OP-ED: An Evidence-Based Strategy for the Opioid Overdose Crisis

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opioids

by Peter Chow

40 years ago, by far the number one drug abuse problem presenting to the ERs in the Sault was alcohol (Remember: alcohol is a drug).

Patients in alcohol withdrawal often presented to the emergency department in the DTs, seizuring or on the verge of seizuring or with GI bleeds, hemorrhaging from the stomach or esophagus. These ER patients were admitted and treated and discharged home, with brochures about AA and the phone number of a rehab treatment center out of town.

Patients with non-emergency withdrawal symptoms were sent to a house beside the General Hospital that served as a detox unit, where they could basically “sleep it off.”

Detox consisted basically of holding their hands, and proselytising about rehab and the AA/NA 12-Step Program.

Today, in the midst of the Opiate Crisis, addiction medicine has drastically changed.

Addiction medicine is a medical subspecialty, formally recognized since 1990.  Addiction medicine specialists have extensive experience and advanced training in the field of addiction medicine to evaluate, diagnose, and treat people who are struggling with substance use disorders.

MEDICATION-ASSISTED TREATMENT (MAT) is now the cornerstone of detox treatment for opiates and most other drugs, as well as for sustaining recovery and preventing overdose.

Sault Ste Marie should be trying to apply for establishment of a SAFE DRUG INJECTION SITE (as Sudbury is doing), rather than a short-term drug withdrawal facility (“detox facility”).

“INTERVENTIONS THAT SHOULD BE AVOIDED BECAUSE OF THEIR ASSOCIATED HIGHER RISK OF DEATH FROM OVERDOSE, SUCH AS REFERRING PEOPLE TO SHORT-TERM INPATIENT WITHDRAWAL-MANAGEMENT PROGRAMS (i.e., “DETOXIFICATION”) WITHOUT PROVIDING CONTINUED ADDICTION TREATMENT OR FOLLOW-UP CARE”

This is the advice from an article from the prestigious New England Journal Of Medicine.

STRATEGIES FOR REDUCING OPIOID-OVERDOSE DEATHS – LESSONS FROM CANADA

In 2016 alone, there were 64,000 drug-overdose deaths in the United States — more than the total number of U.S. military deaths during the Vietnam War.

This upsurge can largely be attributed to the emergence of FENTANYL and related analogues (e.g., CARFENTANIL) in the illegal-drug supply. An examination of data from 10 U.S. states found that MORE THAN HALF the people who died of opioid-related overdoses during the second half of 2016 tested positive for fentanyl.

There are lessons to be learned from Canada, which has taken bold action on a number of fronts with THE PRINCIPLE OF HARM REDUCTION, reducing deaths related to fentanyl, fentanyl analogues, and other opioids.

For instance, in March 2016, the Canadian government made the overdose-reversal drug NALOXONE available without a prescription.

The Canadian Government has passed legislation aimed at facilitating the development of medically supervised safe injection sites (SSM and the SAH and Algoma Public Health and CHAAT should be applying!) where people who use drugs can inject opioids under the supervision of health care staff.

Although research has found that supervised injection sites can reduce rates of fatal overdoses by more than 30% and can help facilitate greater uptake of addition treatment, there are few, if any, such programs in the United States. In recent months, however, public health officials in several U.S. cities, including San Francisco, Seattle, and Philadelphia, have endorsed plans to open pilot supervised injection programs to address increasing rates of overdose deaths.

Within Canada, British Columbia has been hit hardest by the fentanyl-overdose crisis and has been at the forefront of enacting strategies for preventing overdose deaths. After declaring opioid-overdose deaths a public health emergency in April 2016, the province developed enforceable prescribing standards to reduce unsafe prescribing of narcotic pain relievers and

EXPANDED ACCESS TO NALOXONE, INCLUDING MAKING THE DRUG FREE OF CHARGE THROUGH COMMUNITY AGENCIES AND PHARMACIES

It has also developed guidelines for establishing federally sanctioned supervised injection facilities that that have permitted the creation of a growing provincial network of such programs.

To improve access to evidence-based treatment for opioid addiction, British Columbia has developed a comprehensive guideline for the treatment of opioid use disorder.

This guideline includes recommendations regarding the easily accessible provision of traditional opioid agonist medications (i.e., BUPRENORPHINE [SUBOXONE] AND METHADONE) and identifies interventions that should be avoided because of their associated higher risk of death from overdose, such as referring people to short-term inpatient withdrawal management programs (i.e., “DETOXIFICATION”) without providing continued addiction treatment or followup care.

The province also provides opioid agonist medications (SUBOXONE AND METHADONE) to low-income people free of charge.

Because less than half the people who are prescribed traditional opioid agonist therapies continue taking them over the long term, the treatment guideline includes

RECOMMENDATIONS FOR THE USE OF SLOW-RELEASE ORAL MORPHINE WHEN TRADITIONAL OPIOID-AGONIST MEDICATIONS HAVE BEEN UNSUCCESSFUL

The provincial government also created a guideline for the use of injectable opioid agonist treatment and has prioritized the establishment of clinical programs that provide pharmaceutical-grade HEROIN (DIACETYLMORPHINE) OR HYDROMORPHONE in each provincial health region.  Those steps followed the release of findings from Canadian studies demonstrating that are offering DIACETYLMORPHINE and HYDROMORPHONE by means of supervised injection sites is an effective therapy for severe, treatment-refractory opioid use disorder.

Most recently, British Columbia provided funding for publicly available anonymous drug testing services, acknowledging that some fentanyl-overdose deaths are caused by fentanyl contamination of non-opioid street drugs (e.g. COCAINE, MARIJUANA, CRYSTAL METH, & ECSTASY).

The program will seek to allow drug users to test the contents of drugs before using them by means of technologies that can distinguish fentanyl from other opioids.

Similar programs were originally implemented in Europe in response to deaths caused by the contamination of illicit drugs associated with electronic dance music festivals (e.g., methylenedioxymethamphetamine [MDMA], or Ecstasy).

Although countless lives are likely to have been saved thanks to the initiatives described above, overdoses remain a pressing concern in Canada, and many lessons can be derived from the Canadian experience.

First, many of these interventions and programs have not been brought to scale.

For instance, despite federal regulatory changes, many hard-hit Canadian jurisdictions (with the exception of British Columbia) have been slow to

IMPLEMENT ACCESSIBLE TAKE-HOME NALOXONE PROGRAMS AND SUPERVISED INJECTION FACILITIES

Similarly, although British Columbia has succeeded in greatly expanding the use of opioid agonist treatment, it has been slow to recognize the important role that extended-release NALTREXONE could play in improving outcomes for people with opioid addiction, particularly patients who may not wish to pursue treatment with agonist medications.

As in the United States, failure to invest in education for health care professionals with regard to evidence-based treatment for addiction.

has hampered the development and staffing of treatment programs.

Finally, as in other North American jurisdictions, there remains an over-reliance on criminal justice interventions for people with opioid use disorder.

in British Columbia and inadequate community-based care on release from jail.

Bold action on the part of policymakers will be required to support innovative evidence-based approaches.

From the HEALTH CANADA page on SUPERVISED CONSUMPTION SITES:

“Authorized services Depending on the site, it may be authorized to permit the use of substances by:

  • injection
  • inhalation (smoking)
  • oral (swallowing) and intranasal (snorting)
  • peer assistance
DRUG CHECKING IS AN AUTHORIZED SERVICE

To operate a supervised consumption site (SCS) for medical purposes in Canada, an exemption under section 56.1 of the Controlled Drugs and Substances Act is necessary.

Health Canada grants exemptions for SCS after satisfactory completion of an application. An application includes consultation with a broad range of people in the community.

Health Canada considers all applications on a case-by-case basis. We are committed to processing applications without undue delay and will keep the applicant informed during the process.”

DOWNLOAD THE APPLICATION FORM