The Opioid Crisis and a Novel Approach to Detox and Rehab

Health Canada and the BC Government have described opioid use and the resulting deaths as an epidemic. Indeed, Canada has the highest rate of prescription opioid use in the world and BC has the highest number of opioid overdose deaths in the country. Approximately 265 people have died of suspected opioid overdose in Vancouver this year (as of September 24th) and the city has issued the following statement:

While various harm reduction efforts have been, and continue to be, hugely successful in saving lives, the situation will only really improve with intensified efforts on expanded outreach and harm reduction, a clean drug supply, a diversity of longer-term treatment options, and access to other social services.

Edgewood Health Network’s new treatment centre, Whiterock, is a state-of-the-art facility that is now open and addressing the need for diverse treatment options. Located in White Rock, BC, only 40 minutes away from downtown Vancouver, Whiterock offers a variety of addiction treatment programs including detox, short-term residential, partial hospitalization, and intensive outpatient.

Unlike in the past, the current opioid crisis touches nearly every segment of the population. Whereas opiate abuse, and specifically heroin addiction, were seen to impact mostly marginalized communities in the past, the proliferation of opiate prescriptions has created an unprecedented problem across all socio-demographic groups. Middle-class Canadians may experience a deeper sense of stigma around seeking help and may also face other barriers to receiving effective treatment. Whiterock is conducting specific outreach and education targeting this population.

Coming Soon: Accelerated Detox at Whiterock

The safest, most successful detox option is known as “medically supervised withdrawal management.” Whether inpatient or outpatient, withdrawal from drugs is made more tolerable by medications that minimize drug cravings and withdrawal symptoms, which are given under the direct supervision and care of a licensed physician. The traditional methods of opioid detox include tapering with methadone or buprenorphine, or discontinuing opiates “cold turkey” and easing withdrawal symptoms with medications such as clonidine.

However, even with medication, withdrawal can be a very uncomfortable experience; patients who are unable to tolerate the discomfort often terminate the detox process and resume abusing opioids. While the mortality rate from opioid withdrawal is low, unfortunately, the mortality rate from resuming opioid abuse after a detox attempt is much higher. This is because the short period of abstinence during a detox attempt lowers a person’s opioid tolerance and thus increases the risk of a fatal overdose when they resume opioid abuse.

Since detox often fails due to a patient’s inability to endure withdrawal symptoms, an effective strategy that maximizes the likelihood of success is to detox as quickly as possible while maintaining a tolerable level of discomfort. With this in mind, clinicians have developed methods of accelerated opioid detox that rapidly induce withdrawal through carefully monitored use of opioid antagonists, while concurrently using hypnotics or mild anesthetics to manage symptoms.  According to the American Society of Addiction Medicine (ASAM) the chief benefit of medically supervised detox is that people can be completely toxin-free within a few days to a few weeks.

As a Canadian innovator in addiction treatment, Whiterock will soon launch a new accelerated detox program available to Canadians. In combination with other programs and services provided by Whiterock, this progressive intervention will serve the needs of patients and help them achieve successful and sustainable recoveries from opioid addiction.

What you should know about Opioid Use Disorder (OUD)/ Opiate Addiction

As declared by Health Canada, we are in the midst of an Opioid Crisis and lost over 3000 victems to opiate overdose last year alone. It is widely accepted that the Opioid Crisis has resulted from the over prescribing of prescription medications, the wide spread availability of potent opiates such and Fentanal and Carfentanal, limited access to appropriate detox services and addiction rehab and the lack of a timely and comprehensive public health strategy.

“Opioids” refer to natural and synthetic painkillers derived from the poppy plant. The related term “opiate” refers to medications that use natural opium poppy products. For example, the drug morphine is an opiate. Doctors typically prescribe opiates to clients when they experience acute pain, often as a result of injury, accidents or medical procedures. Opiates are also used in cancer treatment for chronic pain. Some well know opiates include:

  1. Morphine
  2. Codeine
  3. Heroin (Diacetylmorphine)
  4. Hydromorphone (Dilaudid)
  5. Hydrocodone (Vicodin, Lortab)
  6. Opium
  7. Oxycodone (OxyContin, Percocet)
  8. Oxymorphone
  9. Meperidine (Demerol)
  10. Methadone
  11. Fentanyl (Sublimaze, Actiq)
  12. Tramadol

To be diagnosed with Opioid Use Disorder (OUD), individuals must meet certain criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Under DSM–5, the current version of the DSM, anyone meeting any two of the eleven criteria during the same 12-month period receives a diagnosis of OUD. The severity of OUD—mild, moderate, or severe—is based on the number of criteria met.

The Eleven Symptoms of Opioid Use Disorder (OUD) as per the DSM-5:

  1. Opioids are often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
  3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
  4. Craving, or a strong desire or urge to use opioids.
  5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
  8. Recurrent opioid use in situations in which it is physically hazardous.
  9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  10. Tolerance, as defined by either of the following:
    a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
    b. A markedly diminished effect with continued use of the same amount of an opioid.|Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.
  11. Withdrawal, as manifested by either of the following:
    a. The characteristic opioid withdrawal syndrome
    b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms

How Do Opiates Work?

One of the reasons why opiates are so addictive is that there are actual receptors in our brains that are a perfect fit to the opioid molecule. When people inject opiates like heroin or take opiate pills like Oxicodone, their active compounds travel to our brains and attach to unique neuro-receptors. Thease neuro-receptors are located in our reward centre of the brain which triggers a sense of intense pleasure or euphoria. These feelings, typically associated with natural experiences like eating, drinking and having sex are hard-wired in our biology as a matter of sheer survival.

Opiate use results in the release of dopamine into the brain’s reward center which produces pleasurable feelings. The problem is that opiates, like other drugs of abuse, trigger the release of dopamine in excess amounts, far beyond what is normal. The resulting “high” is a very powerful reinforcement; reinforcement to use again and again to achieve that intense pleasurable high.

The High associated with opiate use can be intensified when the drug is administered intravenously (like heroin) or by routes other than those prescribed or recommended. For example, the prescription painkiller OxyContin can be snorted or injected to enhance its euphoric effects.

Prolonged and increasingly higher doses of opiate drugs literally change the brain so that eventually it functions normally when the drug is present and abnormally when the drug is removed. This anatomical change in the brain results in drug tolerance (the need to take higher and higher amounts to achieve the same effect) and opioid dependence (susceptibility to withdrawal symptoms). That’s why it’s said that someone with opiate dependence uses the drug in order to just feel “normal.

Side Effects of Opiate Use and Abuse

Anyone exposed to opiates will experience excess dopamine released in the reward center of their brains. Most people do not become addicted after taking opiates and many people can take prescription drugs like Oxycontin responsibly as prescribed The risk of abusing opiates is higher if “it rruns in the family” and you have a genetic predisposition to addiction or if you have experienced a psychological trauma or social situations that have been damaging.

While the pharmaceutical industry and irresponsible prescription practices by physicians may be to blame for the Opiate Crisis, there has also been a dramatic increase in nonmedical use of illicit opiates in Canada. Opiate use and abuse is on the rise, particularity in youth which has lead to an overdose epidemic.

Side effects of opioid abuse may include:

  • Dry mouth
  • Drowsiness
  • Nausea
  • Constipation and severe abdominal cramping
  • Depressed respiration

Signs and symptoms of opioid intoxication may include:

  • Problematic mental health, behavioral or psychological changes such as agitation, impaired judgment or apathy
  • Drowsiness or unconsciousness including coma
  • Impaired attention or memory
  • Slurred speech
  • Constricted pupils

Opiate Withdrawal and Relapse

Withdrawal from opiates is typically characterized by symptoms of discomfort including severe physical and emotional symptoms and cravings for the drug. It is well known that the mere fear of withdrawal symptoms often keep people from seeking detox or rehab treatment for addiction. This avoidance leads to on-going abuse of the drug, increased tolerance and higher risk of overdose and death.

Withdrawal “detox” symptoms may include:

  • Muscle cramps, limb and “bone pain”
  • Insomnia and restlessness
  • Flu like symptoms including vomiting, diarrhea, fever, tremors and shakes
  • Agitation often accompanied by involuntary leg movements
  • Anxiety, irritability and mood swings
  • Irregular heart rate

Even after an acute “detox” phase passes, people can experience more serious, long-term consequences of opiate withdrawal including serious mental health problems like depression and anxiety. In addition, cravings for the drug often last for months and contribute to the vulnerability people have to relapse particularly when confronted with stress or pain. The high risk of relapse we see in opiate users is accompanied by a high risk of accidental overdose and death. This is because a person who returns to the same dose after losing their tolerance to opiates risks overdose, respiratory suppression and death.

This risk of opiate overdose has become a defined crisis by Government largely due to the expanded access to very powerful opiates such as Fentanyl and Carfentanil. Fentanyl is a strong synthetic opiate typically administered to clients following surgery, to manage chronic pain or to produce sedation during medical procedures. Although similar in effect to morphine and heroin, Fentanyl is 50 to 100 times more potent. Carfentanil is an analog of Fentanyl and is 100 times more powerful than Fentanyl and 10,000 times more powerful than morphine. Both Fentanyl and Carfentanil have become widely known drugs of abuse and have contributed significantly to the Opioid Crisis and to unprecedented rates of overdose deaths across North America.

Medication Assisted Treatment (MAT) and the Opiate Crisis

Medication Assisted Treatment (MAT) refers to any treatment for a Substance Use Disorder (SUD) that includes pharmacological intervention as part of a larger, more comprehensive addiction treatment plan. At EHN-Canada MAT involves the use of medications approved by Health Canada in combination with education, psychological counseling, behavioral therapies and peer support to provide a comprehensive, evidence based approach to care.

Medical professionals currently have three types of Medication Assisted Treatments or therapies (MATs) at their disposal for treating clients with SUD including Opioid Use Disorder (OUD). MAT options include:

  • Buprenorphine– is a partial opioid agonist which means that although it can produce typical opioid effects and side effects such as euphoria and respiratory depression, its maximal effects are less than those of full agonists like heroin and methadone
  • Naltrexone– is a non-addictive opioid antagonist that blocks the effects of opiates. It is typically administered as a daily pill in Canada however, it is readily available in monthly injection form and implants in other parts of the world
  • Suboxone is a brand name medication that contains two active ingredients: Buprenorphine and Naloxone. Naloxone, sold under the brand name Narcan, is an opiate antagonist (like Naltrexone) and is used to block the effects of opioids and reverse overdose.Suboxone therefore, is an “opioid agonist/ antagonist” that blocks the reinforcing properties of opiates while alleviating craving for the drug and reducing withdrawal symptoms. Suboxone is administered daily in the form of dissolving tablets or cheek film. It is non-addictive and is not typically abused by clients.  Suboxone has become the gold standard in MAT for opiate dependence.
  • Methadone While becoming less widely used, Methadone is an opioid agonist that does not block the reinforcing properties of opiates but does prevent cravings and withdrawal symptoms while taking it. Methadone is dispensed daily in liquid form in specialty regulated clinics. It requires laboratory testing and monitoring and can be abused because of its addictive properties.

Although methadone is commonly used to ease opioid withdrawal and has been an effective drug for many clients, EHN-Canada supports the use of Suboxone because most medical experts view Suboxone as a better alternative with fewer side effects and a significantly better client safety profile. There is also much less potential of abuse and overdose with Suboxone as compared to Methodone and it is far less complicated to administer and monitor. In addition, the use of Suboxone is in keeping with many clients’ goals of using Medication Assisted Treatment (MAT) for a transitional period as opposed to long-term, indefinite maintenance.

Because of the unique challenges in addressing opiate addiction, and because of its unique vulnerability to relapse, accidental overdose and death, EHN-Canada provides Medication Assisted Treatment (MAT) as an adjunct to psychological and behavioral therapies. This “holistic” clinical approach is supported by a high degree of scientific evidence, especially in the treatment of Opioid Use Disorder or opiate addiction. Because MAT helps decrease withdrawal symptoms and cravings, clients are better able to engage in treatment and focus on learning new skills and ways of relating to people, places and things that could trigger relapse. Indeed, with the support of evidence based psychological interventions such as Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT), clients have a much higher likelihood of achieving long-term recovery which may eventually include abstinence from drugs in many cases.