Northwestern Ontario Prescription Drug Abuse Treatment Program

Dr. Sharon Cirone Dr. Ashok Krishnamurthy

DISCLOSURE OF COMMERCIAL SUPPORT

• This program has received NO financial support • This program has received NO in-kind support from • No potential for conflict(s) of interest for this program • Faculty: Dr. Sharon Cirone

• No commercial relationships or interests

• Faculty: Dr. Ashok Krishnamurthy • No relationships with commercial interests

Outline • History of Northwestern

Ontario PDA Epidemic and Responses

• Epidemiology • Policy • Program Development • Buprenorphine • Community-wide measures

of wellness in a remote First Nations community

• Summary and Discussion

History of Northwestern Ontario PDA Epidemic and Responses

• Chiefs of Ontario • Health Canada • Individual communities

History of Northwestern Ontario PDA Epidemic and Responses

• Chiefs of Ontario – Regional chiefs in North-western Ontario have declared prescription drug

abuse (PDA) to be an epidemic/crisis/state of emergency in some communities ~ 2009/10

– Dr. Claudette Chase- first community based treatment program 2010 • Primary care physician based in a small First Nations Community in Sioux Lookout Zone • Started induction of ~ 5 pts on 5-7 day detoxification on Buprenorphine • Counselling in community provided • Led to further interest in other communities and development of other community programs

to treat opioid abuse • Purdue’s impending discontinuation of Oxy Contin in 2012 accelerated the preparation of

community based programs to deal with the epidemic

Epidemiology

Canada has had the second-highest levels of PDA globally behind the United States Non-medical PDA has not been declining in special

risk populations such as First Nations

Epidemiology Northern Ontario First nation’s communities: more than

50% of the adult population are reported to be PDA users and in need of treatment

Main drug of abuse is Oxy Contin

The number of deaths due to opioid overdose ~ two-to-five times higher in First Nations communities

Emergency room visits related to opioid use in Ontario

MOHLTC 2011

Policy

The Chiefs of Ontario in collaboration with the First Nations and Inuit

Health Ontario Region (FNIH-OR) undertook Resolution 08/68 to Develop recommendations that would:

build upon promising practices in First Nations with the goal of preventing, treating and eliminating prescription drug abuse

inform the development of federal, provincial and First Nations research practices, programming, policy directions and associated resources

be flexible, adaptable, and culturally appropriate, to respect the unique and distinct needs for each First Nations community

enhance the capacity of Ontario First Nations to address the PDA

Policy

Spring 2011: First Nations leaders in Ontario called on the Provincial/Federal

governments for assistance in handling a health crisis following Health Canada’s decision to cut NIHB funding the addictive opiate painkiller Oxy Contin

June 29, 2012, the Trilateral First Nations* Health Seniors Officials Committee (TFNHSOC) approved a work plan that recommended :

• A series of immediate, short term and long-term results-based initiatives that will

improve mental health and addictions services for First Nations people living on reserve in Ontario

• All in the aim of reducing PDA • Enhance access to a full continuum of services for people addicted to prescription

opioids * Organization of all levels: First nations, Provincial and Federal Government health officials that were tasked to find a solution to the opioid abuse epidemic

First Nation Programs Specificity/Success

Community takes ownership and leadership Program uniqueness, tailored to the community Encourage healthy lifestyles Enhance the resiliency of First Nation People, families and communities Program delivery by community members Community and Community Elders participation/endorsement of new program participants

First Nation Programs Specificity/Success

Build upon the resiliency of First Nation people, families and

communities Program delivery by community members Community and Community Elders participation and

endorsement of new program participants

Program Development

Community-based prescription opioid abuse treatment programs to help deal

with the opioid abuse crisis Holistic-treatment programs: counselling and support Pharmacological supports: Buprenorphine for withdrawal/relapse

prevention Life skills development, cultural knowledge and resiliency building Emphasized traditional culture, community development and

engagement After Care programming, integrating First Nation values, beliefs, ways of

knowing and doing in all facets of care

Programmatic Preference for Buprenorphine

First Nations communities express a strong preference for access to

Buprenorphine as an opioid pharmacotherapy over methadone Buprenorphine is easier to store and dispense in remote communities. Abstinence-based programs have high relapse rates For remote community members, the others challenges of methadone

include: daily dosing schedule higher risk of overdose with methadone need for physicians to meet certain prescribing

requirements/licensing requirements

Buprenorphine Policy

Ontario provincial drug plan added

buprenorphine/naloxone (Bup/Nlx) to its formulary then followed by the Non-Insured Health Benefits program (First Nations community drug insurance provider) in 2012

College of Physicians and Surgeons of Ontario permits all physicians to prescribe bup/nlx, even if they do not have a methadone license

Community-Opioid Treatment Program Partnerships

• Physician: assesses the program participants and prescribes Bup/nlx • Pharmacist: dispenses and packages the Bup/nlx and sends it to a nursing station in the First Nation. • Nurse/community health worker administers the Bup/nlx to program participants. • Support worker: mental health, addictions or peer counsellor – provides support, counselling and referral services to program participants. • Referral services: made to specialized psychosocial support providers or to parenting, education or life skills programs as appropriate • Community-based healers/mentors/elders mentor and provide guidance to participants

First Nation Community Community members: 1000 Population on reserve: about 800 Language: English, Oji-Cree

The Community

The Program • Developed through the initiatives of the The Chiefs of Ontario, with the

support of local clinicians, community programs and support services and Health Canada

• Pre-treatment program: 7 deaths related to PDA • Community developed a PDA working group • First group induction July 2012; group treatment and OST • 2012; 4 group inductions, 2013; 4 groups, 2014; follow up and

individual intakes, 2015; follow up and aftercare programming • Total in treatment; 170 community members • In-community retention rate 98% • Daily observed dosing, take home doses for travel and work • Random UDS

Community-wide measures of wellness in a remote First Nations community

experiencing opioid dependence Evaluating outpatient buprenorphine-naloxone substitution

therapy in the context of a First Nations healing program

Dinah Kanate, David Folk MD CCFP, Sharon Cirone MD CCFP, Janet Gordon RN Mike Kirlew MD CCFP, Terri Veale RN(EC), Natalie Bocking MD CCFP, Sara Rea, Len Kelly MD MClSc FCFP FRRM

Measures of Wellness in 2014 • Drug-related medical evacuations (assaults, suicide attempts,

overdoses, and sexual assaults believed to be directly related to drugs or addiction) fell by 30.0%

• Needle exchange dispensing decreased by more than half • the nursing station noted that children and elderly patients were being

brought in for medical care at earlier stages of illness • the nurses noted that the community clinic became more of a primary

care centre than a trauma centre, as they were now caring for less drug-related violence and its medical sequelae

• seasonal influenza immunizations had dramatically gone up by 350.0%

Measures of Wellness in 2014 • school attendance increased by 33.3% • child protection cases fell by 58.3% • attendance at community events increased robustly • sales at the local general store have gone up almost 20% • police criminal charges had fallen by 61.1%

Evaluation of 6 remote First Nations community-based buprenorphine programs

in Northwest Ontario

• Still in print

References • Balfour-Boehm, J., Rea, S., Gordon, J., Dooley, J., Kelly, L., & Robinson, A. (2014). Commentary: The evolving nature of narcotic use in northwestern Ontario. Canadian Journal of Rural Medicine, 19, 158-160. • Caverson, R. (2010). Prescription opioid-related issues in Northern Ontario: a pan northern strategy framework for action on misuse, abuse and diversion. Northern Ontario Area – Provincial Services Centre for Addiction and Mental Health. • Dhalla, I.A., Mamdani, M.M., Sivilotti, M.L.A., Kopp, A., Qureshi, O., & Juurlink, D.N. (2009). Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. Canadian Journal of Medicine, 181, 891-896. doi: 10.1503/cmaj.090784 • Expert Working Group on Narcotic Addiction. (2012, October). The way forward: Stewardship for prescription narcotics in Ontario (Catalogue No. 015919 75). Retrieved from http://www.health.gov.on.ca/en/public/publications/mental/docs/way_forward_2012.pdf • Health Canada (2011). Honouring our strengths: A renewed framework to address substance use issues among First Nations people in Canada (HC Pub: 110114). Retrieved from http://nnapf.com/wp-content/uploads/2014/02/Honouring-Our-Strengths-2011_Eng1.pdf • Kahan, M. (2014, February 13). Statement made by Dr. Meldon Kahan (Medical Director, Women’s College Hospital, As an Individual) at the Health Committee. Retrieved from https://openparliament.ca/committees/health/41-2/14/dr-meldon-kahan-1/only • Katt, M., Chase, C., Samakhvalov, A.V., Argento, E., Rehm, J., & Fischer, B. (2012). Feasibility and outcomes of a community-based taper-to-low-dose-maintenance Suboxone treatment program for prescription opioid dependence in a remote First Nations community in northern Ontario. Journal of Aboriginal Health, 9, 52-59. Retrieved from http://www.naho.ca/jah/english/jah09_01/jah_volume09_Issue01.pdf • Kiepek, N., Hancock, L., Toppozini, D., Cromarty, H., Morgan, A., & Kelly, L. (2012). Project report: Facilitating medical withdrawal from opiates in rural Ontario. Rural and Remote Health, 12. Retrieved from http://www.rrh.org.au/publishedarticles/article_print_2193.pdf • Ministry of Health and Long-Term Care (n.d.). Continuity of community-based Suboxone programs during the evacuation of First Nations. Retrieved from http://www.health.gov.on.ca/en/pro/programs/emb/firstnation/docs/firstnation_fs_suboxone.pdf • Prescription Drug Abuse Strategy Panel – Chiefs of Ontario. (2010, November 18). Final report: Prescription Drug Abuse Strategy. Retrieved from http://www.chiefs-of-ontario.org/sites/default/files/files/Final%20Draft%20Prescription%20Drug%20Abuse%20Strategy.pdf • Sioux Lookout First Nations Health Authority. (2009, June 5). SLFNHA Chiefs Forum Reports: Answering the Call for Help: Reducing Prescription Drug Abuse in Our Communities. Retrieved from http://addictions.knet.ca/sites/default/files/Final%20PDF%20-%20Forum%20on%20Social%20Issues%20with%20Appendixes.pdf • Sioux Lookout First Nations Health Authority. (2015, September 17). Supporting long-term core funding to combat addictions (Resolution #15-20). Retrieved from http://www.slfnha.com/files/6014/4293/3506/15-20-_Supporting_Long-Term_Core_Funding....pdf • Uddin, F. (2013). Hope in Fort Hope: First Nations community is winning the battle against prescription drug abuse. Canadian Family Physician, 59, 391-393. Retrieved from http://www.cfp.ca/content/59/4/391.ful • Windspeaker, S.L. (2012). Combating prescription drug addiction a priority. The Aboriginal Multi-Media Society, 30(5). Retrieved from http://www.ammsa.com/publications/windspeaker/combating-prescription-drug-addiction-priority

Special Thanks • Dr. Claudette Chase • Dr. Meldon Kahan

- for providing guidance and information used for the preparation of this presentation