Category "Drugs"


‘Unintended consequences’: Why taking patients off opioids quickly can be dangerous – National

by BBG Hub

Whenever he runs out of his pills, Tony hops in his car or goes for a walk and buys Percocet off the street.

Sometimes it’s once a week, other times it’s every few days.

The Toronto-area resident, whose last name is being withheld to protect his identity, says his doctor refused to fill his Percocet prescription in July after he had been on the pain pills for the past five years.

Tony says his doctor worried he had developed a dependency on the drug after he asked for his prescription to refill every 26 days instead of 28. He now gets Percocet solely from dealers.

READ MORE: Doctor-prescribed addiction — How these Canadians got hooked on opioids

A car crash followed by subsequent operations has left Tony in chronic pain, and the 63-year-old says he needs the pills to function. He does not want to be addicted and wants to be tapered off the pills safely — not left out to dry.

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Tony feels like the way he was cut off left him with no choice but to buy street drugs. He is worried about withdrawal and has raised his concerns with his doctor.

“[It’s] tough enough for a healthy person, but I’ve had four massive heart attacks,” he says. “I’m pretty sure withdrawal could be dangerous for me.”

What are the new opioid-prescribing guidelines?

Tony’s case could be an example of the new opioid guidelines gone wrong.

In 2017, the opioid crisis sparked the introduction of new Canadian opioid-prescribing guidelines, which include information on tapering. In the U.S., new guidelines have also changed prescribing habits, causing health-care providers to stop prescribing the painkillers as liberally as they had in the past or, sometimes, altogether.

How each federal party plans to deal with the opioid crisis

How each federal party plans to deal with the opioid crisis

The “crackdown” is intended to reduce opioid use as addiction and overdose rates have climbed in recent years.

But these new opioid guidelines are frequently misinterpreted, experts say, resulting in high-dose opioid users being tapered off too quickly. For people who have come to rely on these drugs, a sudden change in dosage not only causes symptoms of withdrawal but can also be dangerous.

READ MORE: Nearly 1,500 died from opioid overdoses in Ontario last year, up from 2017

“Everybody [doctors] has jumped on this bandwagon, and they’ve indiscriminately, in many cases, cut people off suddenly without any thought about what the unintended consequences are going to be,” says Dr. Peter Selby, chief of medicine with the psychiatry division at the Centre for Addictions and Mental Health.

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For those who have developed a dependency, the risks are even greater.

“You can’t just cut people off because … simply detoxing people off opioids puts them at high risk for overdose deaths and puts them at high risk for relapse,” Selby says.

“We have seen these unintended consequences both south of the border … and occurring here as well.”

READ MORE: University of Calgary, AHS launch course to help doctors taper patients off opioids

Selby says that while there are certain circumstances in which it is ethical for a doctor to refuse to refill opioid prescriptions, a medical assessment must be conducted and the rationale documented.

If a patient meets the criteria for an opioid use disorder, Selby says, the doctor needs to assess the risk of harm and make appropriate arrangements if they have decided to not give the prescription.

For people with an opioid addiction, opioid agonist therapies using methadone or buprenorphine are recommended treatments.

It’s not wise to ever leave a patient without support.

Why are doctors misinterpreting guidelines?

The Canadian chronic non-cancer pain guidelines suggest that for patients beginning opioid therapy, doses should be restricted to under 90 milligrams of morphine or its equivalent daily, with the maximum single dose under 50 milligrams.

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Patients who are already on a high dose of opioids, which is considered more than 90 milligrams of morphine per day or its equivalent, “should be encouraged to embark on a gradual dose taper and [have] multidisciplinary support offered where available to those who experience challenges,” the guidelines state.

Rising opioid overdose deaths in Calgary coincide with end of supervised consumption site review: report

Rising opioid overdose deaths in Calgary coincide with end of supervised consumption site review: report

Dr. David Juurlink, head of the clinical pharmacology and toxicology division at Sunnybrook Health Sciences Centre and a professor at the University of Toronto, says many physicians interpret these guidelines to mean high-dose users need to be cut down to 90 milligrams — and fast.

For long-term users of opioids, their doses have likely been steadily upped for years, and they may be on incredibly high doses, Juurlink says.

“If you’re on 400 milligrams of morphine today, and I, as a physician, misinterpret the guideline to say you should be cut back to 90 milligrams a day and just do that abruptly, you run the risk of getting extremely sick,” Juurlink explains.

READ MORE: It’s been called a national crisis, so why isn’t opioid abuse an election discussion?

The potential harms of tapering are directly related to how quickly the tapering takes place.

“When the dose is tapered too rapidly, we destabilize patients whose bodies have become accustomed to high doses of these drugs,” he says.

This puts patients into opioid withdrawal. Symptoms of withdrawal include nausea, vomiting, drowsiness, confusion, depression, sweating and muscle aches.

“Opioid withdrawal in some people manifests as a flare in pain,” Juurlink says.

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Toronto physician says Purdue Pharma lied about opioid safety

Toronto physician says Purdue Pharma lied about opioid safety

“And so people will, quite understandably, interpret that as the loss of the beneficial therapy when, in fact, if it was beneficial, they wouldn’t have escalated to those high doses in the first place.

“What they’re going through is withdrawal.”

READ MORE: For more than 5 years he was addicted to opioids. This is one man’s story of recovery

According to Lena Salach and Loren Regier, co-directors of academic detailing at the Centre for Effective Practice (CEP), there are challenges physicians face around prescribing opioids. CEP is an independent organization that supports health-care workers and provides guidance on opioid tapering.

Salach and Regier say doctors are more cautious around prescribing opioids and point to a qualitative study on family physicians and their role in managing the opioid crisis.

The research found that doctors “experience a tension adhering to guidelines while attempting to effectively manage patient symptoms, which creates a feeling of being caught in the middle of the opioid crisis.”

“This is why [we] provide family physicians with visits on managing opioid therapy for patients living with chronic non-cancer pain,” say Salach and Regier. “They help family physicians weigh the benefits and risks.”

How should people be tapered off opioids?

Juurlink says opioid tapering should happen at the “patient’s pace.”

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“I like to frame it as a marathon rather than a sprint; there’s no urgency to get people on lower doses,” he says.

READ MORE: ‘Manipulating physicians’ — How drug reps pitch your doc

The Canadian guidelines say a “gradual dose reduction of five to 10 per cent of the morphine equivalent dose every two to four weeks with frequent follow-up is a reasonable rate of opioid tapering.”

“Slower tapers are recommended for patients who are anxious about tapering, may be psychologically dependent on opioids, have co-morbid cardio-respiratory conditions or express a preference for a slow taper,” the guidelines state.

Juurlink says patients on high doses often fear tapering off the powerful pain meds because the process happens too quickly. If a patient has been a long-term user of opioids for many years, their dosage could be very high, meaning coming off the drugs may be harder.

Chronic pain patients struggling to access opioid medications in southern Alberta

Chronic pain patients struggling to access opioid medications in southern Alberta

Selby says that if a patient is cut off too quickly and is struggling with pain, they may be inclined to turn to opioids bought off the street.

“This kind of situation can leave people very desperate,” he says.

What about long-term users with chronic pain?

Some long-term users who experience chronic pain say the stigma around opioids has negatively affected their well-being.

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HELP_Alberta, an advocacy group for chronic pain sufferers in the province, says patients who use medications to manage day-to-day pain now have issues accessing opioids.

Chronic pain patients who say they do not abuse their opioids and are not addicted feel the barriers to access are unfair.

READ MORE: Big pharma pours millions into medical schools — here’s how it can impact education

“As they lose their medication, they lose their life in all kinds of ways,” Penny Kowalchuk, southern Alberta representative for HELP_Alberta, previously told Global News.

“What I’m seeing — it started with my family and now, especially as part of HELP_Alberta in southern Alberta — is a lot of patients that are being de-prescribed from their medications for no reason.”

Other health advocates have also argued opioids are important for people living with chronic pain and that tapering and de-prescribing efforts are hurting such patients.

But Juurlink doesn’t agree that opioids are a necessary part of most people’s pain treatment.

He says there’s very little data to support that opioids are effective at treating long-term pain. What’s more, he argues, the harms of opioids often outweigh possible benefits.

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Big pharma paying big bucks to doctors, hospitals

Big pharma paying big bucks to doctors, hospitals

“The pills shouldn’t be abruptly taken away, but there’s still merit in a discussion about gradual, patient-centred tapering to improve all the side effects [of opioids],” Juurlink says.

Health-care providers need to put their patients’ well-being first, Selby says, and not taper them off opioids in a way that causes harm. It’s also important that patients have a strong support system and access to resources.

If someone has an underlying pain disorder that isn’t treated properly, he adds, they will seek out whatever medication they need to ease that pain.

“That doesn’t mean that they are addicted or bad people, it just means that the system has failed them,” Selby says.

Whenever Tony buys pills, it’s a gamble: he doesn’t know if they are tainted or laced with another substance, like fentanyl.

Still, street drugs feel like his only choice.

“I don’t know how long I’m going to live for,” he says. “All I want to be able to do is get by, and this helps me function.”

— With files from Danica Ferris  

[email protected]

© 2019 Global News, a division of Corus Entertainment Inc.

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Ketamine for depression divides experts: ‘I’ve seen these drugs come and go’ – National

by BBG Hub

Depression can be completely debilitating, making it difficult to do even the simplest tasks — like getting out of bed or brushing one’s teeth.

Unfortunately, it’s very common. According to the World Health Organization, more than 300 million people around the world are currently suffering from depression.

Now, there may be a new way to treat the illness: ketamine.

READ MORE: ‘Emotionally draining’: The effect depression has on tasks like brushing hair, showering

Ketamine is commonly used as an anesthetic and painkiller in animal and human surgery. It also rose to popularity as a party drug in the 1990s. Now, it’s being lauded as a possible cure for treatment-resistant depression.

“We have a large sub population in our country with depression who can’t work… they just can’t break this vicious cycle,” said Dr. Roger McIntyre, president of the Canadian Rapid Treatment Centre of Excellence (CRTCE).

McIntyre hopes ketamine can break that cycle.

The CRTCE, which administers rapid onset treatments for depression in the form of ketamine injections, is the first of its kind in Canada.

How does the treatment work?

At the CRTCE, ketamine is delivered through intravenous infusion. According to the clinic’s website, “the protocol for administering ketamine is still being refined. Nonetheless… most individuals will receive four infusions (i.e. two infusions per week for two weeks).”

The cost of this treatment at the CRTCE is $3,000, and it is not paid for by the public health plan of Ontario (OHIP).

The process is overseen by a physician trained in anesthesia, as well as a nurse.

“The dose of ketamine by someone on the street… is about 10 times higher than the dose [you would be given] if you went to the hospital this afternoon for a procedure that required anesthesia,” said McIntyre. “The dose that we use to treat depression is about one-10th… of the dose used in anesthesia. So we’re using ‘sub-anesthetic doses.”

According to McIntyre, this does not mean the process is without safety concerns.

WATCH BELOW: ‘He likes to give hugs’: Man says emotional support alligator helps his depression

“[We] know it’s generally well received by patients, but it would be inaccurate to say that you don’t get any side effects,” said McIntyre. 

According to Centre for Addiction and Mental Health (CAMH), ketamine can produce “vivid dreams and a feeling that the mind is separated from the body.” This effect is known as “dissociation.”

The intensity of the effects depend on several factors, including: your age, your body weight, how much you take, how often you take it, how you take the drug and more.

“Some people do become addicted, and continue to use ketamine even when they plan not to or despite its negative effects,” as stated on the CAMH website.

Ketamine works faster than other treatments

If a patient presents with intense suicidal thoughts, ketamine may be a more effective short-term treatment than other antidepressant medication.

“Most antidepressants take approximately four, six or even eight weeks to work. That’s a long time,” said McIntyre. “If you’re suffering, ketamine can work within one day.”

Dr. David Gratzer, a psychiatrist at CAMH, is hopeful about the effects of ketamine on depression for this reason.

READ MORE: 8 signs your child may be going through depression

“We are looking for a way of providing more rapid relief of depression than one might ordinarily see with Prozac and [similar] drugs,” said Gratzer.

“The evidence is there but we have to take it with a grain of salt because it’s early days. That being said, we do seem to find evidence that it helps people very quickly, particularly people who have many thoughts of suicide.”

Ketamine is a last-ditch effort for those who have tried everything else

Depression is difficult to understand — even for medical professionals.

“As with most diseases in physical medicine and mental health, we have a sense of what’s involved but we don’t exactly know,” said Gratzer.

According to Gratzer, doctors do know that family history and certain traumatic life events are connected with a higher risk of depression.

“However, two people can be raised in the same household and eat the same foods and have a relatively similar childhood and one can get heart disease while the other doesn’t,” said Gratzer.

WATCH BELOW: Study links exposure to infection in the womb to increased risk of autism, depression

“Likewise, you can get [depression] and your sibling may not. So, while we do recognize there’s a strong genetic component… it’s not 100 per cent. There’s more going on.”

Because of the evasive nature of depression, finding a treatment that works can be difficult.

Once someone is diagnosed, they are usually prescribed one of or a combination of three kinds of treatment: exercise, talk therapy and medication. According to Gratzer, patients “do the best” when they do all three.

READ MORE: Is ASMR an effective way to treat anxiety and depression?

But, for some patients, none of these treatments work. And that’s where ketamine can be an exciting option.

“Ketamine is one of a handful of medications that is out of the box,” said Gratzer. 

To be eligible for treatment at the CRTCE, there are three criteria: you are over the age of 18, you are medically stable and you have had a minimum of two other treatments for your depression.

‘Early reports are good, but now we need to take it to the next step’

McIntyre admits that the full effects (positive and negative) of the drug are unknown.

An issue McIntyre and his team are paying close attention to is the impact ketamine can have on other organs, like the kidney or the bladder.

Another is whether ketamine can act as a gateway to other, more severe drug abuse, said McIntyre. 

The CRTCE website states that, “it is critical to understand that ketamine researchers are still exploring a multitude of ways that ketamine infusions impact the human brain. They are working towards understanding why this form of treatment works so quickly and effectively.”

Despite its positive impact thus far, Gratzer isn’t ready to call ketamine a “wonder drug” yet.

WATCH BELOW: 5 ways to help a friend with postpartum depression

“I’m optimistic, but I’ve got a few gray hairs, so I’ve seen these wonder drugs come and go,” he said.

“We need to take it to the next step… can we use it on more people safely? What sort of side effects do they get? Are the effects [on depression] we see with ketamine lasting?”

Gratzer is interested to see whether the effects of ketamine can remain beyond the days after it’s injected.

“It’s great that some people might see relief… if you’ve got a pain on your left hand, it’s great that you feel better with a Tylenol. But that tends to fade and maybe what you really have is a little infection of the skin and what you should really take is antibiotics,” said Gratzer. 

“I hope this is working out because it will be helpful, but I don’t really know and I don’t want to be too optimistic. Like a lot of private healthcare, the sales pitch may not be as good as the reality.”

If you or someone you know is in crisis and needs help, resources are available. In case of an emergency, please call 911 for immediate help.

The Canadian Association for Suicide Prevention, Depression Hurts and Kids Help Phone 1-800-668-6868 all offer ways of getting help if you, or someone you know, may be suffering from mental health issues.

[email protected]

© 2019 Global News, a division of Corus Entertainment Inc.

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