Module 8: Harm Reduction – Topic B Determine, in collaboration with the person using opioids, whether they are experiencing or are at risk of experiencing harm and determine an appropriate course of action based on critical analysis.

Learning Objectives

By the end of this topic, the student should be able to:

• Identify commonly experienced harms related to opioid use.
• Determine a course of action in collaboration with the person using opioids to reduce the associated harms.
• Describe the importance of collaborating with people using opioids to determine whether they are at risk of experiencing harms related to this use.
• Discuss how to collaborate with an individual who may be at risk of or is experiencing opioid-related harm.

Key Concepts

• Early detection of problematic opioid use is the most effective way of preventing harms.
• Sensitivity and non-judgment must be used to approach an individual who might be at risk of opioid related harms.
• Harm reduction refers to evidence-based, client-centered interventions that seek to reduce the health and social harms associated with substance use, without requiring people who use substances from abstaining from drug use.
• Health and social service providers work in collaboration with the person using drugs to determine appropriate steps towards harm reduction and treatment.

Early Detection of Problematic Opioid Use

Signs of opioid-related harms might include the following:

• withdrawal from social activities that were once enjoyed
• sudden and dramatic mood swings that seem out of character
• impulsive actions and decision-making
• engagement in risky activities, such as driving under the influence
• poorly managed pain

The Canadian Pain Task Force (2019) summarized the following signs of poor pain management:

• reduced quality of life and general health
• decreased mental and emotional health, including increased worrying, stress, anxiety, sadness, depression, anger, and frustration
• problems with cognitive function, such as reduced processing speed, selective attention, memory, and executive functioning
• increased fatigue, exhaustion, and sleep problems
• reduced activities of daily living and physical and social functioning (e.g., sleeping, caregiving, participating in recreation and community life)
• school/work absence and reduced productivity
• increased disability and inactivity
• decreased social connections and supports
• increased health care use
• suicide ideation and increased risk of suicide

Commonly experienced harms related to opioid use

• Death: Between January 2016 and March 2020, there were 16,364 opioid-related deaths in Canada.
• Poisoning resulting in hospitalization: During the same period, there were 20,523 opioid-related hospitalizations (excluding Quebec).
• Overdose: There were more than 4560 opioid-related overdoses (data is from nine provinces and territories) (Special Advisory Committee on the Epidemic of Opioid Overdoses, 2020).

Side Effects of Using Opioids

Signs of Opioid Use Disorder (OUD)

To determine a diagnosis of OUD, at least two of the following should be observed within a 12-month period (DSM-5 Diagnostic Criteria for OUD):

For more information on spiritual, emotional, mental and physical effects of opioids, see Topic 6A.

Determining Appropriate Steps Towards Harm Reduction

Harm reduction refers to evidence-based, client-centered interventions that seek to reduce the health and social harms associated with substance use, without requiring people who use substances from stopping drug use completely (Canadian Mental Health Association, 2020).

This approach:

• emphasizes providing a choice for people who use drugs on how they will minimize harms through non-judgemental and non-coercive strategies,
• enhances skills and knowledge to assist people who use drugs to live safer and healthier lives, and
• includes expanded access to safe injection sites and opioid therapy, and naloxone for individuals who may be at risk of experiencing an overdose.

Efforts need to be made to educate the broader community and support staff in community settings on strategies to prevent, recognize, and respond to an overdose.

This includes:

• education strategies to address the stigma associated with opioid use, and
• encourage development of peer training opportunities for people who use drugs to support individuals at risk of an overdose.  

Understand the Collaborative Care Process

The collaborative care (CC) model involves a number of health professionals working with a person who uses drugs. The goal is to comprehensively address issues related with opioid use.

Normally, the collaborative care team consists of:

• a medical professional,
• a case manager (ideally someone who can offer help with medication), and
• a mental health specialist.

This model is based on the chronic care model which integrates behavioural health (mental health or substance use condition) into primary care (Van Eeghen, Littenberg, & Kessler, 2018).

Evidence suggests that by using the collaborative care approach, treatment outcomes can be significantly improved.

• Watkins et al. (2017) carried out a randomized controlled trial of 377 patients assessing the impact of a collaborative care versus usual primary care
  • Those individuals who received collaborative care reported abstaining from opioids 6 months after treatment
• The stepwise collaborative process matches treatment intensity, pharmacotherapy, delivery setting, and support to indicators of user stability (Stoller, 2015).

Determining Appropriate Course of Action

Course of Action - Tapering

The 2017 Canadian Guideline for Opioids for chronic non-cancer pain recommends that adults on ≥90 mg morphine equivalent dose daily be tapered to the lowest effective dose or discontinued if possible (Busse & Juurlink, et al., 2017). Basic guidance includes:

• Gradually reduce 5% to 10% of the morphine-equivalent dose every 2 to 4 weeks with frequent follow-up
• Switch the patient from immediate-release to extended-release opioids on a fixed dosing schedule
• Collaborate with a pharmacist to assist with scheduling dose reductions

Alternative Methods of Tapering

• Rapid dose reduction in a medically supervised withdrawal centre (may result in severe withdrawal)
• Switch to methadone or buprenorphine/naloxone and then gradual tapering

Tapering may reduce future opioid induced harm and improve overall quality of life; however, patients have to be actively engaged in discussions regarding tapering and be prepared to utilize nonopioid therapies to manage pain and comorbidities. Options include:

• Acetaminophen
• Nonsteroidal anti-inflammatory drugs (NSAIDS)
• Tricyclic antidepressants
• Serotonin norepinephrine reuptake inhibitors
• Gabapentinoids
• Cannabinoids

Nonpharmacological treatments must also be utilized in tandem to optimize treatment:

• Psychosocial support
• SMART goal-setting
• Outlining schedule of dose reductions
• Frequent follow-up and having a plan to manage withdrawal symptoms

Formative Questions

Taking a multidisciplinary or team-based approach to managing tapering can lead to higher success of treatment outcome. Use a motivational approach to having discussions on opioid tapering (Murphy, et al., 2018):

• Ask about the pros and cons from the individual’s perspective
  • “Tell me about how your opioids help you now, compared to when you started?”
• Reflect on any responses and emotions
  • “So your opioids just take the edge off your pain?”
  • “So you are worried about what these are doing to your body?”
  • “You think nothing else will work?”
  • “It sounds like you don’t want to be on opioids, but you are scared about the pain if you come off?”
• Listen carefully and then group together the pros and cons (is possible)
  • “So on the one hand, you still are not able to do all the things you want to do inside and outside of the house and you are worried about all the risks related to opioids, but you are scared about withdrawal and not having anything to manage your pain”
• Ask “permission” to provide information
  • “I have some information that I would like to share with you about opioids. Would today be a good day to discuss this?
• Individualize benefits and risks to review with patients (e.g., sleep apnea, hormonal changes, mood, risk of death, hyperalgesia, interdose withdrawal)
• Recommend specific tapering strategies
• Discuss withdrawal management
  • Talk about what other patients have said or how they have described their experience

Stop and Think

Now that you have reviewed this content, grab yourself a pen and paper:

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References