ATTACK ON ADDICTION
New guidelines call on doctors, hospitals to join in fight against opioid epidemic
With the death rate from the opioid crisis surpassing the height of the AIDS epidemic, it’s time for family doctors and emergency departments to step up, according to a new set of national guidelines for treating addiction.
The benchmark, under the headline “management of opioid use disorders: a national clinical practice guideline,” was published Monday in the Canadian Medical Association Journal.
The authors lament that overdose victims are revived in emergency departments and sent home with no followup. There is a medication that can save lives, but hardly anyone uses it.
For a Windsor addictions specialist already advocating for what the CMAJ suggests, the guidelines have been a longtime coming. “At last, we are now beginning to counter the results of the most ghastly failed experiment of using very high doses of opiates to counter chronic, malignant pain,” said Tony Hammer, an addictions doctor at the Erie- St. Clair Clinic. “The experiment was a disaster because the risks outweighed the benefits.”
“We explored the highest doses we could with no limit, raising the expectation that we were capable of conquering pain. We now know we couldn’t.”
The Public Health Agency of Canada reported in December there were 2,861 opioid-related deaths in 2016. Preliminary figures for the first half of 2017 suggest a grim new record with the number of deaths likely to surge past 4,000. Essex County is among the hardest-hit regions in Ontario. In January, the Windsor-Essex County Health Unit said the provincial opioid death rate is about 6.2 per 100,000 population. Windsor-Essex’s rate is 46 per cent higher at 9.1 per 100,000 people.
“All sorts of people are unique in the way they are affected by this,” said guideline co-author Dr. Keith Ahamad, a family physician and clinical researcher in British Columbia.
“But one common denominator is most people have access to family doctors and emergency departments. As it stands right now, we are doing nothing in those areas,” Ahamad added.
“Right now, people are accessing the health-care system and detox facilities, doing risky things, and emergency departments are doing nothing, family doctors’ offices are paralyzed.”
The guideline authors said the epidemic has been fuelled by a combination of over-prescription and the influx of potent illegal synthetic opioids such as fentanyl. “We’re eclipsing the HIV and AIDS death rate at its peak,” Ahamad said.
To combat the problem, the recommendations focus on getting primary-care professionals such as family physicians, nurse practitioners and emergency room doctors in on the fight. Ahamad said a key way they can do that is to start treating patients with a “vastly underutilized” combined medication called buprenorphine-naloxone, sold under the brand name Suboxone. Naloxone blocks the effects of opioids. It’s used to combat overdoses. Buprenorphine is an opioid, but it’s in a different category than others such as dilaudid and fentanyl. It doesn’t get a person high like those opioids, but it suppresses cravings, and it is difficult to overdose on. After a trial period, patients can take it at home without being in the presence of a health-care professional. It’s a life-saving tool and “no one is using it,” Ahamad said. “Essentially, addiction has been ignored by the health-care system for decades,” he added. “It’s never been the job of the family doctor or the emergency doctor or anybody in health care to treat addiction despite the fact that there is a mountain of evidence guiding us on what to do.”
For people who don’t respond well to Suboxone, the guidelines say methadone treatment is the next best choice. If that doesn’t work, slow-release oral morphine can be prescribed in daily witnessed doses.
The guidelines also stress that detox — quitting cold turkey — should stop. Although often used, it’s worse than doing nothing, Ahamad said.
“We have had this culture for decades of admitting people to withdrawal centres, detox facilities, and just tapering them rapidly off of opioids, and then waving at them as we shut the door behind them and wish them good luck,” he said. “Rapidly tapering people off of these drugs and going cold turkey, the science is pretty clear here — like 90 per cent of people will relapse.”
If Suboxone is underused across Canada, some Windsor specialists are ahead of the curve. Hammer said the Erie-St. Clair Clinic has used Suboxone for five years. Dr. Donald Levy, chief of emergency services at Windsor Regional Hospital, said his emergency department has had Suboxone for four years.
“We provide Suboxone in the department for replacement therapy, and for outpatient therapy we refer them with the hope that they be seen within 24 to 48 hours,” Levy said. “We provide them with therapy until they reach that.” Byron Klingbyle, a harmreduction specialist with the AIDS Committee of Windsor, said a big advantage of Suboxone is that the rules for taking it are less restrictive than those for methadone. There’s always a chance a struggling addict won’t head to the pharmacy each day to take methadone, he said. “The more options you have the better, because some might not fit me,” Klingbyle said. “I might not be comfortable with methadone but I might be comfortable with Suboxone, or vice versa. So the more options you have the better, because everybody is different.” Whatever the medication, he said, counselling is still necessary. “Let’s say I’m on methadone or Suboxone and I’m still dealing drugs or I’m still hanging around the drug subculture. I’ve still got people coming over doing illegal activity,” he said. “Sooner or later, I’m going to start using again. “So you have to have counselling with that. Unfortunately, a lot of doctors don’t take the time for that or have a counsellor for every client that’s going to come in. So it all depends on the integrity of the doctor, too.”
Hammer said there is another “gaping hole” in the system that the guidelines don’t appear to directly address. When someone overdoses and survives, he said, there is often no followup with the patient.
“They walk out of the hospital after a near miss with no one following up,” Hammer said. “Does that make sense? It’s a bit like if there were motor vehicle accidents and the cop came along and said, ‘No one injured? Not interested. No one died. I don’t care. Nothing to learn here.’ We have much to learn from these near misses.” Levy said Windsor Regional’s emergency department has crisis specialists, and refers patients to a clinic that provides opioid replacement therapy.
“We are involved in that, and certainly our crisis workers assess people for substance abuse issues including opioids and we provide them with counselling,” Levy said. “We discuss their concerns with the patient.”
But he acknowledged addiction services could be better organized in Windsor.
“There are multiple clinics in Windsor that offer opioid replacement therapy to my knowledge, and they’re not as well co-ordinated as other areas of the province,” Levy said.
He said the Erie St. Clair Local Health Integration Network is looking to better co-ordinate care by setting up a clinic similar to a pilot site in Sarnia where there is a dedicated addiction service team. The hospital would refer people to that clinic, Levy said.
“The guidelines are a step in the right direction,” he said. “We agree with them. The pilot project in Ontario is a step in the right direction and I think probably with the LHIN support we should be making good progress on having a better co-ordinated system in Windsor.”
Ahamad said the new guidelines also deal with those near misses by “empowering primary care.” Doctors need to have bedside chats with opioid users about addiction, risks and medication the same way they would with a smoker, he said. “This guideline helps change the culture across Canada that empowers primary care to be able to do a medical intervention upstream,” Ahamad said. “We spend so much time treating the downstream consequences of addiction — infections, HIV, hepatitis C and overdoses and all these sort of things — and the reality is that, man, we can start medications that can save people from all this harm.”
They walk out of the hospital after a near miss …It’sabitlikeif there were motor vehicle accidents and the cop came along and said, ‘No one injured? Not interested.’