Saturday, September 28, 2013

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

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