Approvisionnement plus sécuritaire et utilisation de la MLLU Panel interdisciplinaire québécois de discussions - Équipe de soutien clinique et ...

Approvisionnement
            PROPOSITION         plus sécuritaire
                et utilisation de la MLLU

            Panel interdisciplinaire québécois
                     de discussions

    Équipe de soutien clinique et organisationnel en dépendance et itinérance
1

© Équipe de soutien clinique et organisationnel en dépendance et itinérance, 2021

                                                                                    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

2

Regent Park Safer
   Opioid Supply
         Program
    Marysia (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
  Marginalized    • Indigenous, black, people of colour
  Populations     • Women, two spirit, LGBTQ2SI

                  • Homeless, precariously housed
 Housing Status   • Living alone

   OD History     • History of non-fatal overdose

 Complications    • HIV, Hep C, endocarditis, spinal abscesses,
                    sepsis, osteomyelitis, prolonged
    of Use          hospitalization related to 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
     16homeless, 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
     Clientshesitant 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 outpatient
    treatment 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 fentanyl
    IV daily
   Initiated on 8 tabs dilaudid dispensed daily
   In program x 8 months – currently continues on Suboxone 12mg
    OD, 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 CAS
DR 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:                1-2 g IV
    • Crystal Meth:            10-20$
    • Tabac:                   ½ paquet

PATIENT X

• Environ 1-2 surdoses par semaine
• Dépistage de drogues dans les urines à la première visite :
      • MET+                        FYL+
      • AMP+                        MOP+

      • COC+                        BZO+

• Tx antérieurs :
      • Méthadone – dose maximale: 155 mg
      • Buprénorphine/naloxone:     24 mg

PATIENT X

• Débuté avec du safer supply:
     • MLLU (KadianMC): 400 mg po die
     • Hydromorphone (DilaudidMC) 8mg: 12 co servis die
• 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 par semaine

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 la réponse
• 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 130 mg

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

Reconnaissance
© Équipe de soutien clinique et organisationnel en dépendance et itinérance, 2021

                                                                                              Avec la participation de :

                                                                                                   Santé Canada

                                                                                    Ministère de la Santé et des Services Sociaux

37

Mentions
© Équipe de soutien clinique et organisationnel en dépendance et itinérance, 2021

                                                                                    « 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. »

38

Merci
              PROPOSITION

     L’Équipe de soutien clinique et organisationnel en dépendance et
     itinérance
     Téléphone ou texto: 514 863-7234
     Courriel: soutien.dependance.itinerance.ccsmtl@ssss.gouv.qc.ca
            Site web: http://dependanceitinerance.ca/
39