5/16/2017

1

Responding to the Opioid Crisis – With Evidence 2017 PAS CONFERENCE

6 May 2017

Dr. Janice Mann

The Opioid Crisis in Canada

The roots of what we now call the opioid crisis can be traced

back many years to the false promotion of opioid prescribing

as low-risk, non-addictive, effective treatments for moderate

pain.

Centre for Addiction and Mental Health, 2016

1

Opioids in Canada

In the past two decades:

• The use of and harms associated with opioids have

increased dramatically.

• The health and social impact of opioid use, including the

related harms of addiction, overdose and death on

individuals, families and communities is devastating.

2

Opioid Prescribing in Canada

Opioids are being prescribed too frequently,

at overly high doses and quantities,

for longer periods of time than medically necessary,

and in contexts that are not supported by evidence.

CAMH Prescription Opioid Policy Framework

3

Addressing the Opioid Crisis

• But ↓ Rx rates is only part of the solution

Also important:

• Opioid use disorder (addiction) treatment

• Harm reduction strategies

And underlying all of these is EVIDENCE

4

5/16/2017

2

6

By November 2017: Analyzing the international literature to identify best

practices and provide evidence-based recommendations, advice and

decision support tools that will inform and guide patients, clinicians and

policy-makers regarding pain management interventions (drug and non-

drug), and the treatment of opioid addiction.

7

Public Commitment

Regular Reporting to Health Canada

CADTH Priority

CADTH Opioid Working Group

Cross- functional team

Drug, Device, Knowledge Mobilization, Rapid Response,

Communication and Patient Engagement

8

Action Plan

Partnerships & Collaboration

Knowledge Mobilization

New CADTH Products

9

Partnership and Collaboration

Coalition for Safe and Effective Pain Management (“Upstream Coalition”)

Knowledge Mobilization

Others

• Report in Briefs

• Topic Teasers

• Conference abstracts

• Presentations

• Hospital News Articles

• CMAJ Quiz

• Social Media strategy

• Support pan-Canadian

collaboration of drug plan

managers

10

www.cadth.ca/opioids

www.cadth.ca/pain

New CADTH Evidence

Focused on:

• Non-opioid alternatives for pain management (drug, non-

drug: physical and psychological)

• Management of acute pain

• Other topics including treatment of addiction

Complete, underway or in planning:

• Rapid Response reports

• Environmental Scans

• Horizon Scans

• Optimal Use (under consideration – not yet started)

11

5/16/2017

3

New CADTH Products

12

Rapid Response

• Intranasal Naloxone

• Tapering, rotation or cross-over of opioids

• Sustained released methadone, injectable hydromorphone, and diacetylmorphine,

• Magnesium for chronic pain in adults

• Scoping – pharmacological, psychological & physical therapies for the management

of acute & chronic pain

Environmental Scan

• Opioid Formulations with Tamper Resistance or Abuse Deterrent Features

• Availability and access to non-pharmacological treatment of Pain in Canada

• Multidisciplinary pain clinics across Canada

Emerging Health Technology Bulletin

• Probuphine (buprenorphine implant) for opioid use disorder

• Vivitrol (naltrexone) for the treatment of opioid use disorder

• Scoping - New Pharmacological Alternatives to Opioids for Pain

Opioid Use Disorder

• Difficulty controlling use of opioids

• Cravings

• Withdrawal

• Tolerance

• Continue use instead of other activities

• Continue use despite harms to self and others

• Illicit or prescribed

• Also referred to as opioid dependence, opioid addiction

13

Treatment Options

• Methadone vs. Buprenorphine/Naloxone

• Alleviate withdrawal symptoms

• Reduce cravings

• Without a feeling of euphoria or a “high”

• Can be used first to manage withdrawal

• Then long-term to prevent relapse

14

Differences in Treatment Options

• Buprenorphine/Naloxone:

• No special exemption required to prescribe

• Sublingual tablet (rather than liquid)

• Lower abuse potential

• Lower risk of overdose

• Can be taken every other day

• Cost?

• Now available in generic form making cost lower

15

The Evidence

• Higher doses of either are more effective than lower doses

• Methadone – stayed in treatment longer

• Bup/Nal – less likely to use other opioids

• No differences in harms

• Costs slightly higher with bup/nal – but studies from before

generic was available and not Canadian

• Guideline recs: choice of treatment should be guided by

individual clinical circumstances and patient preferences

16

Methadone vs. Bup/Nal

Bottom-line:

• Compared to Methadone, Bup/Nal appears to be a safe,

effective, cost-effective option for treating opioid use

disorder

17

5/16/2017

4

Beyond Methadone and Bup/Nal

More evidence reviews on:

• Sustained release oral morphine

• Injectable hydromorphone

• Prescription diacetylmorphine

• Buprenorphine implant

• Naltrexone (Vivitrol)

18

Alternatives to Opioids for Pain

Examples of CADTH evidence:

• Topical NSAID

• TENS

• Magnesium

19

Treating Acute MSK Pain

• Most common treatments for acute MSK pain are:

• NSAIDs

• Acetaminophen

• Weaker opioid (i.e., codeine)

• Strong opioid (i.e, morphine, oxycodone)

• Harms associated with all

20

Topical NSAIDs

• Topical NSAIDs:

• Available Rx or OTC

• Many different types and formulations

• Bypass systemic absorption

• Directly deliver drug to the site of the injury

• But do topical NSAIDs work?

• Compared to placebo or no treatment

• Compared to opioids

21

Topical NSAIDs for Acute MSK Pain

Bottom-line:

• Compared to placebo:

• Topical NSAIDs reduce acute MSK pain

• Adverse events were rare (i.e., skin reaction)

• Compared to opioids:

• No evidence

22

Non-pharm Option for Chronic Pain

Home-based transcutaneous electrical nerve stimulation

(TENS)

• Electrodes placed on skin

• Area stimulated with low-voltage electricity

• Often used in health care settings with a health care

professional – but now readily available for home use

• Does home-based TENS work to treat chronic pain?

23

5/16/2017

5

The Evidence

• Limited evidence

• Mixed results for treating chronic pain

• No studies comparing home-based TENS to opioids or

other drug treatments

• Guidelines did not recommend TENS for

• OA of the knee

• Chronic neck pain

• Chronic low back pain

• Guidelines recommend purchase and use only if TENS

already proven effective in clinical setting

24

More Non-Pharm Options

• More CADTH reviews on non-pharm options at:

• www.cadth.ca/pain

• www.cadth.ca/opioids

• More CADTH reviews coming on:

• Chiropractic

• Physiotherapy

• Occupation Therapy

• Psychological

• Multidisciplinary/interprofessional approach

25

Magnesium for Chronic Pain or Migraine

• Magnesium:

• Impacts signal transduction

• Analgesic effect by blocking the NMDA receptor

• But does it work to treat chronic pain or migraine?

• Prophylaxis vs. treatment

• Route of administration: oral, iv, im, others

26

The Evidence

• Acute migraine: Mg vs. Placebo – 3 SRs + 1 guideline

• 1 study showing ↓ pain and ↓ need for rescue meds

• 1 study showing no difference

• 1 study showing benefits in migraine with aura subgroup

• 1 guideline did not recommend Mg for acute migraine

• Migraine Prophylaxis: Mg vs. Placebo – 1 RCT + 2

guidelines

• ↓ attacks but no ↓ in severity or days with migraine

• 2 guidelines recommended Mg for migraine prophylaxis

27

The Evidence

• Complex regional pain syndrome: Mg vs. Placebo – 2

RCTs

• 1 RCT showed no difference with IV mg

• 1 RCT showed benefit for some (not all) measures of

pain with IM Mg

• Refractory chronic low back pain: Mg vs. Placebo – 1

RCT

• IV mg followed by oral Mg improved pain

28

Questions?

JaniceM@cadth.ca

@JustSayIt_MD

KathleenK@cadth.ca

CADTH Liaison Officer for SK

29

5/16/2017

6