P R O P O S I T I O N

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Équipe de soutien clinique et organisationnel en dépendance et itinérance

Approvisionnement plus sécuritaire

et utilisation de la MLLU

Panel interdisciplinaire québécois

de discussions

Divulgation de conflits d’intérêts potentiels

Kenneth Wong, directeur Méta d’Âme : Aucun conflit

Sofiane Chougar, infirmier, CHUM : Aucun conflit

Caroline Fauteux, IPS-PL, CIUSSS E CHUS : Aucun conflit

Leslie Chalal, travailleuse sociale, CIUSSS CCSMTL : Aucun conflit

Dre Amanda Violato, médecin, CIUSSS CCSMTL : Aucun conflit

Stéphanie Foucher-Laurent, pharmacienne communautaire : Aucun conflit

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1

Regent Park Safer

Opioid Supply

ProgramMarysia (Mish) Waraksa RN(EC) NP PHC

Nurse Practitioner

No conflict of interest

Downtown East Collaborative SOS

Program

• Street Health

• Regent Park

Community

Health Centre

• South Riverdale

Community

Health Centre

Downtown East Collaborative SOS

Program Each team consists of:

1 Nurse Practitioner

Primary care, Safer Opioid Supply Prescribing

1 Registered Nurse

Primary care supports, harm reduction, care co-

ordination

1 Community Health Worker

Case management, support with housing, replacing

ID, accessing community resources

Each site has a safe injection site on premises

Role of Nurse Practitioner

NP-led care – autonomous provision of SOS Prescribing and

primary care

Ontario – no restrictions on NP prescribing

Limits to scope of practice at this time: ordering CT/MRI,

completion of some forms (insurance, hearing aid funding),

POC testing

Referral & Intake Process

Majority of referrals are internal from safe injection site

staff

CHW & RN run weekly drop-in intake session to screen for

eligibility

If eligible, are booked with the Nurse Practitioner for

intake

Prioritization Criteria

• Indigenous, black, people of colour

• Women, two spirit, LGBTQ2SI

MarginalizedPopulations

• Homeless, precariously housed

• Living aloneHousing Status

• History of non-fatal overdoseOD History

• HIV, Hep C, endocarditis, spinal abscesses, sepsis, osteomyelitis, prolonged hospitalization related to use

Complicationsof Use

Eligibility Opioid Use Disorder per DSM V

Self-reported regular illicit opioid use

Previous unsuccessful OAT monotherapy, or decline OAT

Positive UDS

No medical contraindication to unsupervised SOS

Severe respiratory, liver disease

Hx GI obstruction or paralytic ileus

Severe CKD

Alcohol use disorder, or unpredictable ETOH intake

Sedative, anxiolytic or hypnotic substance abuse

Regent Park SOS Clients

24 clients total have received an SOS prescription

Housing

8 with permanent housing

16 homeless, living in shelters, or have precarious

housing

Medical complications

8 with previous hx of treated/cleared HCV

8 with positive HCV RNA at intake

2 coinfected with HCV/HBV

5 hx of endocarditis

SOS Dosing

Initial doses

Kadian 100-200mg observed daily

Dilaudid 8mg x 8-12 tabs dispensed daily

Titration

Kadian titrated q48hrs x 100-200mg/day

Dilaudid 8mg titrated q48 hours x 2-6 tabs/day

Maximum doses

Kadian 1600mg

Dilaudid 8mg – 30 tabs daily

Dosing – Typical Titration Schedule

Visit Kadian (SROM) Dilaudid 8 mg (# daily

dispensed)

1st visit 200mg 12 tabs

2nd visit 200mg ↑18 tabs

3rd visit ↑400mg 18 tabs

4th visit 400mg ↑24 tabs

5th visit ↑500mg 24 tabs

Long Acting Medications

Methadone (5)

Kadian (15)

Suboxone (1)

Hydromorphone

Contin (2)

None (1)

Missed doses

If client misses dispensing x 2 days, prescription is held

and prescriber must be contacted

Kadian – decreased per BCCSU SROM Guidelines

Dilaudid – per clinical judgment – working towards a

standardized protocol

Reductions also guided by client’s use patterns – a more

modest reduction may be used if client has high fentanyl

use during period of missed doses

Urine Drug Screening

On enrollment to confirm presence of illicit opioids

On follow up, q~1 Month to confirm presence of SOS

medications in urine

UDS collected unobserved

Emphasis placed on non-punitive approach to UDS

Presence of illicit opioids does not lead to discharge from

program

Program issues

High missed appointment rate

Difficult provider coverage

Client access – lack of phones

Inadequate response to dilaudids

Future alternatives?

Drug shortages

Dilaudid, APO-hydromorphone

Kadian – upcoming?

Stigma and interaction with other

providers

Hospitalization

++Difficulties with continuity of care

Dose de-escalation

IV vs. PO dose equivalency issues

Restrictions in maximum doses of IV dilaudid allowed to

be administered in non-ICU units

Clients hesitant to request PRN doses, or not aware of

availability

Clients frequently leaving “against medical advice” due

to intolerable withdrawal symptoms

Stigma and interaction with other

providers

Incarceration

++Difficulties with continuity of care

Existing OAT providers

Mixed responses received

Pharmacists

Key partners in SOS program!

Mostly positive responses

Some issues with client experience of stigma and denial of care

SOS Case #1 – Typical Presentation 42yo female, Indigenous, previous long history of homelessness, now in a

rooming house.

History of multiple witnessed non-fatal ODs requiring naloxone and O2

administration

Hx hepatitis C, spontaneously cleared

Was previously on Methadone, up to 80mg, but with frequent missed doses,

only on 30mg at intake

Was using 2 “points” fentanyl IV on intake

Initiated on 200mg Kadian and 8 tabs dilaudid daily

Now on program x 4 months

Dose Kadian 500mg OD and 16 tabs daily

Uses 4 tabs IV or PO – about 50/50 oral and IV dosing

Uses 1-2 points of fentanyl IV/week

SOS Case #2 – High dose SROM

32yo male, LGBTQ, housed

Using 8-10 points fentanyl IV on intake to program

Initiated on 300mg Kadian and 12 tabs dilaudid daily

8 months in program – Kadian 1000mg po od, 28 tabs Dilaudid daily

Abstinence from fentanyl in the last month

Now taking Dilaudid oral-only

Wishes to stay on current SOS doses but attend outpatienttreatment for OUD

SOS Case #3 – Suboxone with SOS

40yo Male, precarious housing, hx of previously treated hep C, substance-induced psychosis

Came to program on 12mg Suboxone, using 4-6 points fentanylIV daily

Initiated on 8 tabs dilaudid dispensed daily

In program x 8 months – currently continues on Suboxone 12mgOD, 14 tabs Dilaudid. 1-3 tabs PO/IV/dose

Infrequent fentanyl use

++ Psychosocial stabilization during program

Client now plans for transition to Suboxone only OAT

Benefits seen in program thus far

Improvements to quality of life

Connections with community services

Housing

Financial stability

Reduction in overdoses

Access & engagement with primary care

PRÉSENTATION DE CASDR CHARLES-ANTOINE BREAU MD, CCFP (AM,EM)

CONFLITS D’INTÉRÊTS

• AUCUN

PATIENT X

• Âge: 32 ans

• Première consommation : 12 ans – cocaïne

• Première consommation IV : 21 ans – diacétylmorphine

• ATCD : PTSD, Anxiété, Dépression,Endocardite,VHC

• Rx: Sertraline,Seroquel XR

• Consommation journalière:

• Fentanyl:

• Crystal Meth:

• Tabac:

1-2 g IV

10-20$

½ paquet

PATIENT X

• Environ 1-2 surdoses par semaine

• Dépistage de drogues dans les urines à la première visite :

FYL+

MOP+

BZO+

• MET+

• AMP+

• COC+

• Tx antérieurs :

• Méthadone – dose maximale: 155mg

• Buprénorphine/naloxone: 24 mg

PATIENT X

• Débuté avec du safer supply:

• MLLU (KadianMC): 400 mg podie

• Hydromorphone (DilaudidMC) 8mg: 12 co servisdie

• MLLU (KadianMC): augmenté de 200 mg chaque 2-3 jours

• Hydromorphone (DilaudidMC) 8mg augmenté de 4 co chaque 2-3 jours

• Dose actuelle :

• MLLU (KadianMC): 1600 mg po OD

• Hydromorphone (DilaudidMC) 8 mg 26 co servis die

• Consommation actuelle :

• Crystal Meth 10-20$, fentanyl 2-3 points parsemaine

LIGNE DIRECTRICE

• Débuter Hydromorphone 8 mg (DilaudidMC) de

6-8 co par jour

• 8-12 co en pratique

• Augmenter de 2-4 co q24h

• Dose max : 24-30 co selon laréponse

• DilaudidMC préférable, si générique -APO

PATIENTY

• Âge : 41 ans

• Première consommation: 19 ans – percocet

• Première consommation IV: 32 ans - M EslonMC

• ATCD:Dépression,TPL,VHC,VIH

• Rx:aucun

• Consommation journalière :

• Crack

• Speed

• Fentanyl 3-4 points par jour

• Tabac ½ paquet par jour

• Cannabis 1 g par jour

PATIENTY

• Surdose x 3 dans le dernier mois

• Dépistage de drogues dans les urines à la première visite :

• Positif pour:MET,AMP,FYL,OXY,MOP,BZO

• Tx antérieur : Méthadone 130mg

PATIENTY

• Débuté avec du safer supply:

• Méthadone 30 mg po die

• Hydromorphone (DilaudidMC) 8 mg: 8 co servis die

• Méthadone augmentée jusqu’à 60mg

• et patient voulait cesser méthadone

• Hydromorphone (DilaudidMC) 8 mg: augmenté jusqu’à 30 co par jour

• Dose actuelle:

• Hydromorphone (DilaudidMC) 8 mg, 30 co par jour

• Méthadone: 0 mg

• Consommation actuelle : 0 fentanyl !

PATIENT Z

• 23 ans

• Vu aux urgences avec fracture cheville gauche et engelure

• Consommation: Fentanyl IV 2g / jour

• Dernière consommation remonte à plus de 6h

• Nécessite :

• 1. Contrôle de la douleur

• 2. Sédation consciente

PATIENT Z

• Traitement de la douleur (double vérification)

• Hydromorphone (DilaudidMC) 32 mg IV

• Fentanyl 400 mcg IV

• Kétamine 0.3 mg / kg – 20 mg IV

• À la grande surprise de mes collègues, patient alerte, orienté. Aucune somnolence.

• Se dit à 5-6/10 de sa consommation habituelle

• Douleur 10/10, maintenant 4/10

• Sédation

• Propofol 140 mg IV

Période de questions

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Reconnaissance

Avec la participation de :

Santé Canada

Ministère de la Santé et des Services Sociaux

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Mentions

« Les vues exprimées ici ne reflètent pas

nécessairement celles de Santé Canada. »

« Les vues exprimées ici ne reflètent pas

nécessairement celles du ministère de la

Santé et des Services sociaux. »

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P R O P O S I T I O N

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Merci

L’Équipe de soutien clinique et organisationnel en dépendance etitinérance

Téléphone ou texto: 514 863-7234

Courriel: soutien.dependance.itinerance.ccsmtl@ssss.gouv.qc.ca

Site web: http://dependanceitinerance.ca/