Youth and Opioid Addictions: by Melanie Willows, Clinical Director, Substance Use and Concurrent Disorders Program at The Royal

1. Genera&on O
How did we get here?
What can we do?
Melanie Willows B.Sc. M.D. C.C.F.P. C.A.S.A.M. C.C.S.A.M.
Clinical Director, Substance Use and Concurrent Disorders Program
Mano&ck Public Informa&on Mee&ng On Fentanyl
November 14, 2012

2. Discussion Points
• Current paOerns of substance use in youth
• What is an addic&on and what is experimental
• Risk Factors and Protec&ve Factors for Addic&on
• What is an opioid? Why are opioids so addic&ve?

3. Discussion Points cont’d
• What makes fentanyl so dangerous?
• Signs and symptoms of opioid intoxica&on and
withdrawal
• Preven&on and Treatment of opioid addic&on
in youth

4. A Genera&on Exposed…
• Although experimenta&on with alcohol and other
drugs is a natural part of adolescence,
experimenta&on involving opioids is high risk as
addic&on occurs much more rapidly than with
other drugs
» Na&onal Ins&tute of Drug Addic&on (NIDA)

5. Table 1. Past Year Drug Use (%) for the Total Sample,
and by Sex and Grade, 2011 OSDUHS (CAMH)
Total Male Female G7 G8 G9 G10 G11 G12
Alcohol 54.9 54.6 55.1 17.4 26.4 50.5 59.6 75.5 78.4
Cannabis 22.0 23.0 21.0 2.4 5.9 11.9 23.5 36.8 36.4
Binge
Drinking
22.3 22.7 21.8 1.1 4.1 13.7 24.4 35.3 39.7
Opioid Pain
Relievers
(NM)
14.0 12.9 15.2 8.5 10.9 13.0 14.9 18.0 16.0
CigareOes 8.7 9.3 8.2 2.8 3.7 10.3 14.5 14.4

6. What is Addic&on?
• Chronic disease of brain reward circuitry
• Addic&on is characterized by inability to
consistently abstain, impairment in behavioural
control, craving, diminished recogniMon of
significant problems with one’s behaviours and
interpersonal relaMonships, and a dysfuncMonal
emoMonal response.
» Excerpt from American Society of Addic&on Medicine (ASAM) defini&on

7. Risk Factors for Addic&on
• Environment
– culture and society
(e.g., laws and availability of
substances)
– peers and family including
actudes
– early/persistent behavioural
problems
– poor school performance,
rebelliousness
– early onset of substance use
• Drug
– cost
– availability
– rapidity with which the agent
reaches the brain
– efficacy of the agent as a tranquilizer
• Host
– inherited suscep&bility
– psychophysiologic vulnerability
to the effects of substances
– mental health disorders

8. Protec&ve Factors
• Posi&ve temperament/self‐acceptance
• Intellectual ability/academic performance
• Suppor&ve family/home environment
• Caring rela&onship with at least one adult
• External support system (e.g. Religion/church) that
encourages prosocial values
• Law abidance/avoidance of delinquent peer friendships

9. What is an Opioid?
• Opioids belong to the drug classifica&on depressants
(as do alcohol and benzodiazepines)
• Opioids are referred to as narco&cs (sleep inducing)
• Opioids are effec&ve pain killers

10. Common Abused Prescrip&on Opioids
Drug Name AcMve Ingredients
Tylenol #1,2, 3 Codeine with acetaminophen
M‐Eslon, MS Con&n Morphine
Percocet Oxycodone with acetaminophen
OxyNeo, Oxycon&n Oxycodone
Dilaudid Hydromorphone
Duragesic patch Fentanyl

11. Why Opioids? Why now?
• Increasing availability of prescrip&on opioids
– 1977 Oxycodone/Acetaminophen (Percocet)
– 1989 Hydromorphone Hydrochloride (Dilaudid)
– 1991 Morphine (MS IR)
– 1992 Duragesic patch (fentanyl)
– 1993 Morphine (MS Con&n)
– 1996 Oxycodone Hydrochloride CR (Oxycon&n)
– 1996 Duragesic patch added to Ontario Drug Benefits Formulary

12. Why Opioids? Why now? cont’d
– 2000 Oxycodone IR (Oxycon&n IR)
– 2000 Oxycodone Hydrochloride CR (OxyconMn) added to
Ontario Drug Benefits Formulary
– 2001 Hydromorphone Hydrochloride (Hydromorph Con&n CR)
– 2002 Hydromorphone Hydrochloride (Hydromorph IR)
– 2006 RanFentanyl Patch (generic) added to Ontario Drug
Benefits Formulary

13. Fentanyl
• First synthesized by Paul Jannsen in 1959
• Synthe&c potent opioid, rapid onset,
short dura&on of ac&on
• Said to be 80 to 100 &mes more potent
than morphine
• 1960’s introduced as an intravenous
anesthe&c Sublimaze

14. Fentanyl cont’d
• Illicit use of pharmaceu&cal fentanyl first appeared in
the mid‐1970s in the medical community
• First Durogesic patch was approved by the US FDA in
1990, marketed in Canada in 1992
• Effec&ve pain medica&on for chronic moderate to
severe pain when used properly

15. Fentanyl cont’d
• Possible to interfere with transdermal delivery
system thereby delivering larger doses of drug more
rapidly to the brain (increases addic&ve poten&al of
this drug)
• Difficult for user to determine dose (overdose risk)
• Depending on dose and delivery, physical withdrawal
symptoms may be felt aler several days or weeks of
fentanyl use

16. Why Prescrip&on Opioids? Why Now?
Why Fentanyl?
• Perceived safety because it is a pharmaceu&cal
• More socially acceptable than heroin
• Purity
• Potent opioid (euphoria effects)

17. Why Prescrip&on Opioids? Why Now?
Why Fentanyl? cont’d
• Easy access (inadequate monitoring of
prescrip&on narco&cs)
• High dose
• Possible to circumvent delivery system:
chew, suck, snort, smoke, inject

18. Opioids Intoxica&on:
What do others observe?
• Drowsiness or “the Nod”
• Constricted or pinpoint pupils
• Slurred speech
• Impairment in aOen&on
or memory

19. Risks of Opioid Intoxica&on
• Overdose (especially if new user, unknown dose, or
combined with alcohol and/or benzodiazepines)
• Tolerance for euphoria increases more rapidly than
tolerance to respiratory depression
• High risk for overdose if relapses aler a period of
abs&nence
• Accidents
• Addic&on

20. Opioids Withdrawal:
What can you observe?
• Dilated pupils
• Anxiety, irritability, anger (drug craving)
• Agita&on (cannot sit s&ll)
• Appears to be ill: nausea, vomi&ng,
diarrhea, sweats and chills, watery eyes, runny nose
• Yawning and Insomnia

21. Preven&on of Opioid Dependence
• Delaying onset of all substance use
• Treatment of any underlying mental health issues
• Protec&ve factors previously discussed
• Safe and secure dispensing, storage and disposal
measures of opioids must be reinforced for pa&ents,
pharmacists and physicians.

22. Treatment Op&ons
• Abs&nence following withdrawal management:
stop using opioids completely
• Opioid subs&tu&on therapy: receive daily dose
of long‐ac&ng approved and controlled opioid
such as methadone or Suboxone
(buprenorphine/naloxone)

23. Op&ons for Treatment of
Opioid Dependence
• Abs&nence Based
– Pa&ent preference
– Has not tried abs&nence based
– Prior sustained response to abs&nence based treatment
– Are a younger age
– Are dependent only on opioids and in par&cular oral opioids

24. Op&ons for Treatment of
Opioid Dependence cont’d
• Abs&nence Based
– Good prognos&c factors
• Socially stable
• Suppor&ve social network
• Short dura&on of addic&on
• No major psychiatric comorbidity
Methadone Maintenance Treatment Program Standards and Clinical Guidelines 4th Edi&on February 2011
Buprenorphine/Naloxone for Opioid Dependence: Clinical Prac&ce Guideline CAMH 2011

25. Non‐Opioid Management of
Opioid Withdrawal
• Clonidine ini&a&ng at 0.05mg TID, check BP if
less than 90/60 then hold; dosing of up to
0.1mg‐0.2mg po TID‐QID
• An&diarrheals :loperamide(Immodium)
• An&nauseants : dimenhydrinate (Gravol)

26. Non‐Opioid Management of
Opioid Withdrawal cont’d
• Analgesics for myalgias: ibuprofen
• Night‐&me seda&on: Trazodone, Seroquel, or
Benzodiazepine (but only for short term)

27. Residen&al Withdrawal
Management Centre ‐ Level 2
• Supervision by trained but non‐medical staff
• May bring prescribed medica&ons
• Loca&ons
– OOawa 613.241.1525
– Cornwall 613.938.8506
– Kingston 613.549.6461 or toll free 1.888.795.6688

28. Substance Use and Concurrent Disorders
Program Assessment and Stabiliza&on Unit
• Within SUCD program have one of three residen&al
withdrawal management level 3 centres according
to CONNEX
• 24/7 medical/psychiatric monitored detoxifica&on
• ASU ROMHC 12 beds (CAMH 18 beds, Humber
Regional Hospital 4 beds) TOTAL 34 BEDS
FOR ALL OF ONTARIO

29. Substance Use and Concurrent Disorders
Program Assessment and Stabiliza&on Unit
• Medical detoxifica&on with
– Buprenorphine/Naloxone
– Methadone
– Clonidine, Diazepam
• Detoxifica&on followed by 28 day residen&al
treatment program

30. Opioid Subs&tu&on Therapy for
Opioid Dependency
• Long‐ac&ng medica&ons can be used for
detoxifica&on (inpa&ent or outpa&ent) or for
maintenance
– Methadone
– Buprenorphine/Naloxone (Suboxone)

31. Methadone
• Synthe&c opioid that relieves drug cravings and
withdrawal symptoms for 24 hr without inducing
seda&on or euphoria
• Methadone has been extensively researched for
safety and its effec&veness to
reduce morbidity and mortality in
intravenous heroin users.

32. Methadone cont’d
• Regulated, physician requires a
methadone exemp&on
• Requirements of observed dosing, limits on ini&al
dosing, weekly urine screens

33. Youth and Methadone
• Pa&ents under 18 years of age may be considered
for MMT, however abs&nence based treatment
and/or opioid subs&tu&on tapering should also be
considered for adolescents, par&cularly those with
a shorter dura&on of opioid dependence

34. Youth and Methadone cont’d
• The MMT physician should ensure that there has
been a discussion with the adolescent (and other
family members where possible) about poten&al
issues with methadone including side effects, risks
and difficulty of tapering off.
Methadone Maintenance Treatment Program Standards and Clinical Guidelines 4th Edi&on
February 2011

35. Availability of Methadone
Maintenance Services
• Ontario currently has 37 000 people receiving
methadone
• Several days to 2 week wait to be ini&ated onto
methadone currently in OOawa
• Covered by for those with Ontario Drug Benefits or
a private drug plan, otherwise cost is $6 per day

36. Buprenorphine/Naloxone
• Is a par&al opioid agonist
• Approved in Canada in November 2007
• Tablet taken sublingually under supervision at a
pharmacy for at least the first 2 months

37. Buprenorphine/Naloxone cont’d
• More rapid &tra&on to stabiliza&on than
methadone
• May be easier to taper off this medica&on
than methadone
• Risk of precipitated withdrawal if taken
when not in significant withdrawal

38. Other Treatment Resources for Youth
• Rideauwood
• Dave Smith Youth Treatment Centre
(residen&al treatment program ages 13‐21)
• Connex Ontario Health Services Informa&on
• Youth Services Bureau

39. Treatment Outcomes for Youth
• High rate of treatment dropout is greater than
that seen in adults and is likely related to the
adolescents’ typically low mo&va&on for treatment
and the absence of perceiving their substance use
as a problem
• Adolescents most commonly report a social
situa&on or peer influence such as socializing with
pretreatment friends as the context for ini&al relapse

40. Post‐treatment factors
• Par&cipa&on in alercare treatment
• Peer/parental social support
• Prosocial ac&vi&es
• Post‐treatment factors have been found to be the
most important determinant of clinical outcomes

41. References
• Methadone Maintenance Treatment Program Standards and
Clinical Guidelines, 4th edi&on February 2011 CPSO
• Buprenorphine/Naloxone for Opioid Dependence: Clinical
Prac&ce Guideline 2011 (CAMH)
• Paglia‐Boak, A, Mann, RE, Adlaf, EM (2011). Drug use among
Ontario students,1977‐2011: OSDUHS highlights. (CAMH
Research Document Series No. 32). Toronto, ON: Centre for
Addic&on and Mental Health.
• NIDA Na&onal Ins&tute on Drug Abuse

42. References
• Lowinson & Ruiz’s Substance Abuse: A Comprehensive
Textbook Filh Edi&on Chapter 57 Adolescent Substance
Abuse R. Milin and S. Walker. Editors Pedro Ruiz &Eric Strain.
LippincoO Williams & Wilkins, Philadelphia, PA, 2011
• Substance Abuse: A Comprehensive Textbook 4th Ed.
Lewinson et al. 2005
• Principles of Addic&on Medicine 4th ed.,
American Society of Addic&on Medicine. 2009

43. Websites
• www.theroyal.ca
• www.connexontario.ca
• www.davesmithcentre.org
• www.rideauwood.org
• www.cahm.net
• www.asam.org
• www.nida.nhi.gov