Monday, September 30, 2013

Grouse Hunting with Gilbert

After overnighting at the Pemberton Valley Lodge we picked up breakfast at the Macdonalds.  Gilbert gets excited just seeing the double gold arches. He had a plain sausage paddy which I broke up for him. Of course he was finished his in time to have some of my sausage mc muffin.  He's likes being included. 

It was supposed to be deer hunting with Gilbert but all we saw today were does. No bucks.  Two lovely sets of mother and young deer.  

Gilbert has great eyes and watched the deer intently.  He sees the grouse in the distance as I  do.  I shot four today with the Bolito 20 gauge.

It was raining mostly. Still great views.  We had a lovely hike and stalk and waited some in the bush.  The grouse were all along side the road and came out at noon when the sun came out for a while.  

I'm just real happy Gilbert finds the birds when I shoot them and holds them down till I get there. I found out something I didn't care to know. He likes partridge poop.  Dogs are disgusting but man's best friend.  

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Exit Ghost
Exit Ghost by Phillip Roth is pure genius.
It is reminiscent of Hemingway's Old Man and the Sea,  a bit like Jack Nickelson in "All About Smit". The protagonist is a 71 year old writer who has been in the Berkshires for 11 years then comes back into New York where he meets his past and his present. He is coming to terms with aging, the death and decline of friends and the young.  
Naturally, there is a young woman but there's also an old woman who was a young woman from his past. There's marvellous architecture in the novel and the use of language in complexity and simplicity is astonishingly gifted, skillful and talented.
I read Phillip Roth years ago. I'd liked him then but don't remember the novel I read and didn't go onto read any more.  I read all of Singer's short stories. I read all of Sommerset Maugham, Doystoyevski and recently Michael Crighton. But I read just one Phillip Roth till Exit Ghost.  I thought Phillip Roth, an elitist academic intellectual with a potty mouth.  He's all of that but so much more.  He's Hardy and Lawrence and Kierkegaard.
I'd thought Phillip Roth's writing very clever and New York, an urban Jew.  At the time I liked urban Jews and New York writers.  I think I saw all of Woody Allen's movies and still think Leonard Cohen, Canada's greatest poet.  Joni Mitchell is a better song writer by far and Gordon Lightfoot is more Canadian.  I loved Bob Dylan and Paul Simon.  
it's just that I decided I wanted to read other Americans from other parts of the country. I'm still reading Carl Hiiansen. I've loved all of Walker Percy, especially, Lost in the Cosmos. Falkner is so different from Fitzgerald. Then there's California too.
Truly I'm more likely to read a thriller these days.  I guess Exit Ghost is that as well. It's dialogue is spotless.  Phillip Roth excels in characterization. His discussions  are definitely New Yorker.  I love his sophisticated wit.  But reading Exit Ghost I was moved mostly by his sensitivity.
It's a mature book.  Like Old Man and the Sea is so much more than For Whom the Bell Tolls even though the latter was my favourite of Hemmingway's until Old Man.  Phillip Roth is a precise writer. There's no waste.  Each word and phrase have relevance to everything.  It's like watching a magician though.  I never knew where the rabbit was coming from or when the pigeon was going.  There were simply that many ribbons up his sleeve in Exit Ghost.  
And I'm older. So I understood so much of this book, this man's inner workings.  I loved too that the book dealt with the personal life and the life of fiction, how the two are truly  'separate but parallel.  Today we judge art so much on the basis of the personal life of the artist.
I thought of 'Spanker Johnson", my favourite historian.  Modern Times,  the Intellectuals.  Then it turns out this family man has a mistress who says he liked to be spanked.  I wonder now  how that influenced his writing of Churchill.
So who this man is in Exit Ghost is only in the imagination of Phillip Roth, but it feels so alive that I feel it must be Phillip Roth,  though it couldn't be, could it?
It's the most amazingly intellectual, emotional and frankly spiritual novel. I  think anyone over 60 should read it.  You don't have to be a Jew.  It's an everyman book.  I'm not sure the young could appreciate the depth of discovery that come with years.  I would like to know what a woman thought of it too.
Exit Ghost is very special.   Thank you Phillip Roth.

Sunday, September 29, 2013

Pemberton Valley

Pemberton Valley Lodge remains a luxury dog friendly hotel with swimming pool and hot tub. I've been coming here since it opened. Pemberton was the first place I hunted deer in BC back in 1986-87.  I tented a lot in early years along the Hurley River. I stayed in the very basic Pemberton Hotel a few times in colder months but once the lodge opened I've become an autumn regular.  It's Gilbert's third year too.
We drove up in the dark and headed right out to the backwood. Lots of does on the road but the only buck was running away from me on the road and when I stopped the truck he sped off into the woods.  It's been raining heavy so no grouse out on the roads. I've not been hiking much which is rather lazy of me.  Even now I'm thinking of skipping the evening hunt, getting to bed early so I'll be able to get up early again for the morning hunt. I always love morning hunts because I have all day to deal with any game I shoot.  I don't like field dressing deer in the dark with a flashlight and that's what it's ended up with.  I also don't like shooting bear at night nearly as much as the morning.
There's a hot tub and pool here and great television in this room.  Order in Chinese.  Gilbert's had some time running around in the woods.  It's going to be hard to get up after I go for the hot tub. I've got some paper work along too so can easily justify skipping the night hunt.  That's the only downsize about the Pemberton Valley Lodge. Once I get here I don't want to leave.
I stopped at the Pemberton General Store and bought another cowboy shirt.  I love that store.  Every type of clothing for outdoors and all great brands.  I even got birkenstock alpros, the little rain clogs.  I've been happy with my hiking boots with orthotics but only had my leather canoe shoes along to change into. With this rain and the size of puddles these will work a whole lot better and pass as shoes.  Up by Gold Bridge there was snow in the woods and at the Pemberton General Store they already had a great selection of flannel shirts.
Of course I had to stop in at the Spud Valley Sporting Goods Ltd (  Today I just picked up a couple of the new combination style trigger locks. I've lost the keys to my other trigger locks so like these. Even while I was there another hunter came in looking for a tool to get his trigger lock off, having forgotten his key.  The combination locks are the trick so long as you don't forget the combination.  One time I was there, Brad's wife was near due and now they've another child.  Brad's started doing more fishing guiding under the business name "Pemberton Fishfinder".  (  Can't think of a better guy to go fishing with or have as a guide.  He told me they're doing ice fishing in December so I might do that. Haven't ice fished since I did it with my brother and father in Manitoba.  I've not been downhill skiing this last decade but still cross country ski so am thinking Pemberton would be the place to come as a break in winter. I've been horse back riding at Mount Curie but see there's a whole lot more horseback riding in the valley with more dude ranches and tourist attractions. The town is really catering to the back woods tourists with lots of backwoods biking on the trails.
Well I hope I get a deer in the morning and the sun comes out so Gilbert gets some grouse. With the medical conference last week it made for a long week, even though attending courses all day was different from my regular work. I had to work in the evenings and I'm now preparing this presentation so more scientific papers to read and writing to follow. I'll have to brush up on Power Point.
I've been listening to Exit Ghost, the truly brilliant audio novel by Phillip Roth.  As a New York city piece of intellectualism and extraordinary character and city descriptions its been as captivating auditorily as the Pemberton Valley has been visually.  Quite the juxtaposition of extremely different landscapes.  Coupled with that have been all these does showing up and driving poor Gilbert mad as I don't let him out to chase them and all he can do is stare.
Gilbert is a great companion even if he can't discuss the genius of Phillip Roth with me.
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Saturday, September 28, 2013

Youth Pill and Pot Abuse and SBIRT

SBIRT for youth - pills and pot
Primary care approaches to Screening, Brief Intervention and Referral to Treatment

Dr. Sharon Cirone MD CCFP(EM) ASAM (Cert)

Presentation given at Canadian Society of Addiction Medicine 2013 - Vancouver

This was a superb presentation that was very useful from a clinical perspective.  It was challenging and encouraged more active consideration of use of tools and organized thinking in the office.  Well researched, extremely well presented, and very informative and obviously coming from a lot of thought and experience. These are my rough notes which I hope will give some idea of the depth and breadth of material.

Youth Alcohol and Substance Abuse
greater than 50% past year
greater 30 % use illicit drugs
-22% marijuana

Harms of Youth Alcohol and Substance Abuse
-Impact on
-academic achievement
Sexuality, family, mental health

Alot of Concurrent Mental Health Disorder

Teen Age Brain Development and Vulnerability to Drug Use
-the later the youth puts off substance abuse the less likely the child will go onto to develop addiction in adult hood
-teen age brain more developped in ‘risk taking’ than ‘consequence consideration’ given the evolutionary development - to move out of home and into wild

The Harm of Youth Cannabis Use
-increasing presentations of cannabis induced psychosis
-exploring the link
-increased access with new legislation

“I’m a consultant to a hospital youth unit and at least once a month see cannabis induced psychosis”

Access to Prescription Opioids
-nomedical use of opiods by youth
  • youth start by accessing opioids in home cabinets

SBIRT -Calling All Youth - Raise the Subject!  Develop a specific approach! Support a youth friendly environment!

Primary Care
-while you are here, can I ask you few questions?
-how is school/work going
-how are things at home
-have you ever had alcohol to drink
-have you ever smoked marijuana or hash
-have you ever used pills or other drugs to get high
-have you ever driven in the car of a driver who had used alcohol or drugs?
What next?  SBIRT

Universal Screening
Brief Intervention
Referral to Treatment

This is for all 12 and up youth - ask all , no matter what they present with

Primary care offers a “teachable moment in a confidential setting”

Collaborative interventions are congruent with adolescent development 
-motivational interviewing is - collaborative - youth have skills to build on 

Brief Interventions with Youth Work

Decrease alcohol and substance us - Breslin research SBIRT in Pediatrics

Screening CRAFFT

Have you ever ridden in a CAR drivine by someone ‘high’ or 
Do you ever use alcohol to RELAX

Making Screening Easier
-Pre printed questioniones in the waiting room or handed out
-put CRAFT on your desktop to ask

-if adolescent says they’ve not used - praise and say how good they’re doing - hope you keep it up!
-if low risk -ask more questions -advise of brain development effects -  some praise with ‘lets talk about low risk drinking guidelines 
CASE PRESENTATION of low risk 15 year old brought in by mother for stealing money from her wallet for once a week marijuana use ‘he’s on drugs’ 
“if you tell me you’re dealing drugs I’m not going to report this however is you are using your seven year old sister with you to deal crack I’m going to have to disclose - set limits of confidentiality”

Affirm - I appreciate you have really considered this and are making some smart decisions regarding marijuana (eg not carrying it to school, not driving with it, etc, whatever positive you’ve heard)
Advice “As a physician, for your health sake, I strongly advise you against use of marijuana”
Open Ended Questions - we both know that only you can decide about how often and how much you smoke marijuana - what do you thihnk is best. 

What if things are more complicated? Moderate or High Risk Use

Moderate Risk - brief Motivational Intervention -and/or referral
High risk - Refer

Use with Risk - Assess
-can you tell me more  about your use
how often
has it caused any problems
have you ever tried to cut down or quit
Do you think you wnat to change anything

Affirm - give positive feedback on healthy decisions

Risk/Confidence assessment
On scale of 1 to 10 how interested are you in changing
On scale of 1 to 10 how confident are you in your ability to risk

Advice - abstience challenge, discuss harm reduction, provide psychoeducation

Assist - Motivational Interviewing, Weigh Pros and Cons, Discuss and write down action plan
Arrange - provide hand out , web based resources, discuss/make referrals

Video used to show brief interventions for a primary care clinician to use with a high risk youth who has reported high risk in context of presenting premenstrual pain and admitting using percocets for the pain
-primary care physician and actor

Decisional Balance Tool
  1. Things I like about....
  2. Things I don’t like about

Send patient home with homework

Referral to Treatment
-further assessment - youth community alcohol and substance use counselling services
-addiction medicine specialists
-mental health providers

Outpatient counselling
Day Treatment
Residential Treatment
Inpatient medical treatment

Take home message

Physicians need to ask
Future direction - we need alot more research and implementation of more SBIRT models
Physicians need to especially ask adolescents about marijuana

I care about you
I am concerned about you
I will be here for you
-Dr. Knight

Choosing Opiate Agonist Treatment

Choosing opioid agonist treatment
Dr. Meldon Kahan
Dr. Maya Nader
Dr. Anita Srivastava

Excellent presentation by three clinicians at the Canadian Society of Addiction Medicine annual meeting in Vancouver, 2013
These are my rough notes which hopefully give an idea of what was a very well presented, researched and clinically useful talk

Learning objections
initiation of opioid agonist treatment
 recent evidence regarding efficacy and side effects of buprenophine versus methadone

Opioid Agonist Treatment - OAT
-bruprenorphine USA 1980
-approved in Canada 2008

History of methadone
synthesized in germany in 1941
first methadone maitenance program in the world founded in Vancouver in 1967

Potential considerations
efficacy, safety, weight gain, mental clouding, sedation, sexual function, pain, withdrawal

Methadone more likely to retain patients than buprenorphine
With fixed medium dosing - buprenorphine less likely to suppress heroin desire

questions raised by cochrane review
-retention - was induction to buprenorphine too slow, etc

Stepped care approach
-Kakko 2007
Only 46% who started buprenorphine stayed and rest switched to MMT 
-treatment retention and urine screens and problems good with this group

Safety concerns
 buprenorphine considered safe
Bell 2009 , australia

QT intervals - evidence for prolonged QT - at higher dosages 200 to 300

Safety - Benzos
risk of overdose increased with any opiates
when benzo used with methadone or buprenorphine - methadone did poorer on benzo - Lintzeris et al 2007

Opioids are a risk factor for fractures in the elderly and it’s dose related

Diversion - patients who use methadone nonmedically have higher hospitalizations rates, greater icu, poorer outcomes

Patient preference
-Summit Trial , Pinto et al 2010
patients preferred methadone 2:1
-subset wouldn’t go on methadone
main reason for choosing buprenorphine
-ease of detoxification
  • more clear headed

Withdrawal severity may be less intense with buprenorphine - gowling et al, cochrane review 2009

At end of day similar relapse rates during withdrawal whether patient was on buprenorphine or methadone

-Neuman, 2013 - equally reduced in methadone and buprenorphine
-suggested alot of pain related to addiction

Adolescent Heroin Users
-better treatment retention with methadone than buprenorphine
-better treatment retention with long term buprenorphine treatemnt versus detox or abstinence (bell, 2006;woody208,)

Weight Gain
-perception of greater weight gain with MMT
-non dose related increase in first 2 years - but when compared to general populations methadone patients less
-no different in weight gain between methadone and buprenorphine

review of patient blogs - mixed response

Mental Alertness/sedation
-both methadone and buprenorphine appear to affect mental alertness and sedation 
-up to 100 mg no difference - but greater than 100 mg more with methadone-winstock 2009

Increased risk of traffic accidents in both patients on MMT and BMT
Bup pts performed somewhat better on psychomotor tasks than methadone
No on road testing done 

-double blind controlled trial (n=150)  - showed improvement in mood on beck in all with no improvement of one over the other drug

Quality of Life

Beneficial effects for both
Early onset of benefits with Methadone versus Buprenorphine but both good

Sexual Function

MMT patients have more erectile dysfunction and lower testosterone levels than buprenorphine

Side Effects
-Summit Trial
greater proportion of MMT complained of sweating, seadation and constipation than buprenorphine

Programmatic differences
-contigency management differences
-patient randomized to buprenorphine in one post jail study - more flexible environment for buprenorphine versus MMT - resulted in better retention and follow up

Soft Factors
-factors other than intrinsic pharmacological 
-family/work obligations -strict MMT requirements associated with treatment to protect against overdose 
-lack of mobility 
-comorbities - tying care to family doctor - a diabetic have buprenorphine in office versus going to clinic
-patient receiving high oral opioid doses from one doctor only
-socially unstable, doesn’t follow up with appointments - methadone might have better retention rate

In states and france - buprenorphine can be prescribed by a family doctor in office versus the clinic based methadone

Buprenorphine has been used in patients who were iatrogenically addicted to opiates for pain management and they are more willing to take buprenorphine

Methadone approved in pregnancy
buprenorphine/naloxone is not
-consider methadone for women at high-risk or planning a pregnancy

-cost - buprenorphine more expensive than methadone

Opiates can reduce testosterone and testosterone replacement and viagra can help
Paitents who are on heroin usually have poor sexual function and the majority have improvement with methadone maintenance

A Call for Evidence Based Treatment (in Addiction)

A Call for Evidence Based Treatment

Dr. Bohdan Nosyk

-health economist with a research focus on substance abuse and infectious disease

Presented at the Canadian Society of Addiction Medicine Annual Meeting, Vancouver, BC 2013. These are my rough notes which only give a jist of the wealth of information presented. Dr. Nosyk has contributed to many papers and his slides were excellent often taking graphs from the research he’d published elsewhere. I hope that these notes though will direct someone to where they might find information they are looking for as well as give some idea of the depth and breadth and controversies in this area.

key recommendations
eliminate financial barriers
increase acces to office based
reduce reliance on detox treatment
evaluate integrate new technologies
increase surveillance, evaluation of quality of care

Background Epidemiology
US 2.3 million with opioid dependence 
75-125,000 injection drugs users; 200,000 people with prescription opioid dependence
Opioid overdose second leading cause of accidental death in US - surpassed only by MVA
In ontario deaths related to PO doubled

Treatment Options

Methadone still more effective and less costly than buprenorphine

Nosyk et al, Am J of Epidemiology 2009
Primary finding was that patients with multiple treatment tended over time to stay in treatment and morbidity and mortality
Tends to be a pattern of increasing length of time in treatment

Abstinence durations were longer folllowing sustatined treatemn versu incarceration.  Paitents with multiple abstience episodes tend to go onto abstinence

OST has been deemed highly cost effective if not cost saving
often the cost of tratemnt are more than offset by recuction in acquisitive crime and use of health resourcs realted to transmission of HIV or Hep C

Diacetylmorphine - NAOMI  - trial 
Nosyk et al, CMAJ 2012 
all the benefits were derived from the longer retentions and 85% , when they relapsed the crime went up and health went down

DAM cohorts - NAOMI cost-effectiveness
Nosyk et al CMAJ 2012

If you have ‘retention benefit’ to treatment you will be cost effective

Eliminating financial barriers to treatment
Canada - universal health care - medications covered to varying degrees - relaxing constraints on the availability, length of take-home doses could reduce costs to clients who pay for their own pharmacy services
Other benefits - increase access to clients in rural areas, allow patients who have demonstrated stability greater freedom to participate in family life and employment

Regulations in place to prevent diversion is the primary argument - ‘the argument is moot if it is only provided under direct observation in a pharmacy or clinic”
-given pharmacological properties, methadone is less subject to abuse and less desirable to other readily available opiates

Mortality due to methadone overdoses cited as another barrier - increases in overdose are largely from methadone prescriptions for pain,
Undue restrictions on prescribind medications counter production

Weekend training and methadone certification programs for GPs
Lower mainland, greater toronto - vast increases in access, indications of satisfied demand
but elsewhere - waiting lists from 2 weeks to 12 months , St. John 12 month, Montreal, 6 to 12 months, Manitoba 6-12 months, BC waitlists problems outside lower mainland

Availability of buprenorphine BP-NX and their inclusion in drug formularies - several provinces have allowed coverage under special authority
-good idea to allow as secondary option to Methadone

Opioid Detoxification
  • most people relapse after detoxification
  • alot of tapering and desire to taper
  • longer tapers have higher odds of success - 12 to 52 weeks versus 12 weeks)
  • 4x more likely to succeed
  • tapers taking more than a year 7x more likely

5% for week for tapering is clinical guideline

Best to decrease by stepped every 2 to 4 weeks

Extended vers Short term Buprenorphine - Naloxone for treatment of Opioid Addicted Youth
  • treatment was far better than taper

Mortality among regular or dependent users of heroin and other opioidsL a systematic review 
  • people are more likely to die outside of treatment by 2.8 factor
  • Degenhard - Drug Alcohol Dependence 2009- 
  • Mortality among clients of a state wide opioid pharmacotherapy program over 20 years  and lives saved

Analysis of OST outcomes in publicly funded clinicisn in Calirofornia 1991 to 2011
-total unique individuals 200,000 plus
-every time they reentered detox - likelihood of success decreased
-every contact with methadone maintenance program - tended to stay longer

Current emphasis on detoxification needs to be addressed
-clients desire unlikely to change
-practitioners should obtain and sign release showing they ahve been advised of risk

New developments
 Injectable morphine
injectable heroin

Buprenorphine Implants for Treatment of Opiod dependence
  • Rosenthal et AL, ADDICTION, 2013
  • - promising 

Naltrexone - was done in russia where methadone illegal
-high proportion of confirmed abstinence
-long acting antagonist - what do you do if your client in car accident with legitimate need for opiate

Need for data collection to improve quality of care

BC Pharmanet, Popdata BC - gold standard

6 patterns of dosing noted in research

-difficulty of giving buprenorphine and methadone in aboriginal communities

What the Future Holds for Addiction Medicine in Canada

What the future holds for addiction medicine in Canada

Sept. 28 ,2013

Meldon Kahan, MD
University of Toronto

Lecture given at the Canadian Society of Addiction Medicine annual meeting, Vancouver, BC 2013. These are my rough notes which I hope will be of some benefit indicating the depth and breadth of material. Excellent presentation by a very experienced clinician and superb communicator.  Cutting edge genius!

Why should physicians treat addiction?
  • broader addiction community - sees role of physicians as limitted for detox and medications

Why should physicians treat addicton
-Most addicted patients can’t attend formal treatment programs
-Patients often prefer to see their physicians
  • addiction programs often have long waiting lists, complex intake procedures
  • addiction programs don’t have the capacity to meet demand
  • MD’s have long term relationship with their paitent - quality of provider-patient relationship more important than actual techniques use - greater predictor of success
  • addiction is chronic relapsing illness
  • physicians can be involved in all phases, screening, treatment, relapse prevention
  • controlled trials have demonstrated that physician counselling is effective for addiction

Addiction counselling is not difficult for physicians and is similar for counsellingfor other chronic illness
-focus on immediate concrete behavioural change

genetic and physiological factors play a central role in precipitating and maintaining addiction, euphoric effects of drugs, tolerance, withdrawal
-medications for alcohol and opioid have been show to improving drinking and subtance use outcomes, decrease health care utilization, improve mobidity

-health care system has greater contact with addicted patient than the ‘addiction system’
addiction system can’t handle the large numbers

Treatment of Acute Withdrawal
-sympton triggered benzo for rx for alcohol withdrawa
-buprenorphine for opioid withdrawal
protocols prevent unnecessary hospital admission

-naltrexone, acaprosate, disulfiram, gabapentin, topramate, baclofen
have benefits in drinking

Opioid and other addictions
-great crisis of age is opiate addiction - primary role- reducing risk talking to colleagues about better patient selection and reducing risk of od

Where should Physicians treat Addictions

  • many work in methadone clinics and addiction treatment programs
  • we’re not reaching those other patients
  • medical or psychiatric illness
  • unstable living conditions

These patients are frequent attenders in ER and community care, and acute care
-don’t receive addiction care in these settings - remain at risk for addiction related harm
need and offten want tx 
  • on site
  • integrated

We need to practice where patients are
near hospitals
near teaching centres
provide consultations and follow up for emergency departmnts, hospitals, community clinics

Addiction Physicians as Teachers

Addiction is orphan medical discipline
their teacherss and mentors never role modelled addiction treatment - Sentinel Student Study
-they don’t know how
-never been taught clinical protocols
-when they see an addiction patient
--it’s not my responsibility
--I can’t help them, beyond treating complicatons
addiction MDs need to role modell, supervise practice, didactic treating
What physicians learn in med school/residency determinest their practice patterns

Addiction MDs as advocates and policy makers
-addiction treatment programs
-general hospitals and clinics
-public health

Many abstinence based treatment programs do not offer evidence based treatments
  • initiation of opioid agonist treatment

  • Case Study - patient was told by inpatient addiction physician that their abstinence based program doesn’t not have a philosophy of accepting buprenorphine patient  - no other medial specialty would accept their treatment being ‘forbidden’

Addiction policy in hospital
-many hospitals don’t have policy

case study of woman want ing to withdraw - given 5 mg diazepam - no evidence of CIWA use - prolonged qt -
Coroner inquest recommended that hospitals use symptom triggered benzodiazepine protocol
-large hospital has only one addiction physician

We have alot to offer
-addiction protocols are rapid, effective and simple

St. Joseph Health Centre - addiction medicine service - implemented hospital wide protocols for 
alcohol withdrawal
opiate management
-elective and selective students 
6 and 12 month clinical fellowship program
initial skepticism but now fully supported

Addiction Physicians and Public Health

The Opioid Crisis
-huge increase in opioid prescribing, in response to a massive marketting campaign
-led to dramatic increase in rates of addiction, overdose death and harms
-most serious medically -caused public health crisis of generation

Pharmaceutical company and his physician lobbyist promoted idea
  • opioid addiction rare in pain patients but truth is that it is common, serious and preventable
  • prescribing high dose to high risk patients puts them at risk for addiction and overdose
  • tapering opioids improves pain, and function and mood

compared to pain physicians , addiction physicians were very quiet
-call to action began with media, public, researchers, then later provincial governments and medical regulatory bodies

Addiction physician response
opioid guidelines
limits on high dose formulations
 defundint oxycontin

Coming Crisis
2014 Health Canada new regulations allow MDS to prescribe dried cannibis
this will harm patients and physicians
no evidence of benefit vs oral cannabinoids
Smoked cannabis not good

Addiction physician as advocate for marginalized patients
Sioux Lookout - 50,000 - prevalence of opioid addiction 50 to 80%
-suicide, overdose, crime, family break up
-attempts to introduce methadone failed
-few family physicians began prescribing buprenorphine
  • addiction physicians beng to fly in to prscribe buprenorphine as locums
  • provide telemedicine
  • provide clinical support through phone and email
  • advocate with NIHB, MOH, medical colleges re funding, licensing requirements, protocols

Over 400 people on buprenorphine
support of band leaders and comunity
local treatment programs have developed eg ceremonial, group induction onto buprenorphine
adapted protocols to rural community

aboriginal communities do not have access to safe inexpense and life saving treatments
-in most provinces only methadone mds can prescribe buprenorphine
-this would not be accepted for any other medical conditon

addiction physicains need to advocate with ministry, public, medical colleagues, funding and resources for addiction treatment,do front line work with underservice populations
  • we need to model ourselves on HIV doctors of 80s and 90s

Challenges for addiction medicine
-isolation and small numbers
some addiction doctors work alone
-powerless against the harmful policies of the institutions where they work
lack of standards in addction
-others specialties have consensus on how problems are managed and expect members to comply
-culture of passivity
-other groups fill the void

Younger physicians
-evidence based
-fierce, fearless and relentless
assumer responsibility
-health care colleagues
-the public

Hepatitis C in Addiction

Hepatitis C in Addiction

Sept 28, 2013

Mark Hull MHSc FRCPC

Lecture given at the Canadian Society of Addiction Medicine, Vancouver, 2013
My poor rough notes just give a slice of the wealth of information presented by this cutting edge researcher, clinician and remarkably fine communicator. I trust this will help someone appreciate the depth and breadth of information available and the extraordinary work and advances being made.  

Hepatitis C Overview

HCV is a RNA virus
single strang Rna 3000 amino acid
North Amer - 1 a and 1 b dominant straints

Overlapping Global HCV and HIV
  • 8 million co infection
  • 33 mill HIV
  • 170 million Hep C

BC Chronic HCV rates
  • gradual decrease since 2002
  • increasing number of women
  • originally male
  • baby boomers with increased elderly

High Prevalance of HCV among PWID Worldwide
Injection drug users in canada make up 60% of HCV

VIDUS Youth   
CEDAR Youth/youth/young adults
Miller C CAn J. Public Health 2005
Spittal P BMC Public Health 2012

Risk for acquiring HCV rises dramatically after 2 years of IV drugs

Harm Reduction and HCV
-number of syringes - associated with decrease in HCV - free needle programs

Harm Reduction and HCV
effect of opiate subtitution treatment on HCV incident
-80% reduction in risk of HepC with OAT
Turn, K et al Addiction 2011

HCV Surveillance - Corrections Canada
Seroprevalence people entering jail fairly high compared to general population but very flat over years
 -about 30% - higher than community
-jail amplifier - New infections acquired in jail
-new infections with tattooing and Intravenous drug use

HCV prevalence by birth cohort in USA
-prevalence in baby boomer 5x higher than others 
-amstrong , G An. Int Med 2010
-most don’t know - may have got young and may have been victim of poor blood transfusion, or very young , or other ways

HCV Natural History
-75 to 85% patient develop chronic infection
20% develop cirrhosis after 20 years

Estimated reduction in morbity by birth cohort
-recommending routine screening if baby boomer - birth 1945 to 1955

Ontario Burden of Infectious Disease Study 2010
-Hep C the most burdensom infectious disease - loss of life and disability - HIV far less

Mortality in Canadian HIV/HCV Co Infection Cohort Study
-rate of death due to liver disease extremely high
-escallates liver disease
-Klein, M

Baseline Assessment
-All PWID (Persons with Injection Drug Use) should be screened for HCV 
-HCV antibody
-if negative, re screen every 6 months if still at risk
-if HCV Antibody positive
--HCV RNA PCR/genotype
--vacinate for Hepatitis A, B if non-immune
-pneumoccocal vacine
-alcohol cessation treatment

Staging of Liver Disease
-all patients should undergo staging of liver disease - cirrhosis - (clinical, laboratory, radiography)
Use of non invasive techniques - fibroscan (transient elastography 
alternative to Biopsy
Stebbing, J et al, J Clin Gastro 2010
biopsy is still used occasional

Evaluation of HCV treatment
Absolute contraindication to treatment
Strong contraindication
  • active autoimmune
  • hepatic decompensation
Relative contraindication
-major depression
-major psychosis
-renal failure

Ideal study - Peg IFN alfa -2a vs Peg IFN alfa-2b 

Serious side effects
 -Neuropsychiatric symptons
20-30 % severe depression

Benefits of successful treatment
  • Van der mer, Jama 2012
  • all-cause mortality reduce- increases long term survival, regeneration of liver

Pegylated Interferon and ribavirine for genotype 2/3
24 weeks if RVR
48 week

Boceprevir - SPRINT2 overal SVR Rates - doubling of response
Telaprevir - 75% cure rate - revolutionary over last 2 years

These drugs also have this effect with those who have relapsed after previous response

There is a very minor subgroup of non responders that are still a tricky problem but hopefully will respond to new drugs.

Now responses to 6 month of treatment excellent

Integrate Models of Care
-Community based multidisciplinary team - grebel, Eur J Gastroenterology Hep

HIV treatment as prevention BC
Patients currently on HAART

HIV engagement in care
HCV Engagement in CAre 

Decreased mortality and morbidity
decrease sero prevalence
Hepatalogy - Martin, n et al 2013 -

PWID have high burden of HCV disease and should be screened routinely 
Treatment uptake is low among PWID
Use of HCV DAA’s have substantially altered treatentn paradigms and success rates will continue to improve
Treatment as PRevention models suggest populations level benefits to improved therapy 

Q&A Periods

1)System failing - British Columbia - restriction on treatment meaning that our patients aren’t being treated.
Reduces morbidity and mortality for individual but also stops spread at population level
Pharmacare is recognising fibroscan - it’s as acceptable as biopsy
Cost effectiveness of dx and treatment to health care system

  1. Viremia - clear and negative tests - might have negative test this month but negative 6 months - want 4 negative tests over 3 years q 6 months
  2. Fatty liver - first nations - seems almost all my patients have - aboriginal care giver gave - results in poorer response to treatment, mortality worsened, 
some treatment programs in us are treating metabolic syndrome as well as liver
4) lady with seizure disorder, socially unstable, on methadone, continues to inject cocaine and heroin - should I treat hep c early - or should I just continue to work at treatment of her addiction - if you waited a year unstable - and stabilize for this year then treat -