FEBRUARY 2016
the
Canadian Journal
Addiction
L e Jour n a l Ca n a d ie n d ’A d diction
VOLUME 7 NUMBER 1
an official publication of the Canadian Society of Addiction Medicine
Featured Articles
Ingredients of Prescription Misuse and
Factors of Opioid Management.................... 4
Nady el-Guebaly, MD
Alberta Healthcare Professionals’
Perceptions of Prescription Drug Misuse..... 5
Opal A. McInnis, PhD, Paula Robeson,
RN, MScN, Sheena A. Gereghty, PhD, Amy J.
Porath-Waller, PhD
Systematic Literature Review on
Buprenorphine/Naloxone Use in Outpatient
Opioid Dependence Treatment.................... 12
Fiona Main, MD, CCFP, Len Kelly, MD, M Clin
Sci, FCFP, FRM
Inpatient Management of a Patient
Enrolled in an Injectable Opioid Study:
A Case Report...............................................18
Tyler Wilson, BSc, Evan Wood MD, PhD,
FRCPC, Keith Ahamad MD, CCFP
Implementation of a Naloxone Distribution
Program in an Inpatient Addiction Service:
A Case Study.................................................22
Cheyenne Johnson RN, MPH, CCRP, Jane
Buxton MBBS, MHSc, FRCPC, Scott Harrison
RN MA, CCHN , Keith Ahamad MD, Seonaid
Nolan, MD, Leslie Lappalainen MD,
Annabel Mead MBBS, FAChAM , Mark McLean
MD, MSc, FRCPC, Evan Wood MD, PhD, FRCPC
Loss and Grief Among Substance Users
and the Programs That Provide Treatment
for Them in Ontario.................................... 26
Nick Doukas M.S.W., PhD Candidate, Dhivya
Balakrishnan M.S.W., RSW
ISSN 2368-4720 (print) • ISSN 2368-4739 (online)
the
Canadian Journal
of Addiction
L e Jo ur n a l Ca n a d ien d ’Ad diction
SCOPE & MISSION OF THE CJA- JCA
The Canadian Journal of Addiction is the official publication of the Canadian Society of Addiction Medicine. It
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Nady el-Guebaly, MD, FRCPC
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FEBRUARY 2016
James MacKillop, MD
Morris Markentin, MD
Louise Nadeau, PhD
Alice Ordean, MD
Amy Porath-Waller, MD
Brian Rush, PhD
Christian Schütz, MD
Evan Wood, MD
2
French Translations:
Emilie Maurais
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VOLUME 7 NO. 1
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3
Ingredients of Prescription Misuse and Factors
of Opioid Management
Canada’s high prevalence
of prescription drug misuse
(PDM) has been reported
for at least a decade. Be it
benzodiazepines,
hypnotics, stimulants or opioids,
Canada has for a while
reported one of the highest
prescription abuse rates in
the world. The first article by
McInnis et al from the Canadian Centre on Substance
Abuse is a survey of health professionals in Alberta as
to their perceptions of their ability to address this major
public health issue. The conclusion is that strategies are
being developed but that we still have a long way to go.
A major component of PDM has been the abuse of
opioids. In the 1990s, I still recall the frequent admonitions at industry sponsored presentations to overcome
our “opiophobia” in the management of pain. We did
indeed!
The next 3 papers discuss new options available to
clinicians in the management of opioid dependence. A
literature search by Main and Kelly reviews 17 studies
of outpatient use of buprenorphine/naloxone. Of note,
prescription drug users experience more successful
FEBRUARY 2016
4
outcome than heroin users. The use of the medication in
primary care settings is advocated.
So what about the treatment resistant heroin users?
Wilson et al’s paper derives from the SALOME comparison of diacetylmorphine to injectable hydromorphone
for opioid use disorders refractory to methadone maintenance. The management of a SALOME subject for an
acute surgical emergency with the help of a conversion
table is reported.
What about when a hospitalised patient is discharged?
Johnson et al details a Take Home Naloxone Program
taught when the patient is close to the anticipated date
of discharge. While no follow up data are provided, this
case report is a good account of the feasibility of this
harm reduction service.
The last paper by Doukas et al is a brief survey of treatment agencies in Ontario as to the provision of grief
therapy and an attempt to delineate the current practice
of this modality.
Rendez-vous à Montréal October 20-22, 2016.
Nady el-Guebaly, MD
Editor-in-Chief, CJA-JCA
CJA JCA
Alberta Healthcare Professionals’ Perceptions of
Prescription Drug Misuse
Opal A. McInnis, PhD, Paula Robeson, RN, MScN, Sheena A. Gereghty, PhD, Amy J. Porath-Waller, PhD
Background: The harms associated with the use of
psychoactive prescription drugs are a serious public
health problem. Healthcare professionals play an important part in addressing this problem; however, there is
limited research examining their role in identifying and
preventing prescription drug misuse (PDM). Methods:
The perceptions of 1,063 Canadian healthcare professionals (HCPs) (physicians, registered nurses and nurse
practitioners, pharmacists, and dentists) regarding
PDM were collected using an anonymous online survey.
Results: Findings revealed that only 27.7% of HCPs felt
adequately supported in addressing PDM. HCPs did not
feel overly effective in preventing or addressing PDM;
they indicated several barriers such as inadequate knowledge and training, as well as those related to communication issues with fellow HCPs. Interpretation: This study
supports the need to increase the capacity of HCPs to
identify and address PDM among patients. This could
be accomplished through clearer protocols and training
on the clinical signs of PDM, as well as strategies aimed
at facilitating better communication among healthcare
providers. By limiting some of the existing barriers, HCPs
will be better prepared to address this public health crisis.
Contexte: Les méfaits associés à l’utilisation de substances psychoactives disponibles sous prescription sont un
problème sérieux de santé publique. Les professionnels
de la santé ont un rôle important à jouer pour faire face
à ce problème, mais peu d’études se sont penchées sur
leur rôle dans l’identification et la prévention de l’abus
de médicaments prescrits (AMP). Méthodes: La perception de 1 063 professionnels canadiens de la santé (PS)
(médecins, infirmières, infirmières cliniciennes, pharmaciens et dentistes) a été recueilli au sujet de l’AMP à
Author Affiliations: Canadian Centre on Substance Abuse (McInnis,
Robeson, Gereghty, Porath-Waller), Ottawa ON, Canada, K1P 5E7
Author Correspondence: Opal McInnis, omcinnis@ccsa.ca
Contributors: All authors participated in drafting the manuscript and
revising it. Amy J. Porath-Waller participated in study conception
and design. Opal A. McInnis and Amy J. Porath-Waller were
responsible for statistical analysis, and all authors contributed to
the interpretation. All authors approved the submitted version of
the manuscript and agree to act as guarantors of the work.
Funding: This study was supported by funding from Alberta Health.
l’aide d’un sondage anonyme en ligne. Résultats: Les
données révèlent que seulement 27,7% des PS se sentent
adéquatement supportés pour aborder l’AMP. Les PS ne
se sont pas sentis trop efficaces à prévenir et à faire face
à l’AMP; ils ont rapporté plusieurs obstacles tels que les
connaissances et la formation inadéquates et les obstacles
reliés aux problèmes de communication avec les collègues.
Interprétation: Cette étude réitère le besoin d’améliorer
les capacités des PS à identifier et faire face à l’AMP parmi
leurs patients. Ceci pourrait être atteint avec des protocoles plus clairs et des formations sur les signes cliniques
de l’AMP, ainsi qu’avec des stratégies visant à faciliter de
meilleures communications entre les PS. En minimisant
quelques-unes des barrières existantes, les PS seront mieux
outillés pour s’attaquer à cette crise de santé publique.
INTRODUCTION
The harms associated with psychoactive prescription drugs
represent a serious public health problem. The misuse of
prescription drugs such as opioids, sedatives-hypnotics
and stimulants can confer risk for addiction, withdrawal,
injury and mortality1-4. In 2009, drug overdose deaths
exceeded those due to motor vehicle accidents in the
United States, and the majority of these deaths involved
prescriptions drugs5. Although national Canadian data
are lacking6,7, within Ontario nearly one in every eight
deaths were opioid-related among individuals aged 25-34
in 20108. Moreover, Canada has one of the highest levels of
prescription opioid consumption globally, with approximately 30,000 Standardized Defined Daily Doses taken in
2010-20129. As such, identifying and addressing prescription drug misuse (PDM) in healthcare settings is essential
to reducing prescription drug-related harms.
Healthcare professionals (HCPs) play a critical role in dealing with this problem, yet few studies have examined their
perceptions and experiences in identifying and addressing PDM. Of those that have, there is some indication
that HCPs meet barriers when attempting to identify and
respond to PDM among their patients. By example, physicians and nurse practitioners identified key barriers that
included a lack of clarity regarding what constitutes PDM,
and a lack of communication between themselves and their
patients, patient’s families as well as between other HCPs10.
5
VOLUME 7 NO. 1
ABSTRACT
Similarly, there have been reports that family physicians and
pharmacists face issues related to properly identifying PDM,
managing inappropriate requests for prescription drugs,
substantiating the legitimacy of requests, and dealing with
threatening responses from patients11. In an Ontario survey,
pharmacists reported challenges in communicating with
physicians, such as difficulty reaching physicians by telephone, or physicians not returning their calls12.
HCPs’ reporting an inability to properly address this issue
is not surprising given their lack of education related to
PDM. A survey of pharmacists in the United States indicated that participants had two hours or less of addiction and
substance abuse education13. Additionally, the Coalition
on Prescription Drug Misuse identified Canadian physicians as lacking training on PDM assessment and painmanagement treatment options14. Fortunately, recent
studies provide evidence that participation in continuing
education on controlled prescription drugs can enhance
HCPs’ willingness to intervene with patients who are
suspected of PDM15-17. Thus, it is important to determine
the level of support available to HCPs as the provision of
adequate training is one practical avenue to reduce the
harms associated with prescription drugs. Indeed this
was a recommendation of the First Do No Harm, a 10-year
pan-Canadian multi-partner strategy to reduce the harms
associated with prescription drugs18.
Of the limited research conducted on HCPs’ perceptions
of PDM, most have examined physicians’ perceptions of
prescription opioid misuse only18-25. The current study
extends this literature by examining perceptions of the
misuse of prescription opioids, sedative-hypnotics, and
stimulants and includes additional HCPs such as dentists,
pharmacists and nurses who also play a role in this issue.
More specifically, this work assessed HCPs’ perceived
efficacy, support, and barriers experienced in identifying
and addressing PDM in patients and explored whether
differences in perceptions existed across HCP groups.
METHODS
SETTING AND DESIGN
FEBRUARY 2016
We collected data from November 13, 2013, to February
21, 2014. Healthcare professionals’ responses were gathered through an anonymous online survey. Following
completion of the survey all participants were provided a
written debriefing. We compensated participants with a
$10 dollar donation to the Red Cross Alberta Flood Relief
Effort. This study was approved by the Health Research
Ethics Board of Alberta - Community Health Committee.
PARTICIPANTS
Eligibility criteria for participants included registered members of one of four selected HCP colleges or
6
associations in Alberta, Canada: College of Physicians and
Surgeons of Alberta (CPSA), Alberta Dental Association
and College (ADAC), Alberta College of Pharmacists
(ACP), and the College and Association of Registered
Nurses of Alberta (CARNA). With assistance from these
organizations, we used a number of recruitment strategies, including emailed invitations, advertisements in
newsletters and on websites, and mailed postcards. All
participants provided informed consent.
A total of 1,063 HCPs participated in the study. They
comprised physicians (n = 99, 9.3%), dentists (n = 112,
10.5%), pharmacists (n = 202, 19.0%), and nurses (n =
650, 61.1%). The majority of our sample was female (n
= 789, 77.1%) and the distribution of genders across the
groups differed χ2 (3) = 302.93, p<.001. While gender was
relatively evenly distributed among physicians (female,
n = 46 and male, n = 52), more men were represented
in the dentist group (women, n = 26 and men, n =79),
and more women identified as pharmacists (women, n
= 139 and men, n =58) and nurses (women, n = 578 and
men, n = 46). Participants’ mean age was 46.40 years
(SD = 12.50, range = 21-81). The groups also differed with
respect to age, F (3, 1037) = 16.41, p<.001, such that pharmacists were younger than the other three groups (all
p’s <.001). The average length of practice was 20.45 years
(SD = 13.00, ranged from <1-55), and this also varied by
group, F (3, 1037) = 7.89, p<.001. Specifically, pharmacists
reported less years of practice than physicians (p<.05),
dentists (p<.05), and nurses (p<.001). Due to these differences, gender, age, and years of practice, were treated
as covariates in any subsequent analyses in which HCP
groups were compared. As well, the sample sizes differed
considerably across the four HCP groups. Thus, for any
subsequent analyses, the data were weighted according
to the initial target population for each group (i.e., the
total number of professionals registered with each association) which were as follows: nurses: 16,005; physicians:
10,640; pharmacists: 3,882; dentists: 2,153.
STUDY QUESTIONNAIRE
The survey instrument was developed based on a review
of the literature and input from a panel with research
and clinical expertise related to PDM and addiction.
To promote consistency in PDM comprehension, we
provided the following description at the beginning of
the questionnaire:
The use of a medication for a medical purpose other
than as directed or indicated, whether intentionally
or unintentionally and whether harm results or not.
Examples of unintentionally misusing prescription medication could include using a prescription
incorrectly either because of misunderstanding
instructions or a faulty memory (e.g., taking the
wrong dosage). Examples of intentionally misusing
CJA JCA
prescription medication could include using the
medication incorrectly for recreational use (e.g., to
get high) or for the medication’s therapeutic benefits
(e.g., to help relieve pain, to improve concentration,
to help sleep, to change one’s mood, etc.).
Participants were presented with a list of potential barriers to addressing or identifying PDM among patients and
asked to rate these factors from a scale of 1 (not at all) to 7
(definitely). This component of the survey also included
HCP group-specific barriers. For example, physicians
were asked if not being the initial diagnosing physician
posed a barrier. Participants were also asked whether
they had adequate support to address PDM, and those
who indicated “yes” were asked how effective the support
was from 1 (not at all effective) to 7 (extremely effective).
Finally, participants were asked how effective they were
in preventing and addressing PDM on a scale of 1 (not at
all effective) to 7 (extremely effective).
STATISTICAL ANALYSIS
We used IBM SPSS Statistics 22 to perform statistical
analyses. Statistical significance was determined at p <
0.05 (two-tailed). Analysis assessing HCP group differences on barriers was conducted using multivariate
analysis of variance (MANOVA) with follow-up univariate ANOVAs. Univariate ANOVAs were used to assess
group differences on perceptions of effectiveness of
support and effectiveness in addressing and preventing
PDM. All pairwise comparisons were conducted using a
Bonferonni correction.
RESULTS
BARRIERS TO IDENTIFYING PDM
HCPs perceived substantial barriers to identifying PDM
among patients. Of the 14-items rated, factors such
as lack of patient honesty (M= 6.38, SD = 1.04), insufficient time with patients (M= 5.95, SD = 1.24), and lack
of communication with the patient (M= 5.94, SD = 1.49)
were rated among the highest barriers. Even factors that
were endorsed the least were still rated at the higher end
of the scale, such as availability of walk-in clinics (M=
4.98, SD = 1.73), use of emergency room (M= 4.84, SD
= 1.68), and symptoms of PDM being obscure or confusing (M= 4.70, SD = 1.70). Importantly, many HCPs also
reported a reluctance to inquire about PDM with patients
(M= 5.41, SD = 1.76) and they indicated that practitioners
have inadequate knowledge or training (M= 5.31, SD =
1.62) (See Table 1).
BARRIERS
TOTAL
PHYSICIANS
DENTISTS
PHARMACISTS
NURSES
Lack of patient honesty
6.38 (± 1.04)
6.28 (±1.22)
6.52 (±0.92)
6.44 (±0.92)
6.40 (±0.96)
Insufficient time with patients
5.95 (±1.24)
5.75 (±1.18)
5.11 (±1.63)
5.75 (±1.29)
6.24 (±1.12)
Lack of communication with
patient
5.94 (±1.49)
5.63 (±1.78)
5.77 (±1.41)
5.67 (±1.48)
6.23 (±1.21)
Lack of access to chronic pain
or addiction specialists
5.82 (±1.49)
5.57 (±1.81)
5.45 (±1.34)
5.69 (±1.30)
6.07 (±1.25)
Lack of communication with
patient’s other healthcare
professionals
5.81 (±1.33)
5.55 (±1.46)
5.66 (±1.21)
5.88 (±1.15)
5.98 (±1.27)
Lack of access to chronic pain
or addiction specialists
5.82 (±1.49)
5.57 (±1.81)
5.45 (±1.34)
5.69 (±1.30)
6.07 (±1.25)
Reluctance to inquire about
PDM with patients
5.41 (±1.76)
4.62 (±2.08)
5.38 (±1.51)
5.57 (±1.52)
5.91 (±1.37)
Uncertainty regarding reporting lines and who to advise if a
patient is misusing
5.39 (±1.66)
4.82 (±1.93)
5.51 (±1.40)
5.50 (±1.56)
5.72 (±1.41)
Inadequate knowledge or
training of practitioners
5.31 (±1.62)
4.91 (±1.81)
4.86 (±1.73)
5.40 (±1.47)
5.62 (±1.43)
Lack of communication with
the patient’s pharmacist
5.16 (1.77)
4.65 (1.90)
5.11 (1.59)
4.94 (1.87)
5.56 (1.58)
VOLUME 7 NO. 1
TABLE 1. Mean and standard deviations of perceived barriers across HCP groups.
7
TABLE 1. Mean and standard deviations of perceived barriers across HCP groups.
BARRIERS
Difficulty accessing provincial
prescribing database
TOTAL
PHYSICIANS
DENTISTS
PHARMACISTS
NURSES
5.04 (±1.98)
4.33 (±2.27)
5.20 (±1.62)
4.74 (±2.04)
5.56 (±1.62)
Availability of walk-in clinics
4.98 (±1.73)
5.21 (±1.69)
4.50 (±1.63)
4.63 (±1.84)
4.98 (±1.71)
Use of emergency rooms
4.84 (±1.68)
4.72 (±1.68)
4.56 (±1.60)
4.31 (±1.65)
5.09 (±1.65)
The symptoms of PDM are
obscure or confusing
4.70 (±1.70)
4.12 (±1.89)
4.88 (±1.51)
4.73 (±1.52)
5.05 (±1.53)
To determine if perceived barriers varied by HCP group, a
multivariate ANOVA was conducted controlling for gender,
years of practice, and age. Results indicated that perceived
barriers varied as a function of HCP group, Pillai’s Trace
F(42, 3315) = 7.97, p<.001, with follow-up ANOVAs revealing
that all but two barriers (lack of patient honesty and lack
of access to chronic pain or addiction specialists) differed
significantly depending on healthcare group (Table 2).
Pair-wise comparisons revealed that a lack of communication with the patient was rated higher among nurses than
physicians (p<.001), and pharmacists (p<.01). Likewise,
inadequate knowledge or training of practitioners was
rated higher among nurses than physicians (p<.001).
Group-specific questions were also asked with respect to
perceived barriers. Specifically, physicians rated from 1
(not at all) to 7 (definitely) the degree to which not being
the initial diagnosing physician acts as a barrier (M= 5.15,
SD = 1.67). As well, pharmacists, nurses, and dentists were
asked about and confirmed that a lack of communication
with the patient’s physician acts as a barrier to identifying
PDM in patients (M= 5.72, SD = 1.39). Upon examining
whether this communication barrier differed across the
three groups, a univariate ANOVA indicated no effect, F
(2, 900) = 0.86, p = .42.
TABLE 2. Univariate ANOVA results and pairwise comparisons with a Bonferroni correction of perceived
barriers across HCP groups.
FEBRUARY 2016
F-Values
Pairwise Comparisons
Lack of patient honesty
F (3, 1116) = 1.55, p = .20
N/A
Lack of communication with patient
F (3, 1116) = 8.89, p<.001
Nurses rated higher than physicians (p<.001)
and pharmacists (p<.01).
Insufficient time with patients
F (3, 1116) = 12.46, p<.001
Dentists rated lower than physicians (p<.01),
nurses (p<.001) and pharmacists (p<.05).
Nurses rated higher than pharmacists (p<.01).
Lack of communication with patient’s other HCPs
F (3, 1116) = 3.43, p <.05
Nurses rated higher than physicians p<.01.
Lack of access to chronic pain or addiction
specialists
F (3, 1116) = 2.16, p =.09
N/A
Reluctance to inquire about PDM with patients
F (3, 1116) = 31.09, p<.001
Physicians rated lower than dentists (p<.001),
nurses (p<.001) and pharmacists (p<.001).
Uncertainty regarding reporting lines and who to
advise if a patient is misusing
F (3, 1116) = 15.32, p<.001
Physicians rated lower than dentists (p<.001),
nurses (p<.001), and pharmacists (p<.01).
Lack of communication with patient’s family
F (3, 1116) = 7.08, p<.001
Pharmacists rated lower that nurses (p<.001),
and physicians (p<.01).
Inadequate knowledge or training of practitioners
F (3, 1116) = 7.88, p<.001
Physicians rated lower than nurses (p<.001) and
pharmacists (p<.05). Dentists rated lower than
nurses (p<.05).
Lack of communication with the patient’s
pharmacist
F (3, 1116) = 11.94, p<.001
Nurses rated higher than physicians (p<.001)
and pharmacists (p<.01).
Difficulty accessing provincial prescribing
database
F (3, 1116) = 26.18, p<.001
Physicians rated lower than dentists (p<.001)
and nurses (p<.001). Nurses rated higher than
pharmacists (p<.001).
The symptoms of PDM are obscure or confusing
F (3, 1116) = 18.26, p<.001
Physicians rated lower than dentists (p<.001),
nurses (p<.001), and pharmacists (p<.001).
Availability of walk-in clinics
F (3, 1116) = 7.78, p<.001
Physicians rated higher than pharmacists
(p<.001), nurses (p<.01), and dentists (p<.05).
Use of emergency rooms
F (3, 1116) = 7.77, p<.001
Pharmacists rated lower than nurses (p<.001)
and physicians (p<.05).
8
CJA JCA
Only 27.7% of respondents felt they had adequate support
for preventing and addressing PDM with their patients.
This varied as a function of HCP group, c2(3) = 11.62, p
<.01, such that nurses and pharmacists were less likely to
report adequate support as compared to physicians and
dentists. Of the participants who reported that support
was adequate, most HCPs indicated feeling that their
current support was only marginally effective (M = 4.15,
SD = 1.50), and these perceptions did not differ by group.
Participants felt they were moderately effective in
preventing and addressing PDM (M = 3.81, SD = 1.48).
A one-way ANOVA revealed significant group differences for this effect, F (3, 1044) = 24.02, p < .001. Pairwise
comparisons identified nurses feeling the least effective
(M = 3.38, SD = 1.42) compared to physicians’ (M = 4.42,
SD = 1.35; p < .001) and pharmacists’ (M = 3.79, SD = 1.29;
p <.05) ratings of themselves. Additionally, pharmacists
and dentists rated their effectiveness less than physicians
did (p<.001 and p<.05, respectively).
INTERPRETATION
Overall, the findings indicate that HCPs perceive
substantial barriers to identify and address PDM in
patients. Among physicians and nurses the top three
barriers identified were a lack of patient honesty, insufficient time with patients and a lack of communication
with patients. Similarly, dentists also indicated a lack
of patient honesty as a top barrier, however they rated a
lack of communication with the patient, as well as with
other HCPs as key barriers. Likewise, pharmacists’ identified lack of communication with patients’ other HCPs
in their top three barriers. Together, these findings point
to key priority areas from which educational strategies
could be targeted for each HCP group (e.g., facilitating
interdisciplinary communication) in order to enhance
their capacity to prevent and address PDM. In line with
these findings, this study also found that perceptions of
other barriers examined varied significantly across HCP
groups. By example, inadequate knowledge or training
was rated higher among nurses than physicians, whereas
reluctance to inquire about PDM was rated higher
among dentists, nurses, and pharmacists compared
to physicians. Together, these differences suggest that
training might need to be tailored to each group in an
effort to enhance HCPs’ efficacy in identifying and
addressing the harms associated with prescription
drugs. Disconcertingly, approximately three quarters of
respondents felt they did not have adequate support to
address PDM. As well, HCPs’ self-ratings of effectiveness
were relatively low. Together, these findings substantiate a critical need for better educational and prevention
initiatives for HCPs to effectively intervene with patients
suspected of misusing prescription drugs. This has been
previously identified in recommendations in the First Do
No Harm strategy18.
These results are consistent with previous qualitative work
which indicated that factors such as a lack of communication among HCPs, a lack of clarity of what constitutes PDM
and unclear and ambiguous symptoms represent barriers
among HCPs10. In line with improving HCPs’ perceptions
of efficacy in addressing PDM, an Ontario study of physicians’ opioid prescribing practices also called for access
to a provincial database and better clinical guidelines26.
Despite the substantial harms associated with PDM, this
study and others consistently highlight a great need for
more education and resources for HCPs13, 19, 26-31. However,
there are existing widespread educational support
strategies ongoing in the United States (US) to improve
prescriber practices of opioids, such as the Risk Evaluation
and Mitigation Strategies (REMS) that are mandated by
the US Food and Drug Administration. Within Canada, a
prescription monitoring program has been implemented
in Nova Scotia to identify risky prescribing behaviours
among physicians and to provide educational interventions for the individuals that are indicated. Finding ways
to improve training for a variety of Canadian HCPs is
essential as there is evidence to suggest that HCPs who
feel unconfident in their abilities to communicate with
patients are less likely to address PDM13, 32 and those who
have had less education related to PDM are also less likely
to intervene with patients32, 33.
Taken together, these findings support the need to
increase HCPs’ ability to identify and address PDM
among patients. This could be enabled through clearer
protocols and training on the clinical signs of PDM, or
through the development and validation of a brief screening instrument or other point-of-care tools. Currently,
there are several tools available to screen patients who
HCPs suspect might be at risk of misusing prescription
drugs, such as the Screener and Opioid Assessment
for Patients with Pain (SOAPP) 34, the Current Opioid
Misuse Measure (COMM)35 and the Opioid Risk Tool
(ORT) 36. However, these tools are limited to opioids and
are not necessarily tailored for specific healthcare professionals, and there remains a need to develop different or
complementary resources for screening the misuse of
prescription sedative-hypnotics and stimulants. 9
VOLUME 7 NO. 1
PERCEPTIONS OF EFFECTIVENESS IN
IDENTIFYING AND ADDRESSING PDM
LIMITATIONS
The study’s findings should be interpreted in light of
its limitations. First, the sample comprised HCPs from
Alberta and thus the findings might not be representative of other provinces/territories or Canada as a whole.
Second, the majority of the sample was female, which
may possibly limit the generalizability of the findings to
males. Third, the number of participants in each group
varied considerably and the response rate for physicians was quite low (representing less than 10% of the
total sample) and nurses represented the largest majority. The inclusion of nurses in the current study is still
very relevant as they play a critical role in their capacity
to screen and intervene with patients under their care.
Nonetheless, overall estimates should be interpreted
cautiously, although examination of group means
revealed consistent trends in the direction of responses
across professional groups and the data were weighted.
Finally, we cannot ensure that each HCP conceptualized
PDM in the same manner. Although efforts were made to
limit variations in how participants might have defined
PDM by presenting a unified description, there is some
suggestion that this may not be sufficient to eliminate
pre-existing beliefs37, 38.
CONCLUSION
The First Do No Harm strategy addresses the harms associated with prescription drugs while giving important
consideration to their therapeutic uses. One of the key
challenges moving forward for HCPs and policy makers
is how to address PDM while still ensuring appropriate
treatment for patients. Professional colleges and associations should enhance current supports and educational
opportunities for their members. Decision makers and
treatment system planners should explore ways to facilitate better communication among HCPs as well as ensure
adequate training. For example, one way the First Do No
Harm strategy is working with regulatory colleges and
associations to address this public policy problem, is by
providing these groups with competencies for a range of
healthcare practitioners so that their members will be
better equipped to mitigate the harms associated with
prescription drugs. Ultimately, by limiting some of the
existing barriers, HCPs will be better prepared to address
this public health crisis.
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VOLUME 7 NO. 1
28. Cochran G, Field G, Lawson K, Erickson, C. Pharmacists’
knowledge, attitudes and beliefs regarding screening and
11
Systematic Literature Review on Buprenorphine/naloxone
Use in Outpatient Opioid Dependence Treatment
Fiona Main, MD, CCFP1, Len Kelly, MD, M Clin Sci, FCFP, FRM
ABSTRACT
INTRODUCTION
Objective: Summarize the literature on buprenorphine/
naloxone for outpatient treatment of opioid dependence
disorder. Methods: a literature of EMBASE and Medline
2000-2014 using the terms “naloxone + buprenorphine”
and “opioid-related disorders”. Results: Over two
hundred articles were retrieved. Seventeen studies were
ultimately selected and reviewed for study quality, using
Downs and Black’s 1998 checklist, the Canadian Task
Force on Preventive Health Care levels of evidence and
study outcome analysis. Conclusion: Buprenorphine/
naloxone appears to be a safe, effective treatment modality
for treatment of opioid dependence. As a recently introduced medication in North America, clinicians are slow
to fully embrace it use. It provides an opportunity to more
widely provide opioid substitution therapy in primary
care settings. Key words: addiction, opioid substitution
therapy, buprenorphine/naloxone, outpatient.
The introduction in the last decade of buprenorphine/
naloxone to the choice of treatment for opioid dependence is reflected in new types of treatment options and
research opportunities. With a recognized safety profile,
less monitoring and even ‘home starts,’ it allows for
outpatient management of substitution therapy where
indicated. A relevant research base is developing. In this
literature review, we explore the outpatient use of the
combination medication buprenorphine/naloxone.
FEBRUARY 2016
Objectif: Résumer la littérature sur l’utilisation de
buprenorphine/naloxone pour le traitement ambulatoire
des troubles de dépendance aux opioïdes. Méthodes:
Recherche des publications disponibles sur EMBASE
et Medline entre les années 2000 et 2014 utilisant les
mots clés “naloxone + buprenorphine” et “opioid-related
disorders”. Résultats: Plus de deux cents articles ont
été extraits. Dix-sept études ont finalement été sélectionnées et examinées pour leur qualité en utilisant la
grille d’évaluation développée par Downs and Black
(1998), l’échelle de classement de la qualité des données
probantes du Groupe d’étude canadien sur les soins
de santé préventifs et l’analyse des résultats de l’étude.
Conclusion: La buprenorphine/naloxone semble être
une modalité de traitement sécuritaire et efficace pour le
traitement de la dépendance aux opioïdes. Puisque cette
médication est nouvellement disponible en Amérique
du nord, les cliniciens sont lents à l’adopter dans leur
pratique. Elle permet d’offrir à plus grande échelle une
thérapie de substitution aux opioïdes dans les milieux de
soins primaires. Mots clés: dépendance, thérapie de substitution aux opioïdes, buprénorphine/naloxone, consultation en externe
Author Affiliations: 1Resident in Family Medicine, Northern Ontario
School of Medicine, Sudbury ON, 2Research Consultant, Sioux
Lookout Meno Ya Win Health Centre
Author Contact: Len Kelly, Box 489 Sioux Lookout ON, P8T 1A8
lkelly@mcmaster.ca, Fax: 807-737-1771
Funding Statement: Supported by the Northern Ontario Academic
Medicine Association Clinical Innovation Fund
Revised Dec 2, 2015 Can J of Addiction
12
METHOD
A search of the literature from Jan 2000- July 2014 was
conducted on EMBASE and Medline databases using the
terms “naloxone + buprenorphine” and “opioid-related
disorders”. This yielded a total of 234 studies. Reference
lists of review papers were also reviewed for relevant articles. The abstracts of all studies were reviewed and studies selected for original research dealing with outpatient
buprenorphine-naloxone maintenance treatment for
addiction. Studies looking at pregnant or HIV-positive
populations, and those dealing with buprenorphinenaloxone induction or inpatient treatment were excluded. Seventeen studies were ultimately selected and
reviewed for study quality, using Downs and Black’s 19981
checklist, the Canadian Task Force on Preventive Health
Care2 levels of evidence and study outcomes analysis.
RESULTS
STUDY CHARACTERISTICS
The characteristics in the studies included are summarized in Table 1. The vast majority of studies had a
predominance of male participants. Eleven/17 data sets
specified type of opioid used (heroin vs. prescription
opioids). Of these, three studies included only heroin
users, four included a majority of heroin users, and
four included a majority of prescription opioid users.
Eleven/17 studies specified the race of their participants. In these 11 studies, 25-94% of participants were
white, with the most common other races being African
American and Hispanic. No studies identified Aboriginal
participants. Fifteen/17 studies were conducted in the
United States, and none in Canada. All studies were
primarily conducted in urban settings.
Many studies had exclusion criteria for those suffering
CJA JCA
Treatment in these studies was administered by a variety of medical specialties including family medicine. A
combination of buprenorphine-naloxone, as opposed to
buprenorphine alone, was used in all 17 of the studies.
RETENTION RATES
Major outcomes are summarized in Table 2. The most
common length of time reported for retention was six
months. At six months, from 36-78% of patients were
retained in treatment with buprenorphine/naloxone.3-8 One
study reported sobriety rather than retention as primary
outcome, and 54% were sober at six months.9 At 12 months,
between 25-77% of patients were retained in treatment.10-12
ABSTINENCE FROM OPIOIDS
In general, studies did not require abstinence from
patients in order to continue treatment. The percentage of opioid negative urines was reported either as an
average of the entire study period, or at the end point of
the study. Between 40-85% of urine samples were free of
opioids at six month end points.3-6 There appeared to be
positive correlation between observer rated abstinence
and urine results.13
QUALITY OF LIFE MEASUREMENTS
Several studies showed significant improvement in quality of life and addiction related behavior during and after
buprenorphine/naloxone treatment.5,10,14,15,16,17 No studies
which examined these outcomes found negative results.
EFFECTS DURING FOLLOW-UP
Relatively few follow up results suggesting long term efficacy of treatment are available. Several studies examined
different durations of treatment followed by tapering,
meaning that patient were all off buprenorphine/naloxone when followed up. One study found that patients
treated with buprenorphine/naloxone and tapered off
during the study were more likely to be in addiction
treatment when followed up, compared to those treated
and tapered off methadone.13 This may be secondary to
a shorter retention duration compared to methadone
and/or a high satisfaction with buprenorphine/naloxone
treatment. One high quality RCT comparing a two-week
maintenance and taper to a 12-week maintenance and
taper found that overall only 8.6% of tapered individuals
maintained abstinence at follow-up.18
Two studies of longer maintenance treatments have
shown varied retention rates demonstrated that of individuals who successfully completed six months of treatment with buprenorphine/naloxone, 38% were retained
in treatment two years later.3,4 An observational study
found that of individuals who successfully completed 12
months of treatment, 77% were still in treatment a minimum of 18 months later.15
FACTORS PREDICTING SUCCESS
Several pre-existing patient factors were found to predict
successful retention and abstinence during the studies. These factors are summarized in Table 3. The most
common variable found to positively predict success was
older age, both at time of treatment and at time of opioid
dependence onset.9,10,18, Drug of choice was also a significant variable, with four studies finding that prescription
drug users, rather than heroin users, had more successful
outcomes.3,7,13,15 Prescription drug users on average may
be younger, have fewer years of opioid dependence, and
less addiction treatment in their past.3,8 Specifically, use
of illicit buprenorphine and methadone may be a positive
variable predicting success.19 One study found that comorbid alcohol abuse may predict failure with buprenorphine/
naloxone treatment.19
Race may be a variable affecting outcome, as two studies
found that African American or Hispanic race negatively
affected treatment success, while controlling for other
variables.7,12
Route of drug abuse was also a significant variable in
three studies, with two finding that non-intravenous (IV)
drug users had more positive outcomes, and a third finding that recent IV drug user predicted success.7,20-22 The
latter study was conducted with youth aged 15-21, and
intravenous drug use was thought to correlate with more
self-perceived severity of illness and willingness to comply
with treatment.20
Although sufferers of severe mental or physical illness were
often excluded from these studies, several times patients
with chronic mental or physical conditions were noted to
have superior outcomes.6,21,23 It may be that these patients
benefit more from analgesic properties of buprenorphine/
naloxone and mental stabilization secondary to treatment.
As expected, variables suggesting stability such as employment, marriage or long term relationship, and not being
homeless are also predictors of treatment success.9,10 In one
study, history of incarceration was found to not significantly influence outcomes.24
13
VOLUME 7 NO. 1
from serious medical and psychiatric illness, including
comorbid addiction with alcohol.
In-treatment variables, which have been thoroughly studied,
involve degree and type of psychosocial support provided. A
Cochrane Review of 27 studies showed that there was no
benefit of additional psychosocial intervention over standard maintenance treatment, in any outcome measured.25
The control maintenance treatment in the studies in this
Cochrane review all included some degree of counseling
services. There does not seem to be any additional benefit
offered by more intensive therapy, when retention, abstinence and success at follow-up are measured.25
Warden (2012) also found that youth who successfully
abstained from illicit drugs during the first two weeks of
treatment were much more likely to be retained for the
study duration.26 Particularly given the safety of buprenorphine/naloxone during induction, these findings recommend higher doses during the induction period.14
ADVERSE EFFECTS/MORTALITY
Adverse effects secondary to treatment were reported in
the majority of studies reviewed, although not compared
statistically. No significant or fatal increase in adverse
events with buprenorphine/naloxone compared to other
treatments was reported.
Although community-level harms such as crime related
to opioid dependence are well documented, no studies
were found which examined the impact of maintenance
treatment on these outcomes.27
DISCUSSION
The documentation of the safety of the combination of
buprenorphine/naloxone is developing. It can also be
assumed from the literature on single agent buprenorphine. A review of buprenorphine from France revealed
over a four year period, the risk of overdose attributable
to buprenorphine was 10 times less than that attributable to methadone.28 Overall, opioid dependence studies
have found much lower risk of death for those in maintenance treatment with buprenorphine or methadone,
compared to those not in treatment.14 One buprenorphine study revealed that a shocking 4 of 20 patients
in placebo control group died over the one year study
period, compared to no deaths in the treatment group.29
Buprenorphine/naloxone seems well suited to substitution therapy with prescription drug use,3,13,15,30 particularly
with patients who have not progressed to intravenous
drug use.7,20-22
CONCLUSION
Since approval in the USA in 2002 and Canada in 2007,
buprenorphine/naloxone is safely meeting a need for
outpatient management of opioid dependence. Research
in its first decade of use has rendered a useful picture
of its use in community-based programs. While inpatient programs will always be needed for complex case
management and treatment. Primary care and outpatient treatment of opioid dependence is facilitated by the
safety and efficacy of buprenorphine/naloxone. Primary
care settings allow for easy access for co-morbid conditions and even other accompanying family members.
Research capacity, prescribing and treatment continuing
medical education pose the next challenges in primary
care leadership in treatment of opioid dependence in the
community.
The literature demonstrates the safety and efficacy of
buprenorphine/naloxone. This evidence supports the
increased use of this treatment modality for treatment of
opioid dependence in the outpatient setting.
TABLE 1: STUDY CHARACTERISTICS
STUDY
DOW NS
& BL ACK
QUALIT Y
SCOR E
(M A X 27)
NUMBER/
TRIAL TYPE
Amato 2010
17
Apelt 2013
FEBRUARY 2016
PARTICIPANTS
TYPE OF USERS
78, prospective,
ll
non-interventional
no race, Italy, urban
heroin
19
384, prospective,
ll
non-interventional
no race specified,
Germany, likely urban
all were in maintenance
tx already, type of opioid
use not distinguished
Bell 2007
20
119, RCT
l
no race specified,
Australia, likely urban
heroin only
Cunningham 2008
14
41, retrospective
ll
90% non-white, urban, US
70% heroin
Curcio 2011
15
707 BP and 3105
MT, cohort
ll
no race, urban, Italy
Dreifuss 2013/Weiss
2011
19/21
360, RCT
l
90% white, urban, US
14
LEVEL OF
EVIDENCE
less than 1% were heroin
users
CJA JCA
TABLE 1: STUDY CHARACTERISTICS
STUDY
Fiellin 2006 and
2008/Moore 2007/
Wang 2010
DOW NS
NUMBER/
& BL ACK TRIAL TYPE
QUALIT Y
SCOR E
(M A X 27)
20/17/16/21 166, RCT, 54 in
follow up
LEVEL OF
EVIDENCE
PARTICIPANTS
TYPE OF USERS
l
75% white race, urban, US
55% hx of IVDU
l
60% white, 2% Native
American, urban, US
30% hx of IVDU
Fudala 2003
22
326 RCT, 461 open
label observation
Kakko 2007
25
96, RCT
no race, Sweden, urban
all heroin
Mintzer 2007
17
99, prospective,
ll
non interventional
94% white, urban, US,
primary care clinics
about 75% heroin addicts
Miotto 2012
15
94, RCT
ll
58% white, urban, US
30% heroin
Neumann 2013
18
356, retrospective
case control
ll
80% white, urban, US,
primary care
74% prescription drugs
Nielsen 2013/Ling
2009
21/20
516, RCT
l
no race, US, urban
stratified by type of use
Parran 2010
14
110, cross sectional
(follow up)
ll
73% white, urban, US
88% heroin
Woody 2008/Polsky
2010/Subramaniam
2011/Warden 2012
20/19/21/19
152, RCT
l
74% white, urban, US
41% heroin, youth 15-21
Potter 2013
20
1269 RCT, secondary analysis
l
74% white, 1% Indian,
urban, US
stratified by type of use
Stancliff 2012
14
100, prospective,
ll
non interventional
25% white, 50% hispanic,
lower SES, urban, US
86% heroin, half
IVDU, “marginalized”
population
TABLE 2: STUDY OUTCOMES
RETENTION
AT END OF
STUDY
ABSTINENCE
Apelt 2013
57.1% at 12 mos 98% negative urine for
opioid at final assmt
Bell 2007
59% at 3 mos
self reported- 52%
reported no use in past
mos at 3 mos
Cunningham
2008
71% at 3 mos
76% negative urines
overall
OTHER OUTCOMES
Those on BP had significantly lower risk
of death during induction; but treatment risk and post-treatment risk was
similar.
BP users urine was 53%
neg, MT users 30% neg
Dreifuss 2013/
Weiss 2011
49% at 3 mos
61% negative urines
overall
8 weeks after taper, 8%
continued abstinence
Fiellin 2006
and 2008/
Moore 2007/
Wang 2010
45% at 6 mos
40% negative urines
overall
38% of those retained at
6 mos were retained at
2 years, with 91% opioid
free urines
Fudala 2003
55% at 6 mos
54% neg urine at six
mos
VOLUME 7 NO. 1
Curcio 2011
RESULTS AT
FOLLOW UP
Serum transaminases were followed
with no significant adverse effects
15
TABLE 2: STUDY OUTCOMES
Kakko 2003
RETENTION
AT END OF
STUDY
75% at 12 mos
Kakko 2007
78% at 6 mos
Mintzer 2007
54% “sober” at
6 mos- urine
free of opioids
Miotto 2012
35% at 5 mos,
25% at 12 mos
opioid use “decreased”
but no numbers given
Neumann 2013
35.7% at 6 mos
85% of completers had
all opioid neg urines
Nielsen 2013/
Ling 2009
ABSTINENCE
RESULTS AT
FOLLOW UP
OTHER OUTCOMES
75% neg urine at 12
mos
self reported/observer reported health
outcomes improved significantly
80% neg urine at six
mos
4/20 died in control group. Tx group
showed sig improvement in addiction
severity index
Presence of psychiatric illness not a
significant predictor of tx outcome.
40% were urine opioid 12% negative urines after
neg after taper, with no 3 mos post taper
benefit to longer taper
(28d vs 7d)
Parran 2010
77% of those retained at
12 mos remained on tx
18-42 mos later
Woody 2008/
Polsky 2010/
Subramaniam
2011/Warden
2012
70% at 12
weeks
57% negative urine at
12 weeks, reported less
injecting, less opioid
use, less cocaine use
than control group
Potter 2013
46% at 6 mos
Stancliff 2012
42% at 12 mos
all tapered, 60% negative urines at 12 mos
f/u, more likely to be in
addiction tx than control
group
Those who remained on bup had less
substance use, fewer psychosocial
complications of addiction, more AA
affiliation activities, and increased
employment at follow-up
TABLE 3: PREDICTORS OF OUTCOMES
Predictors of Success
Predictors of Failure
Apelt 2013
older, married or living with a partner, working in a fulltime job and living in their own flat
Alford 2011
older, employed, and who self-maintained with illicit African American or Hispanic race had
buprenorphine had significantly higher odds of success significantly lower odds of treatment success
Cunningham 2008
users of street methadone
Dreifuss 2013/Weiss 2011
age, lifetime major depressive disorder, having only used previous use of heroin, having used
opioids by swallowing or sublingual administration, Oxycontin as most frequent drug
and receiving no prior opioid dependence treatment
Fiellin 2006 and 2008/ Prescription opioid use only.
Moore 2007/Wang 2010
users of alcohol and opioid analgesics
Incarceration history was not significantly
associated with tx outcomes
FEBRUARY 2016
Mintzer 2007
private insurance coverage (possible surrogate for
employment?), older age, and longer duration of
treatment
Neumann 2013
Counseling attendance and history of past injury/trauma. Chronic pain not measured.
Nielsen 2013/Ling 2009
PO users had significantly more opioid free urine at end
of study, significance disappeared when controlling for
physical conditions.
Parran 2010
being employed at entry into the study and the use of Lower SES slightly more likely to be
prescription opioids rather than heroin
retained, but more likely to report continued opioid abuse.
16
CJA JCA
TABLE 3: PREDICTORS OF OUTCOMES
Predictors of Success
Predictors of Failure
Woody
2008/Polsky Recent IVDU, active medical or psychiatric condition,
2010/Subramaniam 2011/ use of medications, early abstinence during study, nonWarden 2012
heroin drug use
Potter 2013
Opioid analgesic users as opposed to heroin or combined older age, African American
users. Non-injectors compared to injectors.
Stancliff 2012
African American race, not influenced by pre tx drug of Latino
choice
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LE, O’Connor PG, et al. Counseling plus buprenorphinenaloxone maintenance therapy for opioid dependence. N
Engl J Med. 2006;355(4):365-74.
4. Fiellin DA, Moore BA, Sullivan LE, Becker WC, Pantalon
MV, Chawarski MC, et al. Long-term treatment with
buprenorphine/naloxone in primary care: Results at 2-5 years.
American Journal on Addictions. 2008;17(2):116-20.
5. Fudala PJ. Bridge TP. Herbert S. Williford WO. Chiang CN.
Jones K. Collins J. Raisch D. Casadonte P. Goldsmith RJ. Ling
W. Malkerneker U. McNicholas L. Renner J. Stine S. Tusel D.
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from a nationwide non-interventional study in routine care.
Pharmacopsychiatry. 2013;46(3):94-107.
11. Miotto K, Hillhouse M, Donovick R, Cunningham-Rathner J,
Charuvastra C, Torrington M, et al. Comparison of buprenorphine treatment for opioid dependence in 3 settings. Journal
of Addiction Medicine. 2012;6(1):68-76.
12. Stancliff S, Joseph H, Fong C, Furst T, Comer SD, Roux P.
Opioid maintenance treatment as a harm reduction tool for
opioid-dependent individuals in new york city: The need to
expand access to buprenorphine/naloxone in marginalized
populations. Journal Addictive Diseases. 2012;31(3):278-87.
13. Woody GE, Poole SA, Subramaniam G, Dugosh K,
Bogenschutz M, Abbott P, et al. Extended vs short-term
buprenorphine-naloxone for treatment of opioid-addicted
youth A randomized trial. Journal of the American Medical
Association. 2008;300(17):2003-11.
14. Bell J, Shanahan M, Mutch C, Rea F, Ryan A, Batey R, et al.
A randomized trial of effectiveness and cost-effectiveness
of observed versus unobserved administration of
buprenorphine-naloxone for heroin dependence. Addiction.
2007;102(12):1899-907.
6. Neumann AM, Blondell RD, Azadfard M, Nathan G, Homish
GG. Primary care patient characteristics associated with
completion of 6-month buprenorphine treatment. Addict
Behav. 2013;38(11):2724-8.
15. Parran TV, Adelman CA, Merkin B, Pagano ME, Defranco
R, Ionescu RA, et al. Long-term outcomes of office-based
buprenorphine/naloxone maintenance therapy. Drug Alcohol
Depend. 2010;106(1):56-60.
7. Potter JS, Marino EN, Hillhouse MP, Nielsen S, Wiest K,
Canamar CP, et al. Buprenorphine/naloxone and methadone
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16. Curcio F, Franco T, Topa M, Baldassarre C, Gruppo
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Inpatient Management Of A Patient Enrolled In An
Injectable Opioid Study: A Case Report
Tyler Wilson, BSc1, Evan Wood MD, PhD, FRCPC1,2, Keith Ahamad MD, CCFP2,3,4
ABSTRACT
Objectives: Methadone and buprenorphine-naloxone
are the standard of care for the treatment of opioid addiction. Due to the inability of these medications to successfully treat some patients, investigators have explored other
medications in treating opioid use. In Vancouver, the Study
to Assess Long Term Maintenance-Opioid Effectiveness
(SALOME) compared diacetylmorphine to injectable
hydromorphone for the treatment of opioid use disorder
refractory to methadone maintenance therapy. This case
FEBRUARY 2016
Author Institution: 1Department of Medicine; University of British
Columbia, 2British Columbia Centre for Excellence in HIV/AIDS,
St. Paul’s Hospital, 3Department of Family Practice, Univeristy of
British Columbia, 4Department of Family and Comminity Medicine,
Providence Health Care
Author Correspondence: Keith Ahamad, MD, CCFP, Clinical Instructor,
University of British Columbia, Urban Health Research Initiative,
BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608 1081 Burrard Street, Vancouver BC V6Z 1Y6, Canada
Tel: 604-682-2344 x66373 • Email: kahamad@cfenet.ubc.ca
Acknowledgements: The study was supported by the US National
Institutes of Health (R25DA037756) and the Canadian Institutes
of Health Research through the Canadian Research Initiative on
Substance Misuse (FMN-139148). This research was undertaken, in
part, thanks to funding for a Tier 1 Canada Research Chair in Inner
City Medicine, which supports Dr. Evan Wood.
Declaration of Interest: The authors report no conflict of interest. The
authors alone are responsible for the content and writing of this paper.
18
report describes the maintenance of opioid agonist therapy (OAT) in a hospitalized surgical patient enrolled in
the SALOME trial where his clinicians were blinded to his
study treatment. Methods and Results: The patient was
admitted with a large bowel obstruction and underwent
emergency decompressive ileostomy surgery. His OAT
regimen was unknown to the addiction physician. Opioid
addiction and pain was treated by ascertaining the patient’s
diacetylmorphine equivalent dose from the SALOME
study team. This was converted to an equivalent dose of
methadone with oral hydromorphone for breakthrough
symptoms with several safety parameters put in place. The
patient recovered well and resumed blinded participation
in SALOME. Conclusions: Inpatient management of
patients on opioid agonist treatments is complicated by
acute medical comorbidities and other factors. This case
was further complicated by the patients blinded status
in a clincal trial and illustrates the safety considerations
when continuing and titrating opioid agonist treatments
in acutely unwell medical hospitalized patients. To best
treat these patients, healthcare institutions must educate
health care providers, create multidisciplinary teams
with addiction expertise, and establish evidence-based
policy.Key Words: Opioid Agonist Treatment, Methadone,
Diacetylmorphine, Hydromorphone, Opioid Use Disorder
CJA JCA
INTRODUCTION
Opioid agonist therapy (OAT) with either methadone
maintenance therapy (MMT) or buprenorphine/naloxone (Suboxone) is the current standard of care for treating opioid use disorder (OUD). As this patient population
grows, the inpatient medical management of patients on
OAT becomes an increasingly pressing concern. While
MMT has been shown to decrease hospitalization rates
compared to untreated opioid users1, patients on OAT
have higher rates of hospitalization and emergency
department utilization then the general population 2.
This population suffers from increased rates of physical
violence, chronic pain, mental illness, HIV, Hepatitis C,
and other chronic conditions1-3. Effective OAT has been
shown to improve overall physical and mental health in
patients with opioid use disorder4.
Treating hospitalized patients prescribed OAT presents
a clinical challenge. While these medications should
be continued during hospitalization, comorbidities,
drug-drug interactions, and differences between OAT
modalities make this complex5,6. Physicians are required
to balance patient safety (e.g. drug toxicities) and avoid
opioid withdrawal, while treating the presenting medical condition. Inpatient methadone (Methadose) use has
been shown to reduce the risk of patients leaving against
medical advice, which is associated with significant
morbidity and increased readmission7.
In addition to methadone and buprenorphine, several
settings are seeking to expand available therapies to
include other medications including diacetylmorphine,
slow release oral morphine (Kadian) and hydromorphone (Dilaudid)8. In Vancouver, a recent trial known
as the Study to Assess Long Term Opioid Maintenance
Effectiveness (SALOME), has compared injectable
hydromorphone to diacetylmorphione (Heroin) for
treatment of OUD refractory to MMT. The care of
blinded trial participants has been particularly challenging due to the fact that hospital clinicians had to remain
blinded to which study medication (hydromorphone vs.
diacetylmorphine) patients are on. As such, conversion
tables were created to help guide clinicians to convert
from injected diacetylmorphine equivalents (DAME) to
oral methadone (Table 1)9. This case report describes the
medical management of a study participant enrolled in
the SALOME trial who had acute medical illness requiring surgical intervention and illustrates the clinical challenges and an approach to management in this situation.
CASE PRESENTATION
A 51-year-old male with a recent diagnosis of rectal
cancer presented to a local academic hospital (Saint
Paul’s Hospital) in Vancouver, Canada with a one-month
history of progressive lower abdominal pain worsening
over 24 hours, hematochezia, diarrhea, night sweats,
and weight loss. A previous CT scan showed a large rectal
mass extending into the mesorectal fascia with enlarged
19
VOLUME 7 NO. 1
Objectifs: Le recours à la méthadone et à la buprénorphine/naloxone pour le traitement de la dépendance
aux opioïdes est une norme en pratique de soins. Étant
donné l’incapacité de ces médications à traiter avec succès
certains patients, les chercheurs ont exploré l’utilisation
d’autres médications dans le traitement de la consommation d’opioïdes. À Vancouver, le Study to Assess Long Term
Maintenance-Opioid Effectiveness (SALOME) a comparé
l’utilisation du diacétylmorphine à l’hydromorphone en
injection pour le traitement des troubles liés à la consommation d’opioïdes réfractaires au traitement de substitution avec méthadone. Cette étude de cas décrit le traitement aux agonistes des opioïdes (TAO) chez un patient
hospitalisé en chirurgie et participant à l’essai clinique
SALOME. L’assignation du bras de l’étude était à l’insu des
cliniciens impliqués dans les soins. Méthodes et résultats: Le patient a été admis à l’hôpital avec une occlusion
intestinale et a subi d’urgence une iléostomie de décompression. Son TAO était inconnu du médecin spécialiste
en toxicomanie. La dépendance aux opioïdes et la douleur
ont été traités en vérifiant les doses équivalentes en diacétylmorphine auprès de l’équipe de SALOME. Ces données
ont été converties en doses équivalentes de méthadone
en combinaison avec de l’hydromorphone oral pour les
épisodes symptômatiques et plusieurs paramètres de
sécurité mis en place. Le patient a bien récupéré et a repris
sa participation au projet SALOME avec bras à l’insu des
cliniciens. Conclusions: La gestion des patients hospitalisés et sous TAO est rendue plus difficile par la présence de
comorbidités médicales et autres facteurs. Cette étude de
cas était encore plus complexe du fait de la participation
du patient à une étude clinique aux bras à l’insu des cliniciens et illustre les considérations à prendre en mesure de
sécurité lorsque le titrage d’un TAO se poursuit chez un
patient hospitalisé pour une condition aiguë. Pour offrir
de meilleurs soins à ces patients, les institutions de santé
doivent éduquer les professionnels de santé, créer des
équipes multidisciplinaires avec une expertise en toxicomanie et mettre sur pied des politiques basées sur des
données probantes.Mots clés: traitement aux agonistes des
opioïdes, méthadone, diacétylmorphine, hydromorphone,
troubles liés à la consommation d’opioïdes
lymph nodes in the superior rectal region and no prominent metastases. Abdominal plain films showed fecal
loading, distension of the colon, and mild gaseous distension of the small bowel. He was seen by general surgery,
diagnosed with large bowel obstruction, and booked for
emergency decompressive diverting loop ileostomy.
With respect to his substance use history, the individual
first used intravenous heroin at age 13 and had multiple
attempts of methadone maintenance therapy (MMT),
the most recent of which was eight months prior to
admission. Other substance use included longstanding
tobacco use, intravenous cocaine from age 16 to 50, methamphetamine from age 41 to 50, daily alcohol from age
20-30 and daily marijuana from age 16-48. While enrolled
in the SALOME study, he denied on-going illicit opioid
use and he was currently blinded to study drug.
On presentation to the emergency department, by nursing report, the patient was agitated, had uncontrolled
loose bowel movements, and refused attempts to clean
his bedding and person. The social worker noted that he
had given up hope and was struggling to cope with his
new diagnosis. Following surgery, he entered the postoperative care unit and received 9 doses of 50 micrograms of fentanyl IV (450 micrograms total) and 11 doses
of between 1 and 10mg morphine IV (44mg total) over
two and a half hours. After being transferred to the ward,
his pain medications changed to 5-10mg morphine PO
q4h PRN and 1-2mg IV q1h PRN, which was increased two
hours later to 10-20mg PO q4h PRN and 1-4mg IV q30min
PRN. He received 5 doses of oral morphine (90mg total)
and 6 doses of IV morphine (20mg total) over 17 hours.
Despite escalating doses of analgesics, nursing notes
indicate poor pain control with complaints of 10/10 pain,
on-going agitation, and refusal of educational sessions
on use of his ileostomy bag.
FEBRUARY 2016
The Addiction Medicine Consult Team (AMCT) was
asked to see the patient. They were able to ascertain
from the SALOME study physician that the participant
had been receiving 720 diacetylmorphine equivalent
dose (DAME) daily divided into three 240 DAME IV
injections. Based on the estimates shown in Table 1,
the individual’s morphine was discontinued and he was
estimated to initially require a minimum of 120mg of
methadone which, for safety reasons was converted to
40mg methadone PO TID plus 5-10mg hydromorphone
PO q3hrs PRN for breakthrough opioid withdrawal
and pain. Over the subsequent eight days, he received
methadone as prescribed and used 20-50mg of hydromorphone daily. During regular follow-ups his pain was
well controlled and there were no reports of withdrawal
or opioid overdose. Nursing notes indicate that he was
alert and oriented, pleasant with nursing staff, engaged
in frequent sessions with his ileostomy nurse on the care
of his ileostomy bag, and reported low pain scores. Prior
20
to discharge, he was tolerating a full diet, passing stool
and gas into his ileostomy bag, and was well informed
on use of his bag. He was discharged home in stable
condition with follow-up arranged to continue as a study
participant in SALOME.
DISCUSSION
We have described the case of inpatient management
of OAT in a surgical patient enrolled in SALOME, a trail
comparing injectable diacetylmorphine to hydromorphone, and blinded to his treatment assignment. This
patient was on high-dose opioids to treat his OUD, which
initially made his pain difficult to control and complicated his medical care. His opioid regimen was converted
to a combination of methadone and hydromorphone
using conversion ratios developed specifically for opiate
agonist treatment9. He reported low pain scores on this
regimen, displayed no signs of withdrawal, and became
engaged with nursing staff around his medical care and
discharge planning.
The importance of continuing OAT in hospitalized
patients is well established6. Maintenance of OAT is
hospital is complex and previously stable patients may
require dose modification to account for new drug-drug
interactions, relationships to underlying disease states,
management of acute pain, and conversion between OAT
modalities6. As was done in this case, these safety concerns
generally require splitting the opioid replacement regimen into multiple daily doses with symptom-triggered
management with close nursing supervision to add or
hold PRN treatments. In this context, acute pain management can be especially challenging in these patients due
to high tolerance and withdrawal can cloud the clinical
picture. Much is known about treating pain while patients
are taking well-studied medications like methadone7;
however, little is known about the unique properties of
newer opioids. Converting between newer opioids is challenging as opioid conversion tables have traditionally been
derived from studies of chronic cancer patients who are
opiate naïve9. More study is required on potency ratios of
these novel opioids in chronic illicit opioid users9.
Many studies have shown the efficacy of diacetylmorphine
when compared to methadone8,10-12 and, more recently,
sustained oral release morphine13,14. As these evidence-based
treatment modalities become more commonly used, physicians will require expertise to effectively treat pain, prevent
withdrawal, and avoid overdose while continuing OAT.
In the brief case report, we have described the case of
an inpatient treated with high-dose opioids for OUD,
blinded to his treatment, admitted with a bowel obstruction, and referred with an acute pain crisis in the context
of inadequate opioid analgesic. As the evidence base for
other treatment expands, these clinical scenarios stand
CJA JCA
to become increasingly common and complex. Although
much is known about treating hospitalized patients
prescribed community methadone, less is known about
medications like diacetylmorphine, hydromorphone and
sustained oral release morphine. Effective interventions
will need to be put into place, including expanding hospital addiction care policies, educating healthcare providers,
and creation of multidisciplinary addiction teams.
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1.
Walley AY, Cheng DM, Pierce CE, et al. Methadone dose,
take home status, and hospital admission among methadone
maintenance patients. Journal of Addiction Medicine.
2012;6(3):186-190.
8.
Oviedo-Joekes E, Brissette S, Marsh DC, et al.
Diacetylmorphine versus methadone for the treatment of
opioid addiction. The New England journal of medicine. Aug
20 2009;361(8):777-786.
2.
Burns L, Conroy E, Mattick RP. Main reasons for hospital
admissions by women with a history of methadone maintenance. Drug & Alcohol Review. 2010;29(6):669-675.
9.
3.
Eyler EC. Chronic and acute pain and pain management
for patients in methadone maintenance treatment. The
American journal on addictions / American Academy
of Psychiatrists in Alcoholism and Addictions. Jan
2013;22(1):75-83.
Oviedo-Joekes E, Marsh DC, Guh D, Brissette S, Schechter
MT. Potency ratio of hydromorphone and diacetylmorphine
in substitution treatment for long-term opioid dependency.
Journal of Opioid Management. 2011;7(5):371-376.
4.
Reimer J, Verthein U, Karow A, Schafer I, Naber D, Haasen
C. Physical and mental health in severe opioid-dependent
patients within a randomized controlled maintenance
treatment trial. Addiction (Abingdon, England). Sep
2011;106(9):1647-1655.
Murnion B. Management of opioid substitution therapy
during medical intervention. Internal medicine journal. Mar
2012;42(3):242-246.
6.
Haber PS, Demirkol A, Lange K, Murnion B. Management
of injecting drug users admitted to hospital. The Lancet. //
2009;374(9697):1284-1293.
7.
Chan AC, Palepu A, Guh DP, et al. HIV-positive injection
drug users who leave the hospital against medical advice:
the mitigating role of methadone and social support.
Journal of Acquired Immune Deficiency Syndromes: JAIDS.
2004;35(1):56-59.
11. March JC, Oviedo-Joekes E, Perea-Milla E, Carrasco F.
Controlled trial of prescribed heroin in the treatment of
opioid addiction. Journal of substance abuse treatment.
2006;31(2):203-211.
12. Haasen C, Verthein U, Degkwitz P, Berger J, Krausz M,
Naber D. Heroin-assisted treatment for opioid dependence Randomised controlled trial. The British Journal of
Psychiatry. 2007;191(1):55-62.
13. Beck T, Haasen C, Verthein U, et al. Maintenance treatment
for opioid dependence with slow‐release oral morphine: a
randomized cross‐over, non‐inferiority study versus methadone. Addiction. 2014;109(4):617-626.
14. Hämmig R, Köhler W, Bonorden-Kleij K, et al. Safety and
tolerability of slow-release oral morphine versus methadone
in the treatment of opioid dependence. Journal of substance
abuse treatment. 2014;47(4):275-281.
VOLUME 7 NO. 1
5.
10. Ferri M, Davoli M, Perucci CA. Heroin maintenance for
chronic heroin‐dependent individuals. The Cochrane Library.
2011.
21
Implementation of a Naloxone Distribution Program in an
Inpatient Addiction Service: A Case Study
4
1,2
Cheyenne Johnson RN, MPH, CCRP1, Jane Buxton MBBS, MHSc, FRCPC5, 6, Scott Harrison RN MA, CCHN , Keith Ahamad MD ,
1,2
2,
2
1,2
Seonaid Nolan, MD , Leslie Lappalainen MD Annabel Mead MBBS, FAChAM , Mark McLean MD, MSc, FRCPC ,
1,3
Evan Wood MD, PhD, FRCPC
ABSTRACT
Opioid overdose is a major public health burden worldwide. While the development of community based
opioid overdose prevention programs have expanded
in recent years, the implementation of such programs
for patients in a hospital setting is not well described.
This case report describes the implementation of British
Columbia’s Provincial Take Home Naloxone Program to
patients evaluated by the Addiction Medicine Consult
Team at St. Paul’s Hospital in Vancouver, Canada between
August 2014 and August 2015. During this period, 61 individuals were educated on the use of naloxone and were
trained on how to administer it intramuscularly in the
suspected case of an opioid overdose. In total, 23 naloxone kits were dispensed for future use in the community upon discharge. Overall, the Take Home Naloxone
program has been recognized as a worthwhile initiative
by patients, physicians of the addiction medicine consult
team and other interdisciplinary hospital staff. Given the
ongoing burden of disease attributable to opioid overdose and the feasibility of providing naloxone education
and take-home kits to high-risk hospitalized patients
with an opioid use disorder and their family and friends,
these findings underscore the unique opportunity that
exists for overdose prevention interventions in an acute
care setting. Keywords: naloxone, overdose, implementation, harm reduction, Vancouver
Les surdoses d’opioïdes sont un fardeau mondial de santé
publique. Bien que le développement de programmes
communautaires de prévention en surdose d’opioïdes
ait crû considérablement au cours des dernières années,
l’implantation de tels programmes en milieu hospitalier
est peu décrit. Cette étude de cas décrit l’implantation
FEBRUARY 2016
Author Affiliations: 1British Columbia Centre for Excellence in HIV/
AIDS, St. Paul’s Hospital, 2Department of Family Practice,
University of British Columbia, 3Department of Medicine,
University of British Columbia, 4School of Nursing, University of
British Columbia, 5British Columbia Centre for Disease Control,
Vancouver, Canada, 6School of Population and Public Health,
University of British Columbia
Author Correspondence: Evan Wood, MD, PhD, BC Centre for
Excellence in HIV/AIDS, 608 - 1081 Burrard Street, Vancouver, BC
V6Z 1Y6, Canada Tel: 604 806 9116 • Fax: 604 806 9044
Email: uhri-ew@cfenet.ubc.ca
Conflict of Interest and Sources of Funding: Cheyenne Johnson serves
on an advisory board for Indivior Pharmaceuticals and has received
compensation for these services. All other authors have no other
financial, consultant, institutional and other relationships that might
lead to bias or a conflict of interest. This case report was not funded.
22
en Colombie-Britannique du programme provincial Take
Home Naloxone pour des patients évalués par l’équipe
de consultation en toxicomanie à l’hôpital St. Paul’s de
Vancouver, Canada entre le mois d’août 2014 et le mois
d’août 2015. Pendant cette période, 61 individus ont été
informés sur l’utilisation du naloxone et formés sur son
administration intramusculaire en situation de surdose
d’opioïdes suspectée. Au total, 23 ensembles de naloxone
ont été distribués pour une utilisation future dans la
communauté. Dans l’ensemble, les patients, les médecins
de l’équipe de consultation en toxicomanie et le personnel
interdisciplinaire de l’hôpital ont reconnu le programme
Take Home Naloxone comme une initiative valable. Étant
donné le fardeau actuel attribué aux surdoses d’opioïdes
et la faisabilité d’offrir de l’information sur la naloxone
et des ensembles à emporter aux patients hospitalisés les
plus à risque, à leur famille et à leurs amis, ces données
soulignent l’opportunité unique qui existent d’intervenir
en prévention des surdoses en établissements de soins
aigus. Mots clés: naloxone, surdose, implantation, réduction des méfaits, Vancouver
INTRODUCTION
Opioid overdose is a major public health issue worldwide1. Previous studies have identified fatal overdose
as the primary cause of death in the illicit drug using
population1,2 In 2013, over 16,200 individuals in the
United States (US) died from a drug overdose involving
an opioid analgesic, a number that has quadrupled since
1999 3. As more individuals turn to heroin, a cheaper and
more accessible alternative, the number of heroin related
overdoses has been on the rise in the US4-6.
British Columbia (BC), Canada has shown similar trends.
Provincial overdose data demonstrates a 70% increase
in heroin and/or morphine related overdoses between
2008-20117. In addition, between 8-12% drug using adults
surveyed in in BC reported experiencing an overdose
in the last 6-12 months and between 12-36% reported
witnessing an overdose in the same time period8. There
has also been a constant increase in fentanyl-detected
overdose deaths over the last three years, with 49 reported deaths in the first 8 months of 2014 compared to a
total of 51 deaths in 20137,9.
Unintentional deaths from opioid overdose are
preventable through a range of interventions including
CJA JCA
CASE REPORT
St. Paul’s Hospital AMCT implemented the THN program
in August 2014. To effectively manage resource allocation
and administrative support, collaboration between the
inpatient AMCT and the St. Paul’s Hospital outpatient
HIV immunodeficiency clinic (IDC) occurred. Naloxone
kits were shipped directly to the IDC and staff from both
the areas shared access to the supply kits, as well as training and educational resources. Site eligibility for involvement in the BC THN program requires the presence of
a prescriber, an educator and a dispenser13. As such,
any staff physician from the AMCT was the designated
prescriber for the program. An Addiction Nursing Fellow,
who was the designated educator and dispenser, provided
training on the THN program’s background and referral
process to all designated prescribers, medical learners on
the AMCT and hospital nursing staff. Individuals were
instructed to contact the nursing fellow with the details
of a patient suitable for enrollment in the program, if the
patient was agreeable.
The AMCT is a unique teaching service comprised of
physicians specialized in addiction medicine, social
workers, clinical fellows completing addiction training
(physicians and nurses) residents and medical students.
The team evaluates patients who are referred for an
assessment of a substance use disorder and severity,
medical management of withdrawal, relapse prevention,
agonist therapy (i.e. methadone, buprenorphine/naloxone) and complex pain. Psychosocial interventions for
long-term recovery, motivational interviewing and harm
reduction approaches to treatment also comprise a large
part of their work.
Two high-risk opioid-using patient groups were targeted
for the program, both groups at increased risk for an
opioid-related overdose. The first was patients with an
opioid use disorder who refused methadone maintenance
therapy (MMT) or buprenorphine/naloxone (Suboxone®)
at the time of hospital discharge. The second was patients
who may have been started on opioid substitution therapy (OST) and were determined to be at increased risk
for overdose as a consequence of their hospitalization,
use of concomitant medications (i.e. benzodiazepines),
alcohol or were at risk for reduced tolerance. If eligible,
the nursing fellow would visit the patient, arrange a suitable time for training and extend the invite for training
to the patient’s friends or family members, if applicable.
To maximize recall, THN training was ideally scheduled
close to the anticipated date of discharge from hospital.
As naloxone is a prescription only medication in BC, the
kit can only be prescribed to the patient with a history
of opioid use disorder and/or prescription opioid misuse
and not directly to friends and family members, although
they are eligible to participate in training.
Though a variety of community sites have adopted the
BC THN program, to date there has been minimal uptake
by inpatient providers. As a result, naloxone distribution in an acute inpatient setting has not previously
been described. This case report attempts to address this
knowledge gap by describing the implementation of a
naloxone distribution program amongst a hospitalized
population of opioid users in a Canadian setting.
Training sessions varied in length from 5 to 60 minutes
depending on the patient’s knowledge of the program,
understanding and familiarity with naloxone and overdose experience. Two patients had previous THN training and therefore only required a 5-minute session, which
provided them with a refill THN kit. Longer training
sessions, sometimes up to 60 minutes, often occurred
with the presence of multiple family members. The
23
VOLUME 7 NO. 1
overdose education using naloxone (Narcan®), an opioid
receptor antagonist. Naloxone is on the World Health
Organization’s list of essential medicines and can be used
to reverse respiratory depression commonly associated
with an opioid overdose10. Numerous naloxone distribution programs exist worldwide - the US alone has more
than 180 programs currently in existence11. BC’s Take
Home Naloxone Program (THN) was developed by the BC
Centre for Disease Control (BCCDC) and implemented in
August 2012. As of July 2015, the THN program has trained
4,038 individuals, dispensed 2,382 naloxone kits and has
had 240 reported overdose reversals12. THN training and
kit distribution primarily occurs at outpatient community
sites (i.e. harm reduction supply distribution, HIV clinics, community health centres) as well as two emergency
departments. The THN program consists of overdose
prevention training, signs and symptom of an opioid overdose, how to respond to a suspected overdose using the kit,
completing required forms and where patients can receive
additional kits and harm reduction supplies. The THN kit
consists of 2 glass ampoules (0.4 mg/mL) of naloxone, 2
retractable VanishPoint® intramuscular syringes, alcohol
swabs, gloves, one-way rescue breathing mask and THN
administration form as well as steps to respond to an
overdose using the SAVE ME acronym (place in recovery
position, call emergency services, S: stimulate; A: airway;
V: ventilate; E: evaluate; M: muscular injection; E: Evaluate
for 2nd dose). At present, the only inpatient THN site is at
St. Paul’s Hospital in Vancouver, BC with the Addiction
Medicine Consult Team (AMCT).
location of each training session was based on patient
preference and included either at the patient’s bedside or
in a private hospital room. At the completion of training, the THN kit and naloxone were labeled with the
patient’s name, provided to the ward unit nurse and
stored safely for the patient until the time of discharge.
Lastly, an interdisciplinary progress note was entered in
the patient’s chart and a note was added to the patient’s
hospital medication record as to the location of the kit.
Patients were provided with additional training material
and resources at their request. Further information on
training and materials for the THN program can be found
at http://www.towardtheheart.com.
Between August 2014 and August 2015 a total of 32 clients/
family/friends were educated about overdose prevention
and trained on the use of naloxone to prevent a fatal
opioid overdose and 23 kits were dispensed (participants
are only eligible to receive kits if they have a past or
current history of illicit or prescription opioid misuse).
Lastly, a further 29 health care professionals including
social workers, physicians, nurses and nursing students
were trained to conduct their own training sessions
for suitable patients, their families and/or friends and
dispense THN kits. Data on the number patients who
refused training and total number of eligible patients or
their friends/family was not captured for the purposes of
this descriptive case study. Eligible patients may have not
received training or the kit due to the pilot nature of the
program.
DISCUSSION
This case study describes the successful implementation of a naloxone distribution program in an inpatient
setting and highlights its acceptability and feasibility
in this environment. To our knowledge, this is the first
inpatient naloxone distribution program in BC.
Previous studies of the effectiveness of naloxone distribution programs have demonstrated a 46% reduction
in opioid overdose mortality14. Furthermore, it has been
shown that training peers and people who use drugs to
administer naloxone or act as peer educators may have
other positive benefits including reductions in their
own drug use and engagement in risk behaviours15.
FEBRUARY 2016
Some challenges that were identified in the implementation of this program include the administrative burden
(for example naloxone is a currently prescription only
medication, which requires detailed documentation in
terms of the prescribing, dispensing and training), variable levels of engagement by prescribers, patients that
were trained leaving or forgetting kits on discharge as
well as difficulty scheduling or locating patients for training. Observed opportunities and benefits of this program
include increasing patient and family engagement and
24
education on harm reduction strategies, a greater involvement of family members in the care and treatment plan
and increased opportunities for addiction education with
nurses and other health care providers.
Recent changes to the dispensing guidelines for program
in May 2015 now allow registered nurses (RNs) to
dispense naloxone kits without a physician’s prescription.
This change is supported by a revised scope of practice16,
decision support tool17 and nursing competencies 18 and
has had a positive impact on the program, by increasing
nursing leadership and decreasing the administrative
burden. As a result of this change, there are opportunities
for the THN program to further expand. More research
is needed to explore the motivations for eligible participants that are not interested in receiving the kit while in
hospital.
While AMCT staff and learners will be encouraged to
continue to identify patients suitable and interested in
the training program, training sessions will occur weekly
through a group format and at a pre-determined time and
location. It is hoped a group training setting will allow
for an expansion on eligibility for participation with the
THN program so as to include any patient with a history
of illicit and/or prescription opioid misuse. One-on-one
training at the bedside will remain available for those
patients with reduced mobility or other limitations to
attending group sessions.
In summary, this case report demonstrates the feasibility
of incorporating harm reduction services such as the BC
THN in a hospitalized population using the resources of
an existing hospital-based addiction care service. There
is strong evidence that naloxone distribution programs
can have a large impact at a population level, with a
clear dose-repose effect, with higher levels of distribution decreasing overdose mortality by 46%14 . Therefore,
there is a continued need to scale up existing community programs like the BC THN program to a variety of
settings, including hospitalized patient populations. If
these expansion efforts are to be successful however, it is
imperative the Province of BC and its health authorities
commit to providing ongoing resources and support for
the program.
ACKNOWLEDGMENTS:
The authors thank Ashraf Amlani at the BC Centre for
disease control and nurses at the Immunodeficiency
Clinic at St. Paul’s Hospital in Vancouver. This research
was undertaken, in part, thanks to funding for a Tier 1
Canada Research Chair in Inner City Medicine, the
Canadian Institute on Health Research (CIHR) through
the Canadian Initiative on Substance Misuse (CRISM)
and Foundation Scheme funding, which supports Dr.
Evan Wood.
CJA JCA
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Degenhardt L, Bucello C, Mathers B, Briegleb C, Ali H,
Hickman M, et al. Mortality among regular or dependent
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Mathers BM, Degenhardt L, Bucello C, Lemon J, Wiessing
L, Hickman M. Mortality among people who inject drugs: a
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Hedegaard H, Chen L-H, Warner M. Drug-poisoning Deaths
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Dasgupta N, Creppage K, Austin A, Ringwalt C, Sanford C,
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Tanner Z, Matsukaura M, Ivkov V, Amlani A, Buxton JA.
British Columbia Drug Overdose & Alert Partnership. 2014.
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Sorge J, Buxton J, Amlani A, Ishiguro S. Substance Use Trends
in BC: A Survery of Harm Reduction Clients. BC Centre for
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9.
Jafari S, Buxton J, Ronald J. Rising Fentanyl-related Overdose
Deaths in British Columbia. Canadian Journal of Addiction.
2015;6(1):4-6.
11. Wheeler E, Davidson PJ, Jones TS, Irwin KS. CommunityBased Opioid Overdose Prevention Programs Providing
Naloxone in the United States, 2010. 2012.
12. Take Home Naloxone Program in BC Infographic. 2015 July
14, 2015. Available from: https://infographic.venngage.com/
publish/6d2db4e4-3d32-4cf8-a342-ee1c3d054067.
13. Banjo O, Tzemis D, Al-Qutub D, Amlani A, Kesselring S,
Buxton JA. A quantitative and qualitative evaluation of the
British Columbia Take Home Naloxone program. CMAJ
Open. 2014;2(3):E153-E61.
14. Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins
M, Sorensen-Alawad A, et al. Opioid overdose rates and
implementation of overdose education and nasal naloxone
distribution in Massachusetts: interrupted time series
analysis. British Medical Journal. 2013;346:f174.
15. Mackesy-Amiti ME, Ouellet LJ, Golub ET, Hudson S, Hagan
H, Garfein RS. Predictors and correlates of reduced frequency
or cessation of injection drug use during a randomized HIV
prevention intervention trial. Addiction. 2011;106(3):601-8.
16. Scope of Practice for Registered Nurses. May 2015 Accessed
July 13, 2015; College of Registered Nurses of BC. Available
from: https://www.crnbc.ca/Standards/Lists/StandardResour
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17. Dispensing Naloxone Kits of Clinets at Risk of Opioid
Overdose. Health Decision Support Tool, Non-certified
Practice [Internet]. April 2015. Available from: http://www.
bccdc.ca/NR/rdonlyres/64310A80-0939-4F0B-BDBCC101B7A2E4E2/0/NaloxoneDSTforNursesApril14approved.
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18. Dispensing Naloxone Kits of Clients at Risk of Opioid
Overdose, Nursing Competencies. Health Decision Support
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VOLUME 7 NO. 1
10. WHO Model List of Essential Medicines. April 2015; 19th
List. Available from: http://www.who.int/selection_medicines/committees/expert/20/EML_2015_FINAL_amended_
JUN2015.pdf?ua=1.
25
Loss and grief among substance users and the programs
that provide treatment for them in Ontario
Nick Doukas M.S.W., PhD Candidate, Dhivya Balakrishnan M.S.W., RSW
ABSTRACT
Background: Grief is an area that needs to be addressed
when working with individuals recovering from substance
use because of the complicated loss associated with the
lifestyle of problem substance users. Problem substance
users may prefer accessing grief services from agencies that
provide substance use services rather than seeking grief
counselling from mainstream services because of the stigma
associated with substance use. Objective: To report on the
number of agencies in Ontario that provide substance use
services and also offer grief counselling by accessing the
Drug and Alcohol Registry for Treatment. Specifically this
study determines which type of agencies provide grief counselling across different settings and service delivery. Results:
Out of the 215 agencies that are registered with the Drug and
Alcohol Registry for Treatment, 47.4% (102/215) responded to
the questionnaire. Among the seven categorical settings the
only two that reported a substantial level of grief counselling
as a service was Short-Term Residential Centers (73.7%) and
Long-Term Residential Centers (58.4%). The overall rate of
agencies that provide grief counselling among the 102 agencies was 29.5% (30/102). Conclusion: This study has briefly
outlined the necessity of grief therapy in addressing issues
of complicated grief and substance use. It is clear that there
is a discrepancy in the number of agencies which provide
grief therapy to substance users. In addressing the grief
component for substance users, the addiction component
may slowly become addressed as both issues are intertwined
and exasperate the other. Key Words: grief counselling, loss,
addiction, substance use treatment centres.
FEBRUARY 2016
Contexte: Le deuil est un aspect qui doit être abordé avec
les individus qui se remettent de leur consommation de
substances en raison de la perte complexe associée au mode
de vie des personnes vivant avec des troubles de consommation de substances. À cause du stigma associé à la consommation de substances, ces personnes peuvent préférer
consulter des services en matière de deuil au sein d’agences
prestataires de services en lien avec la consommation de
substances plutôt que d’obtenir des services d’un conseiller
grand public. Objectif: Rapporter le nombre d’agences en
Ontario prestataires de services en lien avec la consommation de substances et des services de counselling en deuil à
Author Institution: 1Centre for Addiction and Mental Health, 60 White
Squirrel Way, Toronto Canada, M6J IH4, nick_doukas@camh.ca,
2
Centre for Addiction and Mental Health, 60 White Squirrel Way,
Toronto Canada, M6J IH4, dhivya.balakrishnan@camh.ca
Acknowledgement of thanks to the staff at DART who helped make this
research possible.
26
partir du répertoire de services Drug and Alcohol Registry
for Treatment de l’Ontario. Plus spécifiquement, cette
étude détermine quel type d’agences offrent des services de
consultation en matière de deuil à travers différents milieux
et différentes prestations de services. Résultats: Des 215
agences inscrites au répertoire, 47,4% (102/215) ont répondu
au questionnaire. Des sept catégories de milieux, les deux
qui rapportent un niveau substantiel de counselling en
matière de deuil sont les centres résidentiels de courte durée
(73,7%) et les centres résidentiels de longue durée (58,4%).
Des 102 agences, le taux global offrant du counselling en
matière de deuil est de 29,5% (30/102). Conclusion: Cette
étude illustre brièvement la nécessité d’offrir une thérapie
pour le deuil lorsque les problèmes de consommation de
substances et du deuil complexe sont abordés. Il est clair
qu’il existe une contradiction entre le nombre d’agences
qui offrent la thérapie de deuil aux usagers de substances.
En abordant la composante de deuil avec les usagers de
substances, la composante dépendance peut petit à petit
être abordé du même coup puisque les deux problèmes sont
entrelacés et s’exacerbent l’un l’autre. Mots clés: counselling
sur le deuil, perte, dépendance, centre de traitement pour la
consommation de substances
INTRODUCTION
Grief is widely accepted as an area that needs to be
addressed when working with clients recovering from
problem substance use because of the complicated loss
associated with addiction issues1. The lifestyle of those
who have abused substances is associated with great loss
and if it goes unresolved, the impact of these losses can
merge into the unconscious and become cumulative2.
These matters may present the individual with longterm guilt and remorse that impedes recovery. This can
be compounded because many addicts have difficulty
expressing their feelings, resolving intrapersonal issues3
and difficulty working through the grief process4. While
grief can develop in any individual, the literature reports
a high degree of grief pathology among those with problem substance use5. The aim of this research was to investigate
the number of substance use treatment agencies in
Ontario that provide grief counselling for their clientele
by accessing the Drug and Alcohol Registry for Treatment
(DART). The study also sought to determine which type
of agencies in Ontario provides grief counselling across
different settings, service delivery, and specialty.
CJA JCA
PROCEDURE
and Mental Health and the project was deemed to not
present any risk and not require REB review and approval. After receiving the final response to the questionnaires, agencies were categorized into setting and types
of services offered, which resulted in seven categories:
Long Term Residential Treatment (LTR); Short Term
Residential Treatment (STR); Outpatient Community
Day Treatment (OCD); Multi-service Agency (MS);
Community Mental Health and Health Centre (CMH);
Community Hospital (CH); Housing and Shelter (HS).
In winter 2015 researchers obtained a list of agencies registered with DART. These are agencies across Ontario that
provide some level of substance use or gambling services
for people seeking help. A questionnaire (Appendix 1)
was emailed to the Executive Directors of all 215 agencies registered with DART. To those agencies that had
not yet responded by the second letter, a third email was
provided two weeks later. The research team consulted
with the ethics review board at the Centre for Addiction
Long Term
Residential
Treatment
Short Term
Residential
Treatment
Outpatient
Community
Day
Treatment
Multiservice
Agency
Community
Mental
Health and
Health Centre
Community
Hospital
Housing
and
Shelter
Over all
totals
Response rate
12=11.7%
11=10.7%
18=17.6%
16=15.6%
28=27.4%
14=13.7%
5=4.8%
215/102=
47.4%
No grief
therapy available
5/12=
41.6%
4/11=
36.3%
14/18=
77.7%
15/16=
93.7%
19/28=
67.8%
13/14=
90.2%
4/5=
80.0%
72/102=
70.5%
Provides grief
therapy
7
7
4
1
9
1
1
25/102=
24.5%
Provides individual
based grief therapy
3
2
4
0
8
1
1
19
Provides group
based grief therapy
2
3
1
1
3
0
1
11
No grief therapy,
but provided if
needed
2
3
1
0
2
1
0
9
Incorporate into
treatment cycle
0
1
2
1
2
1
0
7
Group How often provided
weekly
weekly
weekly
weekly
weekly or every
2nd week
not offered
weekly
weekly
or twice
weekly or
every 2nd
week
Group How many sessions
8-13 weeks
5-12 weeks
indefinite
10 weeks
8-16 weeks
not offered
indefinite
5-16 weeks
indefinite
Group How long are
sessions
60 minutes
60-90
minutes
60 minutes
60
minutes
60-120 minutes
not offered
120
minutes
60-120
minutes
Individual
How often provided
weekly
weekly
weekly
not
offered
weekly
weekly
weekly
weekly
IndividualHow many sessions
13 weeks
5-12 weeks or
indefinite
2 weeks or
indefinite
not
offered
2-7 weeks or
indefinite
4-6 times
indefinite
4-13 wks or
indefinite
Individual
How long are
sessions
60 minutes
60-90
minutes
60 minutes
not
offered
60 minutes
60-90 minutes
60
minutes
60-90
minutes
RESULTS
Out of the 215 agencies that are registered with DART,
almost half responded to the questionnaire, showing a
response rate of 47.4% (102/215). The category with the
highest response rate was CMH (27.4%), followed by OCD
(17.6%) and MS (15.6%), and concluding with Hospitals
(13.7%), LTR (11.7%), STR (10.7%) and HS (4.8%). Among
the seven agency categories, the only two that reported
a substantial level of grief counselling as a service was
27
VOLUME 7 NO. 1
DATA RESULTS TABLE
STR (73.7%) and LTR (58.4%). Mental Health and Health
Agencies (32.2%) and OCD (22.3%) showed that they
provide some level of grief counselling within their service
provision, but of the three remaining categories, only one
agency within each category reported that they provide
grief counselling to their clientele. The overall rate of agencies that provide grief counselling among the 102 agencies
that responded to the questionnaire was 29.5% (30/102).
Among the 30 that responded as providing grief counselling, 19 offered individual and 11 in a group format, with
several categories offering both. Results were examined
to identify how many agencies provide grief counselling
among agencies that offer services to both men and women
and for women and men separately. Results show that out
of 86 agencies that responded to the questionnaire who
provide services to both men and women, 22 offer grief
counselling (25.5%). Out of the 8 that provide services only
to women, 3 provide grief counselling and 1 out of 8 do so
for men specific agencies.
DISCUSSION
To our knowledge, this study is the first of its kind to
investigate the number of substance use treatment agencies that provide grief counselling for their clientele. The
study also determined which types of agencies provide
grief counselling across different settings, service delivery
and specialty. This helps to identify what type of agencies
provide a higher rate of grief counselling and which type
are lacking in this area of service provision.
When examining the LTR category it might be expected
that these types of settings would have more agencies
that provide grief counselling services than 7/12 (58.4%)
when considering clients are able to establish a longer
and closer therapeutic relationship with their treatment
providers. The lower than expected rates could be that
these long-term homes are more associated with housing and accommodation in an alcohol free setting. These
settings are also known to act as a transitional program
that fosters responsibility and life skills to work towards
independent living.
FEBRUARY 2016
Short term residential treatment agencies show the most
grief therapy (7/11 = 63.6%) offered among the seven
categories. Much of the work done in these types of agencies are group based, so it is consistent with the results
that show grief counselling being offered more in a group
setting as opposed to individual counselling.
The CMH category showed the highest response rate among
the seven groups at 27.4% and was third in providing grief
counselling among all the categories at 32.2%. Agencies
in this category tend to provide on-going, long-term case
management for their clientele, because some clients may
require frequent and closer attention due to a high rate of
co-occurring mental health and addiction disorders.
28
In the OCD category, results show that 4/18 agencies
provide grief counselling. The low rate of grief counselling offered by this category might be due to many of
the agencies focusing on outreach and brief treatment,
which has resulted in many agencies taking on a solution
focused approach to counselling.
When viewing the results of the three remaining categories we see a significant decrease with agencies that
provide grief counselling. The multiservice category is
among the three categories that reported only one agency
as providing grief counselling. These type of agencies are
more concerned with their case management and referral
specialty. The second category that has only one agency
offering grief counselling is hospitals. The models of
care and services provided among these hospitals are
very similar, with outpatient treatment or withdrawal
management as their main type of service. The third
category that has only one agency that offers grief counselling is the housing category. What is unique about this
single agency is that it is the only shelter on the list that
responded to the questionnaire. What is impressive about
this shelter is that it provides both group and individual
grief counselling that runs indefinitely. This shelter may
act as a model for other shelters, given that some clients
may remain in the shelter system indefinitely, so it would
be beneficial to provide grief work as a service.
What is interesting to note is that all four Aboriginal
agencies that responded to the questionnaire provide
some form of grief counselling. Another note of interest
is women-specific agencies provide more grief counselling (3/8) than men-specific agencies (1/8).
After examining agency service profiles, researchers
found that out of the 24 agencies that replied YES to
providing grief counselling, two of the 24 provided this
information as a service in the DART registry. We then
contacted DART and informed them of our findings.
After reviewing the results of the questionnaire, it would
appear that the long and short term residential settings
that provide the highest rate of grief counselling are ideal
settings for individuals to seek grief counselling and that
shelters should consider extend their services to include
grief counselling.
STUDY LIMITATIONS AND FURTHER
RESEARCH
There are limitations that are evident from this study. The
questionnaire does not allow for elaboration from agencies and the few questions were limiting in gathering more
information. The questions were designed to have short
and non-detailed answers so as to not be time consuming
for the agencies to fill out and to foster a good response rate,
which was somewhat achieved. However, the answers were
CJA JCA
not as detailed as they could have been. For example, none
of the questions identify what types of therapy were offered
to clients. Also, the questionnaire was not able to assess for
the drop-out rate, benefits, and deterrents of grief therapy
within each agency setting. This is beneficial for this study
because it would have informed the researchers of what is
helpful in grief therapy and what is not helpful, along with
other factors such as the therapist’s experience. Additionally,
the credentials, experience, and style of therapy of the therapists/facilitators leading the group or individual sessions,
would have been beneficial to this study because it would
indicate the level of expertise and how well this helped
clients in this situation. Also of interest would have been
to inquire on whether agencies who refer clients to the
community for grief counselling do so to the general grief
counselling agencies or do counselors seek out other addiction agencies that do provide grief counseling. If this is the
case, then it is imperative, that the grief service be provided
in an agency’s service profile in DART.
agencies offer grief counselling on an as needed basis,
or incorporate it into their overall treatment modality.
This would demonstrate that agencies consider this area
of treatment, but do not provide it in a structured way
and that there is significant reason to assume overlap
between programs. Finally, three of the five references
used are dated. There is a vast amount of trauma and
grief research available from when these three authors
began contributing to the literature, but all three are
pioneers in this area of work. Denny and Goldberg are
writers who have contributed specifically to grief among
problem substance users, unlike much of the literature
that incorporates trauma into the research. In addition,
Denny is the first of only three researchers to date who
have conducted a grief, intervention-based study with
problem substance users. These citations were used
because of their specific relevance to the topic.
Examining and tracking which type of agency setting
refers to an outpatient program may be useful because
it establishes what settings are significant points of
grief identification and then what setting-type are they
referred to for treatment. This could lead to training and
the application of grief scales which help in identification, referral and treatment purposes. The questionnaire
could have also provided questions pertaining to whether
This study has briefly outlined the necessity of grief
therapy in addressing issues of grief and substance use.
It is clear that there is a discrepancy in the number of
agencies that provide grief therapy to substance users.
By addressing grief in a therapy setting, before it develops into complications, the individual may experience a
measure of stability in their recovery.
CONCLUSION
REFERENCES
1. Dayton T. The use of psychodrama in dealing with grief and
addiction-related loss and trauma. Journal of Group Psychotherapy,
psychodrama and Sociometry. 2005;Spring, 15-34.
2. Goldberg M. Loss and grief: Major dynamics in the treatment
of alcoholism. Alcoholism Treatment Quarterly. 1985;2, 37-45.
3.
Denny G, Lee L. Grief work with substance abusers. Journal
of Substance Abuse Treatment. 1984;1(4), 249-254.
4.
Rosenblatt P, Walsh R, Jackson D. Grief and mourning. 1976;
New Haven, CT: Human Relations Area Files Press.
5. Zuckoff A, Shear K, Frank E, Daley D, Seligman K, Silowash
R. Treating complicated grief and substance use disorders:
A pilot study. Journal of Substance Abuse Treatment. 2005;
30(3), 205-211.
APPENDIX 1
Does your agency provide grief counselling to clients___________________________
VOLUME 7 NO. 1
If the answer is yes please move on to the next questions
Is the grief counselling provided individual___________________________________
Is the grief counselling provided group based__________________________________
Is the grief counselling provided co-ed_______________________________________
How long are the sessions_________________________________________________
How often do the sessions run eg., once weekly, daily___________________________
How many sessions consist of a regular cycle__________________________________
Does your agency use volunteers/peers to help facilitate counselling________________
29
CSAM-SMCA & ISAM
2016 MONTREAL
Marriott Chateau Champlain
OCT 20-23, 2016
An international hub of culture, creativity and innovation, Montreal enjoys an enviable reputation as a modern and cutting edge North American centre. Shaped by
nearly 375 years of exciting history, Montreal of today is a cultural beacon, a gourmet
destination, a digital arts capital and a hotspot for design, architecture and fashion. It is a warm city with European flair that is expressed through diversity, culture,
neighborhoods, its downtown area, businesses, fine cuisine and communities. Its
dynamic and discovery-rich neighborhoods move to the beat of the joie de vivre and
hospitality of its 4 million citizens, while its streets, parks and venues are annually
host to its one-of-kind festivals, non-stop nightlife and array of events for all tastes
and ages.
FEBRUARY 2016
With memories of New France swirling amongst
ultramodern construction, it’s no wonder that
Montreal was the first North American city to be
appointed a UNESCO City of Design (2006). Most
locals are bilingual (French/English). In this part
of Canada not only do our trees turn yellow, gold
and orange in the autumn, or sumacs and sugar
maples turn fiery tones of red as well, so that the
color combinations are stupendous at their peak
in late September to mid-October, and often well
into November. Montreal island itself has several
fine locations for a walk or drive among the bright
autumn trees or, if you can get out of town, there are
hilly drives in several directions that will bring you
out among the fall colors.
that provides its guests with one of the most central
locations of any downtown Montreal hotel close
to downtown Montreal’s extraordinary boutiques,
expansive shopping districts, eclectic restaurants
and lively nightlife.
This year we are excited to announce that ISAM will
be having a joint scientific conference with CSAMSMCA (Canadian Society of Addiction Medicine) in
historic Montreal, Canada October 20-22, 2016 at the
Marriott Chateau Champlain, rated four-diamond,
30
CONFIRMED PLENARY SPEAKERS
INCLUDE:
•
Dr. Nora Volkow, NIDA, on Drug Abuse &
Addiction Research
•
Dr. Pedro Ruiz, on Dual Diagnosis
•
Dr. Amine Benyamina, on Genetics of Addiction
•
Dr. Kathleen Brady, on PTSD
•
Dr. Julie Bruneau, on Opiates
•
Drs. Marc Galanter & Gregory Bunt, on Social
Supports in Promoting Abstinence
•
Dr. Harold Kalant, on Marihuana Regulation
•
Dr. Jurgen Rehm, on Substances and Gambling
Prevention & Policies
CJA JCA
Registration as well as the Call for Abstracts (deadline for submission May 1, 2016) and for Symposium
(deadline for submission April 1, 2016) is now open
– please consult isamweb.org or csam-smca.org for
more details.
We look forward to having you join us for what we
feel will be a very educational event to those working in the field.
INTERNATIONAL CERTIFICATION EXAM
ISAM’s Certification of Addiction Medicine is a
credentialing process that assures the public that
the holder has the pre-requisite knowledge competence to practice in that field within the confines
of his/her medical license. The overall Objective is
to meet the needs of an international membership
of practicing physicians for standardized, valid and
affordable credentialing in addiction medicine.
The examination is composed of 225 multiple choice
questions testing knowledge and some clinical
judgment. The exam will take 4½ hours and will be
administered in two parts (2 hrs 15 min each) with a
15 min health break in between. The main reference
book will be the Textbook of Addiction Treatment:
International Perspectives (Springer Publishing
www. Springer.com).
In 2016 the Exam is being offered in Montreal,
Canada on October 19, 2016 the day before the start
of the 2016 joint ISAM and CSAM-SMCA Scientific
Conference at the Marriott Chateau Champlain.
Please see the ISAM webpages for details and application form: isamweb.org
FELLOWSHIPS
A limited number of Grant-In-Aid-Of-TravelFellowships will be offered for Young Investigators
and Physicians from World Bank Category C & D
countries to assist with costs in coming to present at
the 2016 meeting.
Please see the ISAM webpages for details: isamweb.org
TEXTBOOK
The Textbook of Addiction Treatment: International
Perspectives is a 4-tome reference available through
Springer Publishing. Presenting a world view of the
spectrum of addictions-related problems across
different cultures, this reference volume highlights
the main differences and similarities between clinical practices in the field of Addiction Medicine based
on neurobiological similarities as well as epidemiological and socio-cultural differences.
This Textbook, which collates the experience and
wisdom of some 250 leaders in the field, from 30
countries, is promoted by the International Society
of Addiction Medicine (ISAM), founded in 1999,
which has as its principal mission the education of
practitioners in Addiction Medicine and their trainees worldwide.
Please go to isamweb.com for the links to discounts
in cost for ISAM members.
31
VOLUME 7 NO. 1
The one-day Fundamentals in Addiction Medicine
course will be offered post-conference on Sunday
Oct 23, 2016 and requires separate registration.
CSAM BOARD OF DIRECTORS
EXECUTIVE
PROVINCIAL REPRESENTATIVES
President
Dr. Paul Sobey
BC & YK Regional Director
Dr. Mandy Manak
Ontario Regional Director
Dr. Melanie Willows
Newfoundland Regional
Director Dr. Wael Shublaq
President-Elect
– Vacant
AB & NTW Regional
Director
Dr. Laura Evans
Ontario Regional Director:
Dr. Suzanne Turner
Member at Large
Dr. Nady el-Guebaly
Quebec Regional Director
Dr. Marie-Eve Goyer
Member at Large
Dr. Ronald Fraser
Quebec Regional Director
Dr. Marie-Eve Morin
Member at Large
Dr. Claudette Chase
Maritime Regional Director
Dr. David Martell
IT Liaison
Dr. Ramm Hering
Past President
Dr. Ron Lim
Secretary/Treasurer
Dr. Jeff Daiter
SK Regional Director
Dr. Morris Markentin
MB Regional Director
Dr. Nichole Riese
CORPORATE SPONSORS
CSAM would like to acknowledge the support of the following: