Since graduating pharmacy school in 2009, I’ve noticed the problem of opiate addiction has had heavy media coverage in Nova Scotia. It feels like once a month we hear of yet another horrible story. Someone overdosed. Someone committed suicide because they couldn’t handle their addiction anymore. Someone is arrested because they are selling prescription narcotics on the streets. The problem is growing every week.
Recently, I took a course on opiate addiction and its treatment through the Centre for Addiction and Mental Health (CAMH). This course highlighted just how vast this problem is, not only in Nova Scotia, but across Canada. The coursework included the physiology of addiction, pharmacology of opiates in addiction and how to treat people with the disease. I learned many valuable lessons from this course and I’d like to share a few with you.
1) Addiction is a brain disease. It is not a choice.
In pharmacy school, I was taught that if an opiate was prescribed for the right patient in the proper circumstances, people could not possibly become addicted to them. The implication here is that the people who are given these prescriptions must CHOOSE to become addicted or they must have a predisposition to addiction. If Mary breaks her leg and is given oxycodone IR to manage the pain, she will be able to come off of those pills without issue unless she decides otherwise.
In the CAMH course, we were shown several videos where patients in methadone and buprenorphine treatment programs discussed how they became addicted. One person broke her leg and was given oxycodone. Another had dental pain and was given Percocet to help her cope. Another guy had chronic back problems. All of them were prescribed these drugs for legitimate reasons by doctors who just wanted to help their patients feel better. Every single one of these patients became addicted. Not because they wanted to, or chose to become addicted. Not because they had underlying mental health issues (though some did, not all) and were self medicating. They became addicted because of the drugs themselves.
With opiates, euphoria sets in during the first dose. Patients feel great when they take them, not only because their pain improves but because they work directly on the reward pathway. Because of this, the person taking an opiate feels fantastic. It’s that same reward pathway that leads to all the trouble. When the euphoria leaves, the patients feel awful. Actually, they feel even worse than before starting drug therapy. And so, they reach for more. In this way, the cycle of addiction begins.
The take home message here, for me anyway, is to change the way I discuss these medications with people. The goal of course, is not to scare them away from proper pain management. Rather, if someone asks me if they can become addictive, to change my answer from the one above learned in pharmacy school to yes, they can be addictive. Therefore, use them when you need to and at no other time. And, if you feel like it is becoming a problem or you’re losing control of your use, talk to someone you can trust.
2) Addiction is a lifelong disease.
I’ve known this for awhile but this course really hammered the point home for me. Addiction is something to be managed, not cured. It is unrealistic to expect that the patient that comes to your pharmacy with their first prescription for methadone will ever discontinue maintenance treatment. It should be looked at like hypertension or diabetes. A chronic illness that we can manage very well and, in doing so, allow our patients to have normal, happy, productive lives.
In that same vein, it is unrealistic to expect that our patient on methadone will never relapse. Addiction waxes and wanes. The patient who was stable for years on 50 mg may have to have a dose increase to 70 mg for a while because they started using again for whatever reason. Just like your patient with hypertension may need a medication adjustment every once in a while, so too will your opiate-addicted patient.
3) Counselling, in all its forms, is essential.
In this course, I learned of the incredible value that case managers, social workers and addictions counsellors give to the treatment of addicted patients. Studies have shown that regular counselling, even if it is simply a 5 minute chat, improves outcomes for these patients. The counsellor speaking to us at the course said that this applies to any health care provider who has contact with these patients. In fact, he pointed to the huge potential role pharmacists have to play in counselling. We see these patients much more often than any other member of their care team. In the beginning, we see them every single day. When they have been stable for some time, we will see them at a minimum of once weekly.
I have used this information to change how I dispense methadone. It is very easy to say “ok John Doe, here is your dose, have a good day.” I’ve started asking how they are feeling. Are they having any side effects, do they notice any withdrawal symptoms? I’ve begun to ask them how they are sleeping, and if they have any pain anywhere. These conversations do not take much longer than the “here’s your dose” conversation but they provide so much information. They also make the patient feel like they can come to me with any issues. One patient mentioned to me that they start sweating 3 hours after their dose. This points to the fact that the dose might be a bit high because sweating is a side effect of increasing methadone doses. Both the patient and myself discussed the issue with the prescribing physician and the issue was resolved.
Conversations like that show the patient that we are on their team and there to help them. They are also the main reason I wanted to be a health-care professional in the first place.
In closing, the problem of addiction in this country is not going to go away any time soon. We need more health care professionals trained to deal with the ever increasing population of patients who need our help. We need more doctors to get their methadone and/or buprenorphine exemptions. We need more pharmacies to dispense methadone. We need to educate the public on the benefits of treating patients who have addictions. We need to help quell the fears of people who are terrified of clinics and pharmacies who are involved in addictions treatments. The studies are there to prove success can be achieved and communities can be saved from this awful disease. We all need to pull together to make that happen.
If you’re looking for more information on this course or addiction material, check out the CAMH website www.camh.ca
Also, previous posts have discussed the More Than Meds project that is ongoing in Nova Scotia. People with addictions need people like pharmacists to help them navigate the healthcare system. Check out the More Than Meds project at http://www.morethanmeds.com
Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.
– , will build off of this and bring the discussion to two more people. If I’m lucky, maybe word of mouth will help the turnout. If I have to do 10 more sessions to help 10 more people, I’ll gladly sign up. As an added bonus, I may even be able to prescribe something for those that ask for help.’
PharmAspire 