and who live with HIV/AIDS.

How was the study done?

We looked at how many, and what types of PWID in the ACCESS Study would be eligible for medical heroin. Participants had to meet eligibility criteria from clinical trials of medical heroin.

The ACCESS study involves people living with HIV who use illicit drugs, mostly living in Vancouver’s Downtown Eastside neighbourhood. Researchers work with participants to look at how social, economic, physical, policy, and individual factors impact the health and well-being of HIV-positive illicit drug users. ACCESS participants do an interviewer-administered survey, and a clinic visit with a study nurse, every 6 months. (text taken from: http://www.bccsu.ca/access/)

What did the study find?

478 participants said they injected opioids. 20% met the eligibility criteria for treatment with medical heroin. Those who were homeless, or were involved in the local illicit drug trade, were more likely to be eligible for medical heroin.

20% met the eligibility criteria for treatment with medical heroin and also said they were homeless and dealt drugs.

Why is the medical heroin useful?

Untreated opioid use disorder among people who live with HIV/AIDS can lead to illnesses, overdose, or death. Medical heroin can play an important role in helping people who have treatment resistant opioid use disorders and who live with HIV/AIDS.

Reference: Klimas, J., Dong, H., Fairbairn, N., Socías, E., Barrios, R., Wood, E., Kerr, T., Montaner, J., Milloy, M. (2018) Eligibility for heroin-assisted treatment (HAT) among people who inject opioids and are living with HIV in a Canadian setting. Addiction Science& Clinical Practice. In Press (https://ascpjournal.biomedcentral.com/track/pdf/10.1186/s13722-017-0104-y?site=ascpjournal.biomedcentral.com)