CADTH Lecture Series — Canada’s Opioid Crisis by Dr. Hakique Virani


I’m Brian O’Rouke, president and chief executive officer of CADTH. just before we get underway I would like
to acknowledge that the in-person session for this meeting here in Ottawa
is being held on the traditional and unceded territory of the Algonquin
nation so I’d like to thank all of you for joining us today for the inaugural
talk in the 2017 2018 Katta lecture series we launched the lecture
series four years ago so that people from across Canada and abroad could hear
directly from prominent scholars and opinion leaders about pressing issues
facing health technology assessment and health care today and of course today’s
lecture is focused on one of the most pressing public health issues that we
face today Canada’s opioid crisis it’s a topic that
many people are interested in as demonstrated by the high attendance for
this lecture we have more than eleven hundred and fifty people registered both
online and here in person according to a September 2017 report from the Canadian
Institute for health information on opioid related harms in Canada opioid
poisonings resulted in an average of 16 hospitalizations a day in 2016 2017 and
that’s a 19% increase from the daily hospitalization rate just two years ago
and at 53% higher rate than a decade ago dr. Teresa Tam Canada’s chief public
health officer has called this a major public health crisis she goes on to say
that tragically there were more than 2,800 apparent opioid related deaths in
Canada in 2016 which is greater than the number of Canadians who died at the
height of the HIV epidemic in 1995 like all of us working in health care I’m
deeply concerned about this crisis having such a profound effect on and
devastating impact on communities families and individuals across Canada I
am proud to say that CAD a–the and then and other pan-canadian health
organizations including the Canadian Center on substance abuse and addiction
and the Canadian Institute for Health Information have joined together with
federal provincial and territorial governments and many other groups across
Canada to address Canada’s opioid crisis caddis
contribution includes delivering evidence-based information on
pharmaceutical physical and psychological treatment options for pain
and addiction to government’s health care providers and patients across
Canada we put together a small but a very dedicated team of researchers and
knowledge mobilization experts to produce an impressive body of evidence
on treating opioid addiction and providing options for pain management
which we commenced last November and for those of you who are with me here in
Ottawa packages containing our latest reports are available and for our online
participants information is available on Cadiz website at the to following links
Kadett see a forward slash opioids and cada thought see a forward slash pain
now please join me in welcoming the moderator for today’s session
dr. Janice Mann a knowledge mobilization officer and co-chair of cádiz opioid
working group Janice thanks Brian
so just a few little notes before I introduce today’s speaker our the
lecture today will be about 40 minutes long and will be followed by questions
both from people who are in the room and from people who are joining us today
online and just a little reminder that if you are on Twitter we encourage you
to tweet during the lecture after the lecture just please use include the
hashtag cata tox so I mentioned the question period just
so we’re all on board with how that works if you’re um doing the livestream
option so you can click I have to read this because I never remember how to do
this click the participate button on the webcast player enter your email address
and write your question in the space provided and hit Send so hopefully that
will work quite well we do have a lot of people online and in
the room today so we might not be able to get to every question but we’re going
to endeavor to do what we can there if you are in the room when we get to our
question period just please remember to turn on your mic otherwise the people
online are not going to be able to hear your question the buttons right in front
of you they’re at the bottom of your mic and it requests to all participants just
to include your name and if appropriate which organization you may be
representing today that’s it for the housekeeping notes so I’m really really
excited to be able to introduce our speaker today dr. hatikvah Ronnie is one
of the leading experts in Canada on the opioid crisis and he also happens to be
the medical director of the Metro City medical clinic in Edmonton and Calgary
and an assistant clinical professor in the department of medicine at the
University of Alberta and in 2015 in response to the opioid crisis in
southern Alberta he championed the first on reserved naloxone distribution
program in Canada and that’s an initiative which has actually led to a
province-wide program he served as a member of Alberta’s Coalition on
prescription drug abuse and he remains involved with College of Physicians and
Surgeons of Alberta in physician education on opioid use disorder and the
development of standards and guidelines for opioid dependency treatment and this
is just a little bit of his CV so just to give you a bit of an idea there he is
a now my note says he’s a vocal advocate I’m gonna say he’s a very vocal advocate
for public health he’s written for the CBC Huffington Post vice the Calgary
Herald The Boston Globe stat news and The Globe and Mail and if you go into
YouTube you can find another a number of interviews with CBC and some other news
outlets as well his clinical and public health work has actually been featured
in a feature-length documentary called dope stick Fenton
deadly grip and it actually won a 2017 Canadian Screen Academy Award
so dr. Virani is here today to share his insights into the opioid crisis and
discuss considerations for considerations for action now that drug
drug poisoning has reached epidemic proportions please join me in welcoming
dr. Hickey Bharani thanks Janice and and Bryan for the introduction and also for
caddis work on on this very important public health issue including the
evidence bundle which I encourage everybody to check out particularly if
you’re a clinician a very useful set of tools synthesizing the evidence on on
treating opioid use disorder but also thanks to katha for recognizing the
importance of this in the context of Canadian healthcare and I would say that
this is probably one of the leading challenges that face Canada period even
even considering issues outside of Health and it’s not just an urgent
public health problem today this is the most urgent public health problem that
I’ve ever seen and that’s keeping in mind that only eight years ago we saw
stage six global pandemic influenza I still think that this is the most urgent
public health problem that we’ve seen in in my generation not only because of its
death toll and its impact but also because I think that it’s a
manifestation of deeper problems in the way that public health is organized and
performs it is a manifestation of persistent inequities in this most
wealthy corner of the world and Austin’s ibly most progressive corner of the
world and normally when we talk about this problem you must have seen talks
looking at it from the perspective of examination rooms where we put patients
into diagnostic buckets and we assess them and treat their problems through
our clinical lens whether it’s pain or addiction
and you’ve probably also seen talks from the perspective of the ivory towers
where questions are asked and studied by the Academy and then key messages are
canned and crafted by the bureaucracy and where big decisions are made or not
made there’s also a space in between these two places between these ivory
towers and our examination rooms where it’s messy and uncompromising and where
real life happens where variables can’t often be controlled for and a place that
requires us to have two separate words for efficacy and effectiveness having
spoken to a lot of people in my practice and outside who are directly affected by
this crisis I think I’ve learned a little bit about that real life space
between our examination rooms and our ivory towers and so I thought I’d spend
my time sharing some of that with you of course I have to show the obligatory
slide that says I don’t have any financial interests in any industry and
that includes lab or pharmacy industry which I think somebody who practices
addiction medicine should have to be able to say but as far as conflict of
interest goes so we have to realize that we all have plenty of them whether
you’re a researcher or a clinician particularly if you’re a public health
practitioner or bureaucrats and government you’re stuck between medicine
and mandates and marching orders and publish or perish and all of those
things that that really do affect in which direction you’re pulled and
ultimately if we don’t recognize that it’s hard for us to put patients in
population health at the forefront of everything that we do I wrote a little
bit about this in the spring and stat news and I rather than go on about this
phenomenon of conflict of interest that is much wider than we’ve ever
acknowledged you can read that if you’re interested so when I did work in an
ivory tower in Health Canada back in about 2006
myself and a colleague of mine dr. salmon Annie started to use business
intelligence tools to analyze what first nation leaders were concerned
increasingly was problematic prescribing of certain prescription drugs to members
of their communities and here what you’re looking at is what we call the
perspective map where every one of those rectangles represents a single physician
prescribing is prescribing to a single First Nation community in Alberta in
2008 and the dimensions of each rectangle reflect how many unique
patients that physician saw in a calendar year and the shade of red or
green reflects what proportion of those patients were prescribed an opioid drug
at one point during that calendar year and so you’re looking at physician
number four three three five who saw three hundred and sixty nine First
Nation patients and his practice in that calendar year and two ninety-one percent
of them prescribed an opioid drug this is a primary care practice that’s all
all types of patients several years later the College of Physicians and
Surgeons in Alberta started to use similar or the same technologies to
analyze trends in the triplicate prescription program and what you’re
looking at here is between 2006 and 2011 2012 about a 50 percent increase in the
total oral morphine equivalents of oxycodone prescribed to the Alberta
population that’s the kind of purplish magenta line at the top of the chart so
that’s not unique to Alberta we know that oxycontin use increased throughout
North America during that time period and if you were to take all the opioids
together prescribed to the Alberta population about a 35 percent increase
in total opioids prescribed to the Alberta population between oh six and 12
that that was mirrored by an increase in acute drug toxicity deaths with or
without alcohol that involved opioids in Alberta and you would have seen this
same phenomenon occur and most widely reported in in United States
jurisdictions where with the increase in opioid prescribing there was kind of a
I ll increase in opioid overdose death it was all very convincing and it’s
still convincing to me that it’s very hard to argue that the way that we
prescribed opioids was not partially responsible or partially contributed to
the genesis of the crisis that we sit on today the College of Physicians and
Surgeons in Alberta started to use better data after 2012 when it became
available through our electronic medical record the pharmacy pharmaceutical
information network that captures all prescriptions as dispensed not as
written like what was captured in the triplicate prescription program but what
you see is that between 2012 and 2015 the slope had flattened out a bit and
now you see a reversal in a trend a slight reversal in trend of total opioid
prescribing to albertans by 2016 and I anticipate we’ll see a decrease continue
in 2017 and that may have something to do with the public attention that this
problem has gotten it may have something to do with the regulatory interventions
that took place with physician education and academic detailing it probably has
something to do with the Centers for Disease Control in the United States
publishing an opioid use guideline and it probably has something to do with the
anticipation of the Canadian guideline in 2017 which i think is a good
guideline it does focus on the areas that we were preoccupied with given the
indicators that we were monitoring particularly maximum dosages so we see
in recommendation sixth and seven that for people who are beginning long-term
opioid therapy that the max dose should be restricted to 90 milligrams of oral
morphine equivalents rather than no upper limit which we previously
practiced by and for patients were beginning opioid therapy for chronic o
chronic pain conditions that that dose be limited to 50 milligrams or less and that for patients who are already on
90 milligrams or more of oral morphine equivalents that we try a controlled
taper to reduce the likelihood of adverse events from occurring but again
most of the recommendations would relate to preventing adverse effects from high
dosages of opioids and the serious adverse effects that were mostly
contemplated were addiction we’re in the synthesis of literature they found that
the risk of opioid addiction and chronic opioid therapy was about one in 20
people just because I’m a public health guy there’s an anti-virus thing the risk
of fatal overdose so serious adverse effect changed with the amount of opioid
prescribed so those patients who are receiving or over a hundred milligrams
per day the rate of fatal overdose death annually was about 0.23 percent so about
one in 400 people and for non fatal overdose about 1.8 percent in patients
who were on over a hundred milligram per day of opioids now these are not the
only adverse effects that were that were looked at but the ones where there was
more good data on than for things like opioid-induced constipation etc so by no
means the only adverse effects that happen from chronic opioid therapy but
the ones that we found to be that we think of when we think of serious
adverse effects so the thing about good indicators or the thing about indicators
that are immediately available to us is that when we’re presented with a problem
we tend to understand that problem based on what is immediately available in
terms of data dr. Kahneman who’s behavioral economist
who won a Nobel Prize not too long ago described this as the availability
heuristic and he described a phenomenon called
what you see is all there is so let me just illustrate that to briefly I will try come on here we go
so this is an awareness test you’re responsible for keeping an eye on the
ball carried by the White team and Counting how many passes that white team
makes kid everybody got 13 okay did you see
the moonwalking bear so watch it again and so you see this noise going on with
these people passing around the ball but so it’s easy to miss something that
you’re not looking for so we’ve been for good reason very very preoccupied with
dosages and with prescribing habits and the reason it’s for good reason is that
we saw that it tracked pretty pretty closely with the way that opiate
overdose deaths changed but we were not nearly watching in as real time the
deaths as we were the prescribing it took me a lot of time to to take the
girls out of this meme to try and to try and not make it sexist it’s hard to be
woke is but we’ve been preoccupied with prescribing data and not nearly as
focused in the past three or four years as we should have been in characterizing
the loss of life that was occurring with drug poisoning when we looked or when it
when we started to look in a more coherent way here’s what we saw and as
dr. Tam as dr. Tam said about 200 2,816 deaths at least in a calendar year 2016
that is an under estimate and that may well be a dramatic underestimate
are there any epidemiologists in the room okay if the people sitting beside
the epidemiologists can hold the epidemiologist hand for a moment I’m going to show you a chart that
should concern you in terms of the the quality of data so the number of
provisos on this chart that has one indicator and very few rows it’s
concerning and the reason there are so many conditions here is that there is
not a standard definition across the country of what gets you counted in this
number so for example if you’re in Quebec you only get counted in this
number if opioid overdose death is the cause of death in a closed or certified
case 44 percent of those in 2016 were still under investigation when this
number was reported so we may be wildly underestimated in that case Saskatchewan
does it the same way Alberta reports unintentional apparent
opioid related deaths only British Columbia reports deaths from all illicit
drugs including but not limited to opioids but if you look at their case
definition if if you’re prescribed an opioid or other drugs and that’s found
for instance on your farm Annette profile and those were the drugs listed
in your drug toxicity death cause you’re not counted because it’s not considered
an illicit drug if there was for example your codeine your morphine your
benzodiazepine and methamphetamine you’ll get counted in the illicit in the
illicit category or if you had a couple of opioids that were prescribed to you
plus heroin or fentanyl that was not prescribed to you then you would be
considered you would be included but it makes it difficult to say that we have a
full picture of what’s going on with opioid overdose death but in fact that’s
what people are saying that’s what official people are saying
that we now have a full picture of what’s going on with the opioid crisis
but unfortunately we do not so oh sorry I don’t know how it came up or maybe I’m
just trying to make a point so so the death rate in Canada is reported as
deaths a hundred thousand population whereas in
Europe the European monitoring services on drugs and drug addiction reports
deaths from all of the drugs at a per million population and their worst
country is Estonia as I show you I’ll show you later
it doesn’t even come close to what the death rate is per million in British
Columbia so it would not be fair to say that nobody’s been watching opioid
overdose deaths though so that the Canadian Center on what was then called
substance abuse but now is is called substance use and addiction was watching
fentanyl in Canada for quite some time probably four years before others were
starting to watch it and they did it through a voluntary kind of Sentinel
reporting undertaking called CC and EU and back in August of 2015
recommended that jurisdictions collaborate to standardize the
information used in for drug poisoning deaths you just saw 2017 data that’s not
standardized but you know government takes time here’s what things are
looking like in British Columbia looking at given their case definition illicit
drug deaths between 2007 and 2016 and you see around 2012 is when the slope
starts to change if you take away fentanyl illicit drug deaths do increase
but relatively stable compared to when you do include fentanyl if you want to
look at what 2017 will look like in BC I kind of have to zoom out to do that
that’s what the line will look like so not only is the is it increasing but the
increase is increasing for those of you are a calculus minded that’s concerning
things are getting worse in spite of the fact that when you look at the
prescribing curve in a place like Alberta things are getting better this
is a moonwalking bear okay so those are what the numbers look like
when we produce them in our ivory towers but what what do they look like in real
life I happen to be speaking in Vancouver two weeks ago and at the time
in Oppenheimer Park twenty-two hundred and forty two steaks like these were
laid out and handwritten to memorialize every somebody’s someone who died from
opioid overdose and those steaks happen to arrive in Ottawa in a coffin on
Parliament Hill this week to demonstrate that these are real people who died this
is what they looked like or this is what some of them would look like so you’ll see in their faces people who
you might have seen serve you at a coffee shop might deliver fliers to your
place might be your neighbor’s kid this is what their moms look like I’ve had
the I want to say pleasure but the conversation was unfortunately an
unpleasant but the honor of meeting three of these moms and and about a
dozen other parents who have lost their kids to opiate overdose and it’s
remarkable that 201 the phrase that they’ve all used independently of one
another is a parent’s worst nightmare now any of you have kids know what that
means there’s no ambiguity around that when somebody says a parent’s worst
nightmare they’re not talking about their kid not making double a hockey
they’re not talking about their property tax going off and they’re sure as heck
not talking about a supervisor overdose prevention sight opening up across their
street when somebody says a parent’s worst nightmare it means that they got
that phone call or that knock on the door in the middle of the night from a
uniformed officer telling you that your kid is dead the same kid that you whose
hair you ran your fingers through at bedtime the same kid who the first time
you held them you promised them that they would be unconditionally loved and
protected from all harm forever and ever and our job as communities and as public
health practitioners and as clinicians and as government’s is to help parents
to keep that promise to their kids and we’ve not been doing a good job of that
we have been looking at the number of people or the number of lives lost to
this problem but another way of looking at this is the amount of life that’s
lost to this problem and the best way to look at that in my view is to consider
potential years of life lost you saw how young those people were who
died and if you look at the demographic breakdown it follows these are very very
young people so what I did was I took a look at at B C’s BC Statistics in 2017
and assumed that the deaths that happened in the first
seven six months of 2017 would continue at the same clip and not increase and I
also to be conservative assumed that everybody who was reported in a ten year
age group died at the top of that ten year age group so if they were reported
as a death between 10 20 and 29 years old I assumed that they were 29 years
old when they died and the reference age that I used for premature death was
younger than 70 because that’s what kyu’s is for international comparisons
of premature death so if somebody died in the 30 to 39 age group I would say
they died at 39 and the potential years of life lost for that person was 31
years so when doing that the absolute P Y ll rate per hundred thousand
population that you come up with in BC for 2017 is about 880 if I instead
assumed that everybody who died in each 10 year age group died at the middle of
that age group which might be more accurate of a way to do it you’re
looking at a py LL of 1020 absolutely rate per hundred thousand population now
just to put in context what that means CAI high on their website has a list of
internationally compared causes of premature death this is what we see for
ischemic heart disease in 2010 230 point one per hundred thousand Canadian
population here’s what you see from cancer 845 point six per hundred
thousand population that’s all cancers including childhood cancers and in 2010
the potential years of life lost in the Canadian population from all external
causes of death all external causes of death means every suicide every homicide
every injury from a motor vehicle crash snowmobile ATV every injury from sport
or adventure and every drug poisoning death in 2010 was 826 and you see that
the trends of all of these things are going in the correct direction for a
developed country but from drug poisoning alone that’s only
one component of external cause of death in 2010 we’re losing more than every
single one of those causes so this is not only shocking from the perspective
of how many people are dying but how much life our population is losing
that’s productive time when people start to parent when people get jobs when they
pay taxes when they build infrastructure with skilled trade we lost a lot of
young men in this epidemic and they would be people that we would build an
economy in a country on and they’re gone now all of these people or many of these
people would have been exposed to something else that happens in real life
between our exam rooms and our ivory towers a drug market and that’s a market
that was dominated for probably about a decade by oxycontin oxycontin was
introduced in the United States in about 1996 I think and by 98 99 it had earned
the moniker hillbilly heroin and small towns like Mann West Virginia were
ravaged by this drug so remote communities more than one or two years
before July 29 2001 had experienced this horrible epidemic of oxycontin addiction
so in 2010 August Purdue introduced an abuse deterrent formulation in the
United States so that you couldn’t crush as easily oxycontin and snort it you
could not suspend it in liquid and inject it and then of course nobody ever
had opioid addiction or died from therapeutic use ever again and we never
had an epidemic no that didn’t happen what did happen was that we saw
smuggling from Canada stateside of the original oxycontin that’s from November
2011 so about a year after the new formulation was introduced in the United
States but you did see to be fair a flattening of the curve of opiate
overdose death where natural and semi-synthetic
where you’d find oxycodone would be so there’s 2010 2011 this was a rise before
2010 and then a flattening out over 11 12 and 13 so that seems okay if what you
see is all there is that’s what heroin was doing so heroin
was not something that was widely traded in the early 2000s but in 2010 we
started to see that take off now some people would say that heroin was
increasing before there was more of a clamp down in opiate prescribing that is
true but heroin started increasing about the same time as oxycodone was
reformulated our oxycontin was reformulated so Canada went the same way
in about from the beginning of February of 2012
Purdue introduced a product called Californio so oxy neo and that was the
same tech the same abuse deterrent technology what we saw in Alberta where
where we can get sorry before I go to what we saw in Alberta so
when a major change happens for those of you our public health people you will
know that that those at most severe risk of adverse events from a major change
tend to be the people who are at severe risk of adverse events from almost
anything so unfortunately we saw in First Nations communities Fort Hope for
example the price of street oxycontin went up to about 400 to 600 dollars per
tablet and people were using five six or more tablets a day because of addiction
and when you’re in the throes of addiction you’ll find a way to get that
four to six hundred dollars and this is the story of a fella who was carving
Eagles from moose antlers and would sell a piece of art for four or five
oxycontin tablets he may be one of the lucky ones you would probably see in
communities like this that things like sex trade and crime would increase what
we saw in Alberta so oxycodone these are the acute drug
toxicity deaths with or without alcohol where opioids were involved
characterized by which opioids were found on top
and so you see that there was an increase in oxycodone between 2011 2012
now I’m not saying that the dots connect just because oxy neo arrived on the
market but we did see that oxycodone deaths decreased in 2013 hydromorphone
creeping up okay we saw them in Ontario too that physicians started to prescribe
hydromorphone more here’s fentanyl the red line right here
the pink sorry the orange line is heroin the pink line contained a number of
cases with six mono acetyl morphine which could have only come from heroin
so we could guess that the heroin line might actually look more like that so
the guys that are increasing the most fentanyl and heroin and the fentanyl was
your illicit bootleg fentanyl what was happening stateside when this occurred
so remember March 2012 that’s what happened with synthetic opioid deaths in
the United States so I know there’s people joining from the US listening
sorry guys we might have had something to do with fentanyl’s arrival in a big
way in the United States and the reason that a lot of this stuff happened well
before I get to the reason let me just show you what I’d spent my time doing
over the weekend so back in 2012 or so when I started to see patients coming in
saying that they were using fentanyl from the street or saying that they were
using heroin from the street I found no heroin on toxicology asked for more
advanced testing with tandem mass spectroscopy and got back fentanyl I
wanted to find out what was going on went online to find out how difficult it
was for me to purchase fentanyl and I found no shortage of open websites where
I could do that mostly from China for about $12,500 per kilogram of fentanyl
which you remember we measure in micrograms when we dose them in human
beings I hadn’t looked for a while but then
spent some of my time on the weekend checking to see how hard it is to get
fentanyl now because there’s been a lot of interdiction efforts and there’s
Ben talks between Canada the United States and China to decrease the flow of
fentanyl into Canada well oops so here was me browsing my web so if you just
type in by pure fentanyl powder or by pure fentanyl online find the one with
the largest the best star rating click on that and here you have it
fentanyl powder choose quantity quantity a kilogram so 3,600 bucks yeah you know
it’s good stuff because they’ll tell you what the street names for this stuff is
so Apache China Girl China white dance fever friend good fell at jackpot murder
AT&T tango and cash so it’s not typically what research chemical sites
would would tell you research chemical sites would probably also not tell you
that you could sell it as a powder spiked on blotted paper mixed with or
substituted for heroin swallow snort injected so clearly the purpose of this
site is to is to sell to drug dealers or drug traffickers and of course the
reviewers are not from PhD lab scientists saying dude your stuff is the
bomb is not typically what dr. Kinberg would say in Alberta very good quality
fentanyl powder arrives in a nice packet which is really what you want from your
pencil so easy to get is the point of showing you that browsing experience if
you think of it from the perspective of a drug trafficker a kilogram at call it
5000 because those were US dollars that you saw at 3600 call five thousand bucks
for a kilogram I had to change these numbers because the price has come down
a kilogram is a million milligrams of fentanyl and each tablet of fentanyl
when it was sold as counterfeit oxycontin or now when it’s sold in
little baggies of heroin or things that look like heroin would have about a
milligram to two milligrams for a euphoric dose in a 70 kilogram man per
unit so a milligram of fentanyl would give you one tab a million milligrams
would give you a million tabs and on the streets that costs about 20
bucks per tab which gives you a 20 million dollar return on a $5,000
investment where your rate of return is about 400,000 percent okay so you can’t
you can’t beat this if what you’re trying to do is introduce incentivize
people from going this way you have to compete with 400,000 percent return on
an investment which is very very difficult for us to do so in speaking to
a number of patients some of whom when at the worst in their addiction history
had to deal drugs to get by I’ve I’ve kind of figured out the best I can
what the motivations and what the factors and considerations were around
this change in the drug market and it seems to me like it reflects most what I
learned in econ 201 around the price elasticity of demand so when the price
of something changes like the price of oxycontin changed in 2012 in Canada how
does the demand respond to that and that depends on a few things so in the
population of people who are already using a product when the price of that
product goes up how does how do you determine whether or not people will
continue to buy that product of the new price well the first thing to consider
is necessity and if somebody is addicted to opioids has a substance use disorder
that involves opioids it is necessary they have excruciating withdrawal pains
and other symptoms and they have compulsions and intrusive cravings that
they cannot control no matter what they do and so they feel that drug use is
necessary because it is how you define the good if you’re the the customer it
is a lot determined on what you’re used to using and so people who were using
oxycontin would define the good as oxycontin gotta get my oxy what
percentage of income somebody would spend on a product of increased price is
not as material to somebody with a substance use disorder because part of
the characteristics of substance use disorder is use despite consequences
namely financial or involvement with crime and so we did see an increase
acquisition crimes in alberta and i for my clinical practice I can tell you
anecdotally an increase in sex trade work amongst both my female and male
patients no matter what age brand loyalty might be the reason that we saw
those counterfeit fentanyl tablets come in as colored and pressed as oxycontin
the original oxycontin not the oxy neo how long the price holds is where public
health and health authorities could have could have taken advantage of so the
example that I provided in Vancouver which was a bad one but I’ll try it on
you guys is milk so if the price of milk per litre went up by a buck you’d
probably continue to buy milk for about a month or so and if it stayed high you
might consider your alternatives like almond milk or soy milk and in saying
this to Vancouver they all looked at me like I was foreign as they sipped their
their hemp milk lattes but we saw in Alberta for example that the price uh
that that when oxycontin tablets went up in a place like Fort McMurray and oil
sands community to about $80 or $100 a tab you also saw heroin get to Fort
McMurray for the first time and I was being sold at about 20 bucks or 25 bucks
a point which is not that much different from the downtown east side of Vancouver
and what the drug traffickers were trying to do the best I can tell was to
make sure that that the price of illicit opioids didn’t stay too high to force
people towards treatment or other alternatives that in that involved them
getting squeezed out of that person’s financial practices the availability of
substitute Goods is what the drug traffickers were working on so they
started off with bringing in heroin but I’ll show you why that was too risky and
why fentanyl came but in terms of initiation of use so people who didn’t
use drugs are still important to drug traffickers drug traffickers need to
continue to create a client base because some of their clients are going to die
or they might go for treatment or something might happen that they no
longer are a customer so you want to continue to build your business any good
business person would so if you look at the same considerations
the things that kind of jump out is not the definition of the good because if
you’re not if you’re not somebody with a substance use disorder and you’re an
adolescent the definition of the good is drugs and drugs are necessary in
adolescence we all know that people have used drugs since time immemorial whether
it’s caffeine or tobacco or cocaine or hallucinogens people have used
substances since time immemorial and there’s nothing that you can do from
stopping a certain segment of people from experimenting with mild
mind-altering drugs but if it’s too expensive they’re not gonna use it so
they’ll go for the stuff that’s widely available that gives them a good buzz
and that’s cheap so if it was oxycontin and it was going for 80 or 120 bucks a
pill you’re not gonna get kids hooked on oxycontin that way so you’re gonna have
to bring in something cheaper and they did terms of brand loyalty we might have
done some disservice to public health by talking about fentanyl the way that we
have been so you see here this is an article from MacLaine’s where the first
thing they say about fentanyl is that’s the king of all opioids and if you’re a
kid whose cognition is very much affected by anchoring bias meaning you
you remember the first thing that you heard you’re gonna remember the king of
all opiates and not a killer drug crisis especially because in adolescents
cognition it’s not as affected by loss of version as it is for adults so
they’re gonna remember the good part of this and that’s that fentanyl fentanyl
rocks because we’re talking about it so much everybody must be using it and it
must be really really good we don’t know very much in Canada about what drugs
people initiate on that’s a problem but it has been studied in the United States
and you can see that especially after 2012 the drug that opioid users start on
is increasingly heroin and decreasing Lee oxycodone and decreasing Lee
hydrocodone which is another very very popularly prescribed opioid in the
United States so while we’re watching prescribing we can’t watch
heroin because we don’t have health services utilization data on heroin not
in terms of dispensing of it but it’s been creeping up to the point where it’s
the most commonly regularly used opioid in anybody initiating an opioid use
career here’s what the drug traffickers were looking at though how do we manage
this demand with a supply that makes sense from a business point of view and
that depends on the availability of raw materials raw materials when it comes to
prescribed opioids had decreased in supply or at least they weren’t
increasing the way that they were before so you couldn’t get them prescribed and
diverted by shopping around doctor to doctor but you could import them and you
can synthesize them without a whole lot of knowledge so even if we were to
succeed at interdiction rest assured that drug traffickers would find a way
to make darn good opioids here here at home the cost that they would consider
are things like material costs but also the inherent cost of risk how hard is it
for us to traffic this stuff and a million dosages of fentanyl can come to
you in a glasses case whereas you’d need to move a crate of heroin to do the same
thing so the storage cost of it the risk of interdiction the risk of prosecution
all increases when you move big drugs and so necessarily in prohibitive
environments drug markets are going to move towards your more toxic small
molecules time to respond again if somebody else is gonna come in with a
way to satisfy demand you might get squeezed out of the market but in the
meantime they’re finding even better ways to satisfy that demand when they
thought the w18 was an opioid W teen is not an opioid but when they thought the
w18 was an opioid it was the same time that we thought the w18 was an opioid
you started to see w18 and they thought that it was much more potent than
fentanyl and so they could move it instead of moving it in a shoe box they
can move it in little golf balls or something we also have seen car fentanyl
which you have certainly heard of and different ways of trafficking fentanyl
like on blotter paper we know this is happening because a it’s
in the press and the press tends to find things out faster than public health
does but also because in the first six weeks of 2017 we saw 15 deaths in
Alberta involved where car fentanyl was detected in all of 2016 we only saw 30
deaths so in six weeks we saw half as many in 17 as we did in all of 16 just
yesterday late last night Andrea whoa and The Globe and Mail reported about
new analogues of fentanyl being found in Vancouver and also other research
chemicals like youth 47 700 which is expected to be more toxic more potent
more powerful than fentanyl and therefore you can move it in smaller
packages you can purchase less of it to satisfy the same population demand I
don’t know if you you all remember what was going on with synthetic cannabinoids
mostly in the United States about 2 or about three or four years ago you
remember k2 and spice and these things that were being sold at head shops in
incense and stuff this is a great example of how the drug market morphs if
you look at 2010 when we start first started to have problems with these
cannabinol mimetics the most commonly found one by the
national forensic lab information service in the US was called J WH 18 JW
Huffman series of synthetic cannabinoids in 2010 that’s what you would find so
things like k2 and spice were this molecule and then they would list that
molecule as a scheduled drug and then the drug market would just move to
another one and there’s countless of these molecules that they can prepare to
the point that in 2013 you need to find anymore J WH and you found other
molecules like XLR so though the names don’t matter what matters is the drug
market changes a lot faster than we would like and a lot faster than we can
keep up with in a prohibition environment there will come a time that
we don’t see fentanyl anymore I am certain there will come a time when
everything that we see are things that we either can’t
TEKT on clinical toxicology or things that are just hard to find or
characterized when they’re seized by police so we’ve been busy concerned
about supply let’s reduce how much opiate is getting to the street from
prescription from prescribing let’s interdict let’s throw stickers on pill
bottles that tell people that it’s bad to use opiates but in the meantime
demand has been skyrocketing not just demand in terms of you know the
structural characteristics of our society that lead people towards
addiction like poor management of mental health conditions traumatic experiences
systemic racism sexism classism but also the immediate demand there’s a lot of
people who have opioid use disorder who have addictions who can’t get access to
care and the way that we should be managing this is with those things that
the evidence tell us will save lives and make people’s lives better off the top
of my head the things that jump out are agonist maintenance therapies so in the
BMJ ‘s has put out the most recent systematic review of methadone and
buprenorphine naloxone showing that you get a about a five fold decrease in
overdose mortality in somebody on methadone maintenance versus somebody
not on methadone maintenance who has an opioid use disorder and from four point
six to one point four and somebody maintained on buprenorphine that’s a
huge mortality benefit for putting somebody on a very simple therapy but
not just reducing their overdose mortality also include a also reducing
their mortality from anything so we know that substance use especially substance
you saw on the street comes with a whole bunch of co-occurring things like
blood-borne pathogens like injury and you see that there is a significant
decrease from thirty six point one person years to eleven point three all
cause mortality in patients maintained on methadone and about two to one
for patients who are maintained on buprenorphine naloxone so the the
buprenorphine the locks and there’s some overlapping confidence intervals but the
size of that difference is significant for all cause mortality but the the
overdose mortality difference is really really convincing um a couple of things
though – in interpreting the systematic review one is that the cohorts in these
studies the enrollment into these cohorts did not ended by 2010 2010 was a
lot different from 2017 in this drug market they also excluded any studies
that had to do with incarcerated individuals or people recently released
from jail and they’re at super high risk of overdose and all cause mortality so
if anything the differences that you see in this systematic review are
underestimates of how important it is to offer these therapies to patients with
opioid use disorder how many people I mean how many people do we need to treat
well it’s tough to know but in 2008 the Centers for Disease Control estimated
that for every death and we know that deaths are the tip of the iceberg for
every death there were a hundred and thirty people who abused or were
dependent to opioids so that’s the old DSM for characterization of substance
use disorders we don’t use the word abuser dependent anymore but for every
person who died one hundred and thirty people were addicted in lay speak so if
you take a look at in my province what the increase in access to treatment has
been recently so between the fiscal year 1314 and the fiscal year that ended 2017
we saw an increase in methadone maintained patients of thirteen hundred
and forty-seven with buprenorphine an increase to two thousand seventy five so
in total the number of patients in Alberta who were receiving agonist
maintenance therapy increased between thirteen fourteen and fifteen sixteen of
thirty 400 people the number of people who died
during that time fourteen hundred and six that’s an underestimate as well
because that excludes people who died from anything other than fentanyl in
2014 and 2015 because we have not received reports on those people so it’s
more like 1800 because there’s about 200 people a year dying from prescription
opioid deaths there’s nowhere near a hundred and
thirty times the number of people who died so we’re not even close how many
people do we need to treat I think would be helpful to know and we would need to
know how many people are using these drugs we have a survey it’s mostly just
a really good smoking survey what we know is that actually the number of
people using pain relievers decreased between 2013 and 2015 the number of
people using illicit drugs increased between 2013 and 2015 but that’s because
of an increase in the use of hallucinogens and ecstasy but not the
use of heroin which they could not describe because there were too few
respondents to give a decent number so we don’t know what the heck is going on
in other words so you see dashes beside heroin because the sample size or the
power of the survey was not enough to detect what the number of people was or
where any differences over time and nobody asked about fentanyl so we’re
missing this in terms of surveillance where we could get good surveillance is
in places like these where people are reporting on twitter who they saw not by
name but who they saw what they were using who overdosed what are their drugs
has positive for it’s just a really important stuff for us to know from a
public health perspective to intervene this comes from a superstar Mary Lou
gong-gong who is with the overdose prevention Society of Ottawa operates
the tent so here you see on one night 47 visits one overdose managed with two
doses of naloxone so there you know how many people use a sight what proportion
of them had an overdose didn’t alloxan work really important surveillance to
have and then another day 28 visits one guest needed monitoring they tested
the drug and it was fentanyl really important information for us to have she
tracked it over time right this is stuff that we could gather as part of a
surveillance system looking at drug pricing and at websites like Street rx
really important indicators to have if we were to have what they call a full
picture of what’s going on with the opioid crisis this would be important
everybody know this guy so this is that that’s how his face gets his David
you’re linked he’s a professor at the University of Toronto and most of what
I’ve talked about is from BC and Alberta but if anything’s gonna be important
somebody from Toronto to say something so so this is this is David who is
probably the most prolific writer on the opioid crisis in the country or in in
the continent this is how his face gets when somebody says the word Purdue so he
says a lot of smart things none smarter I think than what he said at FEM rack in
June which was I like to quote a geek who said there’s never been a more
dangerous time to use drugs from the street
that’s not something I said just because it fits nicely 140 characters is it’s
the best that we can glean about what’s going on in the opioid market it’s not a
don’t do drugs message it is so we need to do something message about risk one
of the first things you learn in public health is that risk is about the
likelihood of something happening the magnitude of an adverse event the
frequency of those adverse events happening and those depend on things
like your exposure characteristics your susceptibility characteristics and
characteristics of the hazard the hazard has never been more dangerous and we
don’t know what proportion of the drug market is flooded with these dangerous
hazards we don’t know which dangerous hazards they are necessarily and we
don’t know how people are exposed to them in terms of the route of exposure
the dosages that they’re taking and we don’t know everybody susceptibility
factors what we do know is that there’s some that are common things that make
people more susceptible our patient characteristics like other conditions
they may have other substances they may use
we may know things about their social environments like if they are poor
they’re more likely to suffer from an adverse event if they don’t have a phone
when they or if they use alone or live alone if they overdose there’s nobody to
rescue them these are things that make people susceptible and we don’t have a
characterization of the people who are at risk in terms of these variables we
do know from the United States that exposure to needles is increasing in
that this is the first birth cohort where the time between initiation of
drug use and initiation of injection drug use has gone down so they’re
starting to inject earlier mostly because the drugs that are most popular
are less so stimulants and more so opiates we also know that people who
smoke drugs also overdose and we know this because if you watch Twitter good
surveillance would watch people who operate overdose prevention sites like
Sarah Blythe who is a hero and you know she’s a hero so here she’s told you how
many people have used the Vancouver OBS in that day and she showed that there
was one overdose in somebody who smoked to their drug you can tell she’s a
rockstar because who but a rockstar would let their phone get to 8% battery
level yeah and leave the Bluetooth on so okay I’m gonna I’ll try and wrap this up
quickly but there’s a couple more really important things I want to get across
one is we use this phrase first do no harm in medicine all the time and we
attributed to Hippocrates or the Hippocratic oath it’s not in the
Hippocratic oath but sometimes we use that phrase to
reflect what the spirit of the Hippocratic oath is which is take care
of your patients don’t mess around and make sure that you don’t hurt them but
it doesn’t say don’t do anything and I know that there’s a press to say you
know if the person decides to take an opiate and dies from it I don’t want to
be the one prescribing it but the approach that we ought to take is let’s
look at the patient and assess their risk based on those variables that I
described before and offer them things that have a greater likelihood of making
their life better than of them suffering an adverse event
if you take a look at the people in Alberta who died from opioid overdose
you can tell that there are some differences in risk characteristics from
people in that top chart who died from an overdose related to fentanyl than the
ones in the bottom chart who died from an overdose related to an opioid that
wasn’t fentanyl like a prescription morphine or hydromorphone or oxycodone
more women in the latter older in the latter and probably some risk
characteristics that you could in doing a deliberate assessment of risk with
that framework that I showed you identify and if you take a look at the
things that happened sorry this is kind of important so here’s what Canada says
about opioids on their website first thing I’ll point out is that it falls
under substance abuse it’s kind of a pejorative way to say that if something
bad happens to you from an opiate is your fault we have to change that
language and secondly it says when used properly they can help but when misused
they can cause addiction overdose and death those are both true statements but
there’s a statement in between that’s not set and that is when used properly
they can also cause addiction overdose and death and I can guarantee you that
some of those people in the two charts that I showed before or in that I’ll
show again did not have addiction and there are some people who died from
fentanyl use who were not addicted to fentanyl but used it in a recreational
way we have to worry about those people as well because they’re actually at
higher risk of adverse events because they don’t have the tolerance and
withdrawal that characterizes an addiction disorder here are the things
that people did in the 30 days before they died from an opioid overdose the
bottom chart is that people who died from prescription opiate overdose and
the top chart is the one who died from fentanyl 11% of the people who died from
a fentanyl overdose visited an emergency department in the month preceding their
death for a substance use condition either intoxication or withdrawal so
they’re presenting telling you what the problem is in the emergency department
but only 2% of them received a dose of agony
maintenance medication in terms of the people who died from a prescription
opiate overdose 57% of them got an opiate from a pharmacy and almost 50% of
them got an ankle it Acorah 90 depressant from a pharmacy if you use
that risk framework you would recognize that combining things might be
responsible for some of the stuff that we’re seeing and they have not mentioned
anything about gabapentin which we should probably be keeping an eye on in
the UK it looks like gabapentin related deaths are increasing with gabapentin
prescribing last week a very bright Toronto group reviewed what the risk is
of adding gabapentin to chronic opioid therapy they found that at doses of
greater than 900 milligrams of gabapentin patients were at almost a 60%
increase of mortality death if they were also known opiate compared to if they
were not on gabapentin so when we do these risk assessments it’s not just
about the max dose of opioids it is about that but it’s also about other
things okay so basically the questions we have to ask ourselves or do you
identify hazards in the patient context did you assess the likelihood of
exposure to those hazards and how they’re exposed did you assess patient
and environmental characteristics that increase their susceptibility to those
hazards or do increase the risk of adverse events from those hazards and
did you add protective interventions or offer them meaningfully in other words
did you assess and and risk manage and harm reduce you have to check out the
guideline for management of opioid use disorder from the BC CSU is excellent it
looks it describes why we ought to avoid withdrawal management alone or detox
particularly inpatient detox which tends to be where governments go when we have
a drug crisis instead opting for outpatient detox over longer periods of
time if a patient insists on detox or residential as opposed to inpatient
looking at agonist maintenance therapies and offering buprenorphine naloxone
first in patients who don’t do well on buprenorphine naloxone or
views or have previously done well on methadone to offer methadone and options
for patients who don’t do well on conventional an agonist maintenance
therapies like slow release oral morphine and it used to be my one beef
about these guidelines that they did not include injectable opiate agonist
therapies but they solve that yesterday when they released their new BCC su
guideline on that which is becoming more important when you think of the risk
framework that I presented you want to keep people from being exposed to
hazards that you can’t predict or hazards worse that you can predict and
are worse than the ones that you that you might offer to them this is from the
riot trial which it was named because that’s what happens when you present
this stuff to recovery group but basically in comparing patients who
received injectable agonist maintenance therapies to conventional oral methadone
agnus therapy there was no difference except that with people who are on the
supervised injectable heroin were significantly more likely to have
reduced the amount of money that they spent on illicit drugs now the money
itself is important because we know that income is a social determinants of
health and if they have poor resources they’re not going to do as well but it
reflects that they’re accessing the illicit drug market less and that’s a
critical outcome even if they continue to use if they’re not using drugs that
are likely to kill them we have a chance at you know a better tomorrow so to
speak okay jail is really really important we
talked about the risks that people who are incarcerated face my province and
several others do a really bad job of offering therapy in jail
tons of blood-borne pathogen transmission in jail from injection drug
use and tons of drugs so with rusty blunted needles so we ought to focus on
them okay last set of stuff that I’m going to say I know there’s one attendee
from the London School of Economics on the livestream
they put out a terrific paper including authors who of five authors who were
Nobel Prize winners in economics describing why the war on drugs has to
end they described it from the perspective of it doesn’t work in terms
of the money spent on investigations enforcement prosecution and
incarceration related to drug related to to drugs do not justify the outcomes but
the outcomes are also negative meaning the more that you invest in an
enforcement investigation prosecution incarceration the worst drug problems
get so those are good reasons another good reason is that Richard Richard
Nixon started it and I’m sorry for putting Richard Nixon in a picture of
our Parliament building but this is what his domestic affairs adviser John
Ehrlichman is said to have said to Harper’s Magazine before he died
Nixon had two enemies the anti-war left and black people we knew we couldn’t
make it illegal to be either against the war or black but by getting people to
associate the hippies with marijuana and blacks with heroin and then
criminalizing both heavily we could disrupt those communities did we know we
were lying about the drugs of course we did whether or not air Lichtman said
that the way that he said or whether this is related to him feeling hard done
by for being thrown under the bus and being in jail for being a co-conspirator
of Watergate it’s kind of kind of irrelevant because if you look at the
effect of the war on drugs in the United States it is that where 10% of the US
population is black but over 30% of those in federal prison for drug
offenses are black and that’s not because black people use drugs more in
fact it’s probably the opposite and it has everything to do with their being
stiffer penalties for using drugs that poor people use than using drugs that
rich people do almost 3,000 per hundred thousand black men in the United States
is in jail largely because of drug-related offenses this is not just
American phenomenon you can imagine who the population is in can
who was affected by our drug laws most guesses indigenous people so very bright
researchers in in British Columbia have demonstrated that even when you control
for all of the things that are likely to put somebody in jail or be associated
with things that put people in jail you still have a substantially increased
risk of be incarcerated if you’re indigenous than if you’re not and that
has a lot to do with drug laws as well ok so please tell our Health Minister
that drugs needs to be decriminalized this is a they really dug their their
their heels in around not pursuing that for anything but marijuana and saying
instead that we have to work on D stigmatization and it’s easy to judge
but Canadians shouldn’t judge people for using opioids when we literally ask
judges to judge people for using opioids you want me off of here right I just
want it because we’re in Ottawa this is happening in Ottawa and I thought we it
should be mentioned so we’re in a legal environment where we’re yes we want
people to be distinct I see if they have substance use problems or if they decide
to use drugs but at the same time so this is what’s happening at the overdose
prevention site in Ottawa bright light being Shawn for 20 minutes at a time on
this tent where people go to use their substances in a way that if something
bad happens somebody can save their life they’re doing this to make it
uncomfortable or to make those people submit to their will do you know what it
it’s called when you do something uncomfortable to somebody to make them
submit that’s called torture there’s also somebody who decided to spread 400
pounds of horse manure around that site in order to prevent people from going to
a place where their life may be saved and you get a $260 ticket for that
meanwhile if your friend who also uses drugs ask you to score for him and you
go pick up that fentanyl and that fentanyl
Hilsum in Ontario in Alberta you’re increasingly likely to be charged with
manslaughter for that but you keep somebody from going to a life-saving
service and you get a $260 fine and a ticket so the reason for
decriminalization is to change the ethos around that stuff
not because decriminalization will magically stop people from using drugs
it does decrease the adverse events associated with them but it allows us to
provide environments where people feel they can attend for cert for for
healthcare services in a stigma and barrier free way there’s Portugal right
there three overdose deaths per million population in the in the adult group and
the other countries with with good drug law like Czech Republic France Germany
Netherlands all are on the low side as well okay last promise that’s the last
thing promise so normally we start off by acknowledging whose traditional lands
were gathered on I thought it might be a good idea to end that way because there
is a significant learning I think from indigenous cultures in ways that might
direct us towards action in a good way so we are gathered on traditional and
Algonquin territory I come from Blackfoot territory and what
an elder taught me was that the best way to describe a community is the way that
Blackfoot women build a teepee and so there will be four Blackfoot women who
come with the long pine poles each of them with a specific job and then some
more will come with the smaller sticks and gather them around and one person
will tie the first animal leather around the top to hold them together and then
two more will bring a large animal high to wrap it and then one usually an elder
with great wisdom will draw in it a design that’s an honor to the earth
everybody had their job and similarly the teepee itself is a demonstration of
how to support each other if one of those sticks were to bend or splinter
the others would hold it up but if you were to take the bend
and splintered one away all of them would fall and so the lesson that she
that she was trying to transmit I think was that the measure of a resilient
community is not how you take care of the weakest member it is actually how
much you depend on each other and I know it kind of makes me a snowflake to say
something like that at a health Technology Assessment place but I think
that’s really really really important and should drive everything that we do
this is what the the American Medical Association has is a credo in their code
of ethics humanity is our patient just because somebody is not in front of you
as a patient does not mean that you don’t have a responsibility to them so
for those of you who are clinicians or researchers or bureaucrats I think we
all could really use some help in convincing decision makers that these
are directions that we need to go if you don’t believe that physician voices are
allowed go on Twitter and search for the hashtag tax fairness and you’ll see we
we can we can speak and then finally since we talk cutting-edge things that
Kadett if you do provide treatment to people who have troubles with substances
or anybody from socially disadvantaged groups really the most important piece
of advice and the most important piece of anecdotal evidence I can get give you
is be nice

2 thoughts on “CADTH Lecture Series — Canada’s Opioid Crisis by Dr. Hakique Virani

  1. I have have been taking opiods for 20 years , and have never felt so bad since us who are taking it for pain are the ones who are suffering from your war on pain. Please help us we are to much in pain to fight in a war we do not know how we got in this war why?

  2. I've been using heroin over 30 years where methadone, Suboxone or even morphine do not work that is why we need more addiction doctors in the Ottawa-Gatineau region where we can get a supervised injectable heroin being prescribe by doctors like Doctor Jeff Turnbull we need the public help here in Ottawa and Gatineau because people are dying for a smaller city like Ottawa compared to Vancouver we have way to many overdoses from lace heroin and poisoned drug supply . So please HELP US ALL HERE IN CANADA FOR A BETTER CANADA ON THE ADDICTION TO OPIATES.

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