Tackling the Opioid Crisis

It’s been called the most complex public health issue of our time.

The opioid crisis has transformed the face of addiction, making health care providers question everything from the way pain is managed to underlying causes of disease.

The severity of the epidemic is evident in the lives that are lost. Since 2006, more than 9,000 Canadians have died from an opioid overdose.

“Many of the patients I see with an opioid addiction are very young, often in their 20’s or 30’s,” says Dr. Sharon Koivu, Associate Scientist at Lawson. “When they die, that’s too many years that are lost.”

Dr. Koivu is a Palliative Care Physician and Addictions Consultant at London Health Sciences Centre (LHSC).

Working in London, Ontario, she sees first-hand the impacts of opioid addiction. London was recently named as the sixth highest city for rate of hospitalizations due to opioid use in Canada.

Recognizing this public health emergency, Lawson researchers are designing and testing solutions with the goal of driving societal change.

Could one opioid be causing an increase in heart infections?

Dr. Koivu began practicing medicine in 1985. It was not until 2011 that she saw her first case of infective endocarditis, a serious and once rare infection of the heart valves. She has now seen hundreds.

Noting a rise in infective endocarditis and that many of the patients were injection drug users, Dr. Koivu suspected that a specific opioid, hydromorphone, was to blame. She soon joined forces with Dr. Michael Silverman, Associate Scientist at Lawson, to better understand the connection.

In one project, the team examined Ontario health data through ICES for 60,529 hospital admissions related to injection drug use between 2006 and 2015. They showed that rates of infective endocarditis in persons who inject drugs have risen dramatically, more than doubling, and not just in London but across the province.

Hydromorphone prescriptions in Ontario increased from 16 per cent of all opioid prescriptions in 2006 to 53 per cent by 2015, paralleling the rise in infective endocarditis.

People who inject opioids often dissolve them in water, but controlled-release hydromorphone, the most common form of the drug, is difficult to dissolve. As a result, pieces get stuck to injection equipment like the metal ‘cookers’ used to prepare the drug. Equipment is often saved, so the rest can be dissolved later. This did not happen with controlled-release oxycodone, the previous opioid of choice that was removed from market in 2011.

From left: Drs. Michael Silverman, Sharon Koivu and Laura Rodger studied which clinical factors are linked to reduced mortality in injection drug users with heart valve infection.

“Reusing equipment allows for bacterial contamination, increasing chances that bacteria will be injected with the drug,” explains Dr. Silverman. “We suspect injection of bacteria may be a contributing factor to the rise in infective endocarditis, and we’re currently studying this in more detail.”

Armed with research knowledge, Drs. Koivu and Silverman are champions for a public health campaign to ‘cook your wash’. It encourages those who inject drugs to heat their injection mixture, known as ‘the wash,’ until it bubbles to kill bacteria.

Discovering effective treatments

When a person who injects drugs develops infective endocarditis, they have a one in three chance of dying.

“When we hear the harrowing statistics of the opioid crisis, they focus on overdose deaths,” says Dr. Koivu. “They do not include the thousands of young men and women who are dying as a result of infectious disease.”

In another study, Drs. Koivu and Silverman set out to improve patient outcomes by understanding what treatments work best. They examined anonymous patient data from 2007 to 2016 at LHSC and St. Joseph’s Health Care London. They found that out of 370 patients with endocarditis, 202 were persons who inject drugs.

When accounting for the severity of a patient’s illness, cardiac surgery resulted in a 56 per cent reduction in mortality. Meanwhile, providing addictions counselling, focused on harm reduction education and support towards recovery while a patient was in hospital, resulted in a 72 per cent reduction.

“We’re not saying every patient needs surgery but our findings suggest it should be considered as a viable option for those most in need,” explains Dr. Silverman.

When we hear the harrowing statistics of the opioid crisis, they focus on overdose deaths. They do not include the thousands of young men and women who die as a result of infectious disease. – Dr. Sharon Koivu

“Support while in hospital is vital,” adds Dr. Koivu. “The majority of patients don’t understand what they’re doing to cause an infection and this could motivate them for a lifestyle change.”

Reducing prescription numbers

North America has the highest rates of opioid prescriptions in the world.

“By reducing the number of opioids being prescribed, we can decrease the risk of them being misused or ending up in the wrong hands,” says Dr. Luke Hartford, a surgical resident in London.

Dr. Hartford is part of a research team at Lawson and Western University that is tackling this issue. They developed a new clinical protocol for general surgery called STOP Narcotics. It combines education for patients and health care providers with an emphasis on non-opioid pain control.

Dr. Luke Hartford is part of a research team that developed and studied a new clinical protocol after general surgery called STOP Narcotics. The protocol cut opioid prescribing in half.

The protocol was studied with 682 research patients who underwent outpatient gall bladder removal surgery, open hernia repair, breast surgery and anorectal surgery at LHSC and St. Joseph’s. Patients received non-opioid medications like Tylenol and Naproxen to help manage their pain for the first 72 hours after surgery. Physicians were also instructed to write a limited prescription for 10 pills of an opioid that expired within seven days. Patients were told to only fill the prescription if needed, and were instructed on how to properly dispose of unused pills.

The STOP Narcotics protocol cut the number of opioids being prescribed in half and only 45 per cent of patients actually filled their prescription, compared to 95 per cent of patients in a control group. Pain was managed just as effectively, with the same levels of postoperative pain levels reported by both groups. The percentage of patients who properly disposed of their medication tripled.

“We recognized before STOP Narcotics that every surgeon had a different approach to pain control and most were prescribing more opioids than needed,” notes Dr. Ken Leslie, Associate Scientist at Lawson. “The new protocol is effective and also standardizes prescribing practices for clinicians.”

Moving forward, the group hopes to expand the protocol beyond general surgery. “If the protocol is translated to other departments and institutions, we can decrease the number of opioids available for illicit use and significantly impact the opioid crisis through prevention,” says Dr. Hartford.

The STOP Narcotics protocol cut the number of opioids being prescribed in half and only 45 per cent of patients actually filled their prescription, compared to 95 per cent of patients in a control group.

Understanding the individual patient

Tackling the issue in another way, one project is looking at how a patient’s personality traits can affect opioid dosing in chronic pain.

Led by Dr. Robert Teasell, the research team is collecting data that shows patients with chronic pain who possess certain obsessive personality traits related to anxiety and coping experience higher levels of pain-related disruptions to daily activities, greater levels of disability and are at greater risk for mood disorders. Preliminary results suggest that in individuals prescribed opioids, there is a correlation between those personality traits and higher doses.

“While our studies are ongoing, we are very excited about the potential impact of this research,” explains Dr. Teasell, Associate Scientist at Lawson. “If we can use personality measures to predict how individuals with chronic pain will cope, we can develop more personalized strategies to better manage chronic pain without overreliance on opioids.”

Dr. Koivu is seeing a shift towards alternative methods of pain management that can create real change.

“My hope is that we can lower prescription numbers, better understand the effects of individual opioids and support individuals with a substance use disorder. Through this work, we can create real societal change.”

A collaborative approach

• To help address the opioid crisis in London and surrounding regions, London Health Sciences Centre and St. Joseph’s Health Care London have created the Opioid Stewardship Council (OSC). 

• The OSC is a collaborative group of professionals who are developing new processes to reduce opioid prescriptions for acute pain. 

• Strategies include ensuring patient education materials accompany every narcotic prescription and are reviewed with the patient by their health care provider, limiting the quantity of medications being prescribed, and developing tamper-resistant prescriptions.

Dr. Sharon Koivu is an Associate Scientist at Lawson, a Palliative Care Physician and Addictions Consultant at London Health Sciences Centre and an Associate Professor at Schulich School of Medicine & Dentistry, Western University.

Dr. Michael Silverman is an Associate Scientist at Lawson and Chair/Chief of Infectious Diseases at Schulich School of Medicine & Dentistry, Western University, London Health Sciences Centre and St. Joseph’s Health Care London.

Dr. Ken Leslie is an Associate Scientist at Lawson and Chair/Chief of General Surgery at Schulich School of Medicine & Dentistry, Western University and London Health Sciences Centre.

Dr. Robert Teasell is an Associate Scientist at Lawson, Medical Director of the Stroke Rehabilitation Program at Parkwood Institute, part of St. Joseph’s Health Care London, and Professor at Schulich School of Medicine & Dentistry, Western University.