Opioid Use Disorder 1

Question 1

Opioid- and Stimulant-related Harms in Canada

Answer 1

30,843 apparent opioid toxicity deaths
(January 2016 – March 2022)

● A total of 1,883 apparent opioid toxicity deaths occurred so far in 2022
(January - March 2022)
○ Approximately 21 deaths per day

● Western Canada continues to be most impacted region in Canada since 2016
● Between January-March 2022, 90% of all accidental opioid toxicity deaths
occurred in BC, AB, or ON

● Males accounted for the majority of accidental apparent opioid toxicity deaths
(76% January - March 2022)
● Majority of deaths, both male and females, were among individuals aged 20 to
59 years
● 85% of accidental apparent opioid toxicity deaths involved fentanyl (January -
March 2022)
○ Of all accidental apparent opioid toxicity deaths so far in 2022, 81% involved opioids that were
only non-pharmaceutical

Question 2

Dual Public Health Crises

Answer 2

COVID-19 is worsening the ongoing and deadly public health crisis of opioid
overdoses
○ Increasingly toxic drug supply
○ Increased isolation, stress, anxiety
○ Changes in availability or accessibility of services for people who use drugs

Question 3

Hospitalizations related to substance use
Stratified to opioids - count per 100,000Opioid Use Disorder

Answer 3

Problematic pattern of opioid use leading to clinically significant impairment or
distress, as manifested by at least two of the designated criteria, occurring within
a 12-month period

Question 4

Opioid Use Disorder - Criteria (DSM 5)

Answer 4

Opioids are often taken in larger amounts or over a longer
period of time than intended
Important social, occupational, or recreational activities are
given up or reduced due to opioid use

Persistent desire or unsuccessful efforts to reduce or control
opioid use
Continued use despite persistent or recurrent social or
interpersonal problems caused or exacerbated by effects of opioids

Significant amount of time is spent in activities necessary to
obtain the opioid, use the opioid, or recover from its effects
Continued use despite knowledge of having persistent or
recurrent physical or psychological problem that is likely
caused or exacerbated by opioids

Craving, or a strong desire to use opioids
*Tolerance - defined as either of the following:
● A need for markedly increased amounts of opioids to
achieve intoxication or desired effect
● Markedly diminished effect with continued use of same
amount of an opioid
- as our receptors become essentially like desensitized to the substance, we need more and more and more to achieve that same initial pleasurable effect that we perhaps derived from the use in the first place.

Recurrent opioid use resulting in failure to fulfill major role obligations at work, school, or home
Recurrent use in situations in which it is physically hazardous
*Withdrawal - manifested as either of the following:
● Characteristic opioid withdrawal syndrome
● The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

Question 5

Opioid Use Disorder - Criteria (DSM 5) severity

Answer 5

Severity # of criteria
Mild 2-3 symptoms
Moderate 4-5 symptoms
Severe 6 or more symptoms

Of note, tolerance and withdrawal are not considered diagnostic criteria to have been met
for individuals who are taking opioids solely under appropriate medical supervision.

So tolerance and withdrawal are physiological responses that will occur regardless of misuse, our bodies will naturally develop a tolerance to a substance that we’re using over a prolonged period of time. And then in the absence of that substance because we have a physiologic dependence, we will experience withdrawal symptoms. So just because someone experiences tolerance and perhaps overtime needs higher doses, and just because someone described some withdrawal symptoms when they’ve gotten to, say a couple of days without their prescription. Those things in and of themselves do not constitute an opioid use disorder

patient buy-in and patient perception of the therapy choice is such an important consideration.

Question 6

Characteristics of opioids

Answer 6

Reinforcing effects
Pain relief (analgesia)
Euphoria
Warmth
Numbness
Relief of anxiety (anxiolytic)

Adverse effects
Constipation
Dry mouth
Hypogonadism
Weight gain: This is like more pervasive with some of the opioid agonist treatment than like opioids themselves, but that is a possible effect.
CNS/respiratory depression

Question 7

Characteristics of opioids

Answer 7

Tolerance:
● A loss of any effect after repeated use
○ Resulting in need for higher doses to get the desired equivalent effect
Dependence:
● Decrease or discontinuation of use results in unpleasant physical symptoms
(withdrawal symptoms)

Question 8

Withdrawal - cardinal symptoms

Answer 8

Rapid heart rate Upset stomach
Sweating Tremor
Restless Yawning
Dilated pupils Irritability
Aches (bone/joints) Anxiety
Runny eyes and nose Goosebumps

when people are in presenting with symptoms of withdrawal, it means they’ve gotten some time without a substance. And what that means is they’ve actually lost tolerance in that time. And people lose tolerance at different rates. A loss of tolerance puts people in a very dangerous situation. And the reason for that is because if I’m used to taking a certain amount every day and this helps me achieve the desired effect. And then I go a couple of days without using. And then when I have access to that opioid again, I use the same amount that I always do. My body is actually not conditioned to use that same amount anymore. And so it’s very likely that if I use the same amount that I’m always used to using, that I could essentially have a poisoning event or an overdose.

it can be very distressing to patients because withdrawal from opioids is not fatal as you can see from the symptoms that characterize it. But it’s extremely uncomfortable. And people will do pretty much anything they can to relieve the symptoms of withdrawal there’s a high risk of death because they will again use whatever they can to try to relieve those symptoms of withdrawal. there is a very high risk of death correlated with people who have experienced a loss of tolerance.

Question 9

Naloxone

Answer 9

● Opioid antagonist
○ In community settings, administered intramuscularly
● Rapidly reverses CNS and respiratory depression secondary to opioids
○ Typical onset within 2-3 minutes
● No safety concerns if administered in opioid naive patients
● No prescription or identification required; free of charge through Alberta’s
Take Home Naloxone program
● Nasal naloxone spray kits covered for patients with NIHB coverage
○ Current pilot program for nasal naloxone spray kits in AB

This is hard to come by one because it’s very expensive. It is now covered by non-insured health benefits for people who have treaty status.
It doesn’t act as quickly
The best-case is to just have as many doses as possible. Hopefully reverse that opioid overdose.

there’s really no safety concerns if we administer naloxone to someone who’s opioid naive or who is non-responsive for another medical reason. The main, I guess the primary concern is that we’re perhaps going down a pathway that’s not related to why they’re unresponsive, but it won’t cause additional harm.