Indigenous Canadians confront prescription opioid misuse
2013; Elsevier BV; Volume: 381; Issue: 9876 Linguagem: Inglês
10.1016/s0140-6736(13)60913-7
ISSN1474-547X
Autores Tópico(s)Pediatric Pain Management Techniques
ResumoPast actions by the Canadian Government and the medical system have left Indigenous communities to deal with a legacy of opioid drug addiction. Paul C Webster reports.As a nurse–practitioner working at Dennis Franklin Cromarty High School in Thunder Bay, the city that serves as the gateway to Ontario's northwestern hinterland, Mae Katts thought she knew it all about substance misuse among Aboriginal adolescents. Cannabis, alcohol, LSD, and ecstasy were the mainstays—crack cocaine and heroin far lesser problems. So, a few years ago when numerous students began returning from their summer holidays agitated, anxious, and complaining of headaches and sore muscles, she wondered what was going on. “These kids seemed to be showing signs of opioid withdrawal”, she recalls.As it turned out, she was right: in sessions with health counsellors, many students admitted they were abusing prescription opioid drugs, especially oxycodone, a highly addictive painkiller that has been widely prescribed and heavily misused in Canada over the past decade. Katts knew that surveys indicate 15% of teenagers in Ontario take prescription opioid drugs for non-medical purposes. But Katts quickly became convinced the misuse levels were even higher among Aboriginal students in her school—especially among those who spent the summers in isolated rural communities along the subarctic shores of Hudson Bay. “Prescription opioid dependency was exploding”, Katts recalls about the situation in 2009, when she first began investigating it.In a series of exploratory visits to some of the student's remote home communities in 2010, Katts confirmed that many of these rural Aboriginal villages were awash with prescription opioid drugs. “The surveys I did suggested that around 40% of Aboriginal teens in the school in Thunder Bay had opioid dependencies”, she explains. “But the communities where they came from had even higher rates.”In the Nishnawbe Aski Nation, which encompasses most of Ontario's northern land mass, with a total Aboriginal population of around 45 000 in 49 communities, more than 50% of the adult population are prescription opioid drug misusers in need of treatment, according to a 2011 assessment prepared for the Nishnawbe Aski chiefs. A study that year by researchers from the Northern Ontario School of Medicine found that 17% of 482 pregnant Aboriginal women from northwestern Ontario misused prescription opioid drugs during pregnancy, with a substantial percentage of exposed newborns experiencing opioid withdrawal symptoms. Faced with increases in family and child neglect, crime, and violence due to opioid misuse, in 2011 the Nishnawbe Aski Nation chiefs formally declared a “state of emergency” and urgently requested assistance from the Governments of Canada and Ontario.The roots of this crisis, Katts explains, lie partly in the health-care system managed by the Government of Canada, which is responsible for Aboriginal and Inuit health care throughout the country. Many Aboriginal people addicted to drugs, she explains, trace their addiction to prescriptions written by “fly-in” physicians working on short-term contracts for Health Canada, the federal department that administers Aboriginal health care. According to Health Canada, 898 opioid prescriptions were dispensed per 1000 Aboriginal individuals aged 15 years or older in Ontario in 2007. “These drugs were dispensed very generously”, says Benedikt Fischer, an expert on Canada's prescription opioid crisis at the Simon Fraser University in Vancouver, who agrees that the Nishnawbe Aski Nation now face a severe emergency. “The government has facilitated this problem, and the medical system is also implicated. But their response has been very hesitant and slow.”In an environment where visiting physicians seldom maintain steady contact with patients for more than a few months, Katts and Fischer believe overly generous opioid prescribing helped trigger widespread addiction. Those who develop dependencies, and are then unable to renew their prescriptions, often turn to illicit sources where pills costing just a few dollars each over the counter at pharmacies trade for up to CAN$1200.For communities long-plagued by deep poverty, high unemployment, overcrowded housing, polluted drinking water, and some of the highest suicide rates in the world, the prescription opioid disaster adds yet another layer of suffering, explains Elijah Moonias, who serves as the elected chief for the Marten Falls First Nation in Ogoki Post, a community of 300 people about 400 miles north of Thunder Bay.Moonias estimates 90% of adults are dependent on prescription opioid drugs in his community. “A lot of the time, the money for these opiates comes from welfare cheques intended to help families with children to feed”, he says. “The adults in these families cannot work because of their addictions, and their children are not getting food and clothes. It is horribly destabilising.”In a 35-year career spanning long periods as a nurse–practitioner both in community health settings as well as in management—including a 6-year tenure as the director of Aboriginal health care in Ontario for Health Canada—Katts says prescription opioid dependency is the toughest health-related problem she's ever encountered. To underline the severity of the crisis, Katts explains that the standard treatment for prescription opioid addiction in Canada is the same as it is for heroin addiction—long term methadone substitution therapy.Thanks primarily to patients with prescription opioid dependence, the number of people in methadone maintenance treatment in Ontario has doubled to more than 28 000 in recent years. But because methadone therapy must be medically supervised, Katts explains, it is not available in remote communities without resident physicians. Instead, Aboriginal people addicted to prescription opioid drugs are obliged to move to towns and cities where methadone programmes have been established. Katts estimates that at least 9000 Aboriginal individuals addicted to these drugs have gathered in Sioux Lookout, a small city that acts as a hub for northwestern Ontario.After realising that dozens of teenagers in her school were opioid-dependent, in 2010 Katts began scouring the medical literature for treatment options that offered more hope than methadone, which was unavailable to her teenage patients in Thunder Bay, and unavailable in their communities back home. She soon hit upon an experimental approach using Suboxone—a tablet that combines two drugs used for opioid drug addiction—buprenorphine and naloxone.After several months of experimental treatment, Katts observed substantial success with a 30-day programme in which Suboxone dosages were gradually reduced and in some cases eliminated following which her teenaged patients were closely observed and offered counselling and care for 12 months. “It worked astonishingly well”, Katts says bluntly. “From February, 2011, to now we've had 50 students in treatment and all have had good success. Many have now completed 12 to 15 months of maintenance and have been weaned off Suboxone—and still remain opiate-free.”Enthused by this success in the school setting, in late 2011 Katt persuaded the Nishnawbe Aski Nation chiefs to allow her and a team of academic researchers and clinicians supported by the Canadian Institutes of Health Research, the Public Health Agency of Canada, the Ontario Ministry of Health, and Long-Term Care and the Centre for Addiction and Mental Health in Toronto to stage a pilot study involving 22 adults addicted to prescription opioid drugs in a small Aboriginal community in northwestern Ontario, which has not been identified to protect the identities of the study participants.Starting with initial small doses, the participants (who had misused prescription opioid drugs for a mean duration of 3·7 years) received increasing amounts of Suboxone daily under direct observation at the treatment site on an outpatient basis. Suboxone tapering began 8 days later. At the end of the 30-day tapering-down period each patient was assessed individually for a personalised treatment aftercare plan, including the potential need for continued low-dose Suboxone maintenance. The aftercare programming, Katts explains “consisted of several weeks of individual and group counselling focusing on relapse prevention, incorporating motivational enhancement, health education, and spiritual support”.While the primary objective of the treatment programme was opioid abstinence at the end of the 30 day tapering-down phase, only one participant was comfortable being completely tapered off of Suboxone. For the others, the research team concluded, opioid dependence may be a chronic condition requiring long-term Suboxone maintenance. But by offering Aboriginal people addicted to opioid drugs a treatment option that allows them to remain in their communities, explains chief Moonias of the Marten Falls First Nation in Ogoki Post, “the Suboxone treatment represents an extremely important step towards helping our communities recover.”At Simon Fraser University in Vancouver, Benedikt Fischer, who worked with Katts on designing and implementing the Suboxone pilot study, says the approach could at last help resolve the problem with lack of treatment in remote communities, which he describes as a legacy of discriminatory government policies that denied methadone treatment while refusing to fund alternatives for Aboriginal people living in their home communities.Blossom Leung, a spokeswoman for Health Canada, says the government is now taking a range of steps to address Aboriginal prescription drug misuse, including the development of a national strategy to cope with the overall crisis of prescription drug misuse in Canada in consultation with Aboriginal experts. Health Canada is also assessing ten treatment projects including Katts' to help Aboriginal communities “identify best practices and refine their local prescription drug abuse programmes”, says Leung. Past actions by the Canadian Government and the medical system have left Indigenous communities to deal with a legacy of opioid drug addiction. Paul C Webster reports. As a nurse–practitioner working at Dennis Franklin Cromarty High School in Thunder Bay, the city that serves as the gateway to Ontario's northwestern hinterland, Mae Katts thought she knew it all about substance misuse among Aboriginal adolescents. Cannabis, alcohol, LSD, and ecstasy were the mainstays—crack cocaine and heroin far lesser problems. So, a few years ago when numerous students began returning from their summer holidays agitated, anxious, and complaining of headaches and sore muscles, she wondered what was going on. “These kids seemed to be showing signs of opioid withdrawal”, she recalls. As it turned out, she was right: in sessions with health counsellors, many students admitted they were abusing prescription opioid drugs, especially oxycodone, a highly addictive painkiller that has been widely prescribed and heavily misused in Canada over the past decade. Katts knew that surveys indicate 15% of teenagers in Ontario take prescription opioid drugs for non-medical purposes. But Katts quickly became convinced the misuse levels were even higher among Aboriginal students in her school—especially among those who spent the summers in isolated rural communities along the subarctic shores of Hudson Bay. “Prescription opioid dependency was exploding”, Katts recalls about the situation in 2009, when she first began investigating it. In a series of exploratory visits to some of the student's remote home communities in 2010, Katts confirmed that many of these rural Aboriginal villages were awash with prescription opioid drugs. “The surveys I did suggested that around 40% of Aboriginal teens in the school in Thunder Bay had opioid dependencies”, she explains. “But the communities where they came from had even higher rates.” In the Nishnawbe Aski Nation, which encompasses most of Ontario's northern land mass, with a total Aboriginal population of around 45 000 in 49 communities, more than 50% of the adult population are prescription opioid drug misusers in need of treatment, according to a 2011 assessment prepared for the Nishnawbe Aski chiefs. A study that year by researchers from the Northern Ontario School of Medicine found that 17% of 482 pregnant Aboriginal women from northwestern Ontario misused prescription opioid drugs during pregnancy, with a substantial percentage of exposed newborns experiencing opioid withdrawal symptoms. Faced with increases in family and child neglect, crime, and violence due to opioid misuse, in 2011 the Nishnawbe Aski Nation chiefs formally declared a “state of emergency” and urgently requested assistance from the Governments of Canada and Ontario. The roots of this crisis, Katts explains, lie partly in the health-care system managed by the Government of Canada, which is responsible for Aboriginal and Inuit health care throughout the country. Many Aboriginal people addicted to drugs, she explains, trace their addiction to prescriptions written by “fly-in” physicians working on short-term contracts for Health Canada, the federal department that administers Aboriginal health care. According to Health Canada, 898 opioid prescriptions were dispensed per 1000 Aboriginal individuals aged 15 years or older in Ontario in 2007. “These drugs were dispensed very generously”, says Benedikt Fischer, an expert on Canada's prescription opioid crisis at the Simon Fraser University in Vancouver, who agrees that the Nishnawbe Aski Nation now face a severe emergency. “The government has facilitated this problem, and the medical system is also implicated. But their response has been very hesitant and slow.” In an environment where visiting physicians seldom maintain steady contact with patients for more than a few months, Katts and Fischer believe overly generous opioid prescribing helped trigger widespread addiction. Those who develop dependencies, and are then unable to renew their prescriptions, often turn to illicit sources where pills costing just a few dollars each over the counter at pharmacies trade for up to CAN$1200. For communities long-plagued by deep poverty, high unemployment, overcrowded housing, polluted drinking water, and some of the highest suicide rates in the world, the prescription opioid disaster adds yet another layer of suffering, explains Elijah Moonias, who serves as the elected chief for the Marten Falls First Nation in Ogoki Post, a community of 300 people about 400 miles north of Thunder Bay. Moonias estimates 90% of adults are dependent on prescription opioid drugs in his community. “A lot of the time, the money for these opiates comes from welfare cheques intended to help families with children to feed”, he says. “The adults in these families cannot work because of their addictions, and their children are not getting food and clothes. It is horribly destabilising.” In a 35-year career spanning long periods as a nurse–practitioner both in community health settings as well as in management—including a 6-year tenure as the director of Aboriginal health care in Ontario for Health Canada—Katts says prescription opioid dependency is the toughest health-related problem she's ever encountered. To underline the severity of the crisis, Katts explains that the standard treatment for prescription opioid addiction in Canada is the same as it is for heroin addiction—long term methadone substitution therapy. Thanks primarily to patients with prescription opioid dependence, the number of people in methadone maintenance treatment in Ontario has doubled to more than 28 000 in recent years. But because methadone therapy must be medically supervised, Katts explains, it is not available in remote communities without resident physicians. Instead, Aboriginal people addicted to prescription opioid drugs are obliged to move to towns and cities where methadone programmes have been established. Katts estimates that at least 9000 Aboriginal individuals addicted to these drugs have gathered in Sioux Lookout, a small city that acts as a hub for northwestern Ontario. After realising that dozens of teenagers in her school were opioid-dependent, in 2010 Katts began scouring the medical literature for treatment options that offered more hope than methadone, which was unavailable to her teenage patients in Thunder Bay, and unavailable in their communities back home. She soon hit upon an experimental approach using Suboxone—a tablet that combines two drugs used for opioid drug addiction—buprenorphine and naloxone. After several months of experimental treatment, Katts observed substantial success with a 30-day programme in which Suboxone dosages were gradually reduced and in some cases eliminated following which her teenaged patients were closely observed and offered counselling and care for 12 months. “It worked astonishingly well”, Katts says bluntly. “From February, 2011, to now we've had 50 students in treatment and all have had good success. Many have now completed 12 to 15 months of maintenance and have been weaned off Suboxone—and still remain opiate-free.” Enthused by this success in the school setting, in late 2011 Katt persuaded the Nishnawbe Aski Nation chiefs to allow her and a team of academic researchers and clinicians supported by the Canadian Institutes of Health Research, the Public Health Agency of Canada, the Ontario Ministry of Health, and Long-Term Care and the Centre for Addiction and Mental Health in Toronto to stage a pilot study involving 22 adults addicted to prescription opioid drugs in a small Aboriginal community in northwestern Ontario, which has not been identified to protect the identities of the study participants. Starting with initial small doses, the participants (who had misused prescription opioid drugs for a mean duration of 3·7 years) received increasing amounts of Suboxone daily under direct observation at the treatment site on an outpatient basis. Suboxone tapering began 8 days later. At the end of the 30-day tapering-down period each patient was assessed individually for a personalised treatment aftercare plan, including the potential need for continued low-dose Suboxone maintenance. The aftercare programming, Katts explains “consisted of several weeks of individual and group counselling focusing on relapse prevention, incorporating motivational enhancement, health education, and spiritual support”. While the primary objective of the treatment programme was opioid abstinence at the end of the 30 day tapering-down phase, only one participant was comfortable being completely tapered off of Suboxone. For the others, the research team concluded, opioid dependence may be a chronic condition requiring long-term Suboxone maintenance. But by offering Aboriginal people addicted to opioid drugs a treatment option that allows them to remain in their communities, explains chief Moonias of the Marten Falls First Nation in Ogoki Post, “the Suboxone treatment represents an extremely important step towards helping our communities recover.” At Simon Fraser University in Vancouver, Benedikt Fischer, who worked with Katts on designing and implementing the Suboxone pilot study, says the approach could at last help resolve the problem with lack of treatment in remote communities, which he describes as a legacy of discriminatory government policies that denied methadone treatment while refusing to fund alternatives for Aboriginal people living in their home communities. Blossom Leung, a spokeswoman for Health Canada, says the government is now taking a range of steps to address Aboriginal prescription drug misuse, including the development of a national strategy to cope with the overall crisis of prescription drug misuse in Canada in consultation with Aboriginal experts. Health Canada is also assessing ten treatment projects including Katts' to help Aboriginal communities “identify best practices and refine their local prescription drug abuse programmes”, says Leung.
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