INTRODUCTION
On December 15, 2003 the Government of Newfoundland and Labrador announced the establishment of a Task Force to assess the extent of the abuse of OxyContin in the province and to develop a comprehensive plan to deal with the issue. An interim report was requested by the end of January 2004 outlining some immediate actions to be taken, with a final report due the end of March 2004. 

The Task Force is a collaborative partnership of the Departments of Health and Community Services, Justice and Education. The mandate of the Task Force is to make recommendations on a comprehensive strategy for the management of OxyContin and other related narcotics abuse. 


OVERVIEW OF TASK FORCE ACTIVITIES TO DATE
Task Force members have been gathering information to further assess the extent of OxyContin use and abuse in the province and potential solutions to the issues identified. To date, Task Force members have met with:

• representatives from Purdue Pharma, the manufacturer of OxyContin 

• Dr. Simon Avis, the Chief Medical Examiner for the province, 

• representatives from the Newfoundland Medical Board, the Newfoundland Pharmaceutical Association, the Newfoundland and Labrador Medical Association, and the Pharmacists Association of Newfoundland and Labrador 

• representatives from Portage, a treatment program for youth and young adults

• as well as other individuals and groups who have expertise in law enforcement, medical treatment, psychiatry and security.

Task Force members have made contact with various individuals and groups across the province as part of the information collection and consultation process. In addition, several Task Force working groups have been established to move forward on specific issues and research best practices in those areas.


OVERVIEW OF INTERIM REPORT
As part of its mandate the Task Force is requested to provide an interim report with recommendations for short term solutions by January 31, 2004. This Interim Report will provide information on the following:

• What is OxyContin?

• The nature and extent of the problem related to OxyContin abuse

• Best practices related to prevention and education

• Best practices related to detoxification

• Best practices related to treatment

• Best practices related to harm reduction 

• Next Steps of the Task Force

WHAT IS OXYCONTIN?
OxyContin is a semi-synthetic, opioid class (narcotic) analgesic. It is indicated for relief of moderate to severe pain requiring the prolonged use of an opioid analgesic preparation. The active ingredient in OxyContin tablets is oxycodone, a compound that is similar to morphine and is also found in oxycodone combination pain relief drugs such as Percocet and Percodan. Because of its controlled-release property, OxyContin contains more oxycodone and needs to be taken less often than other oxycodone-containing drugs. It is available in strengths of 10mg, 20mg, 40mg and 80mg tablets. 

OxyContin, like other narcotics, has the ability to produce drug dependency. Those who take the drug repeatedly can develop a tolerance or resistance to the drug's effects. It is important to note that when prescribed appropriately and taken correctly under a doctor's supervision, prescription pain medications are safe and effective. 


NATURE AND EXTENT OF THE PROBLEM
In the United States, abuse of OxyContin was first reported in rural and industrial regions along the Eastern Seaboard that rely on labor intensive industries that are generally located in economically poor areas. Individuals may have started off with prescriptions for OxyContin but soon discovered that they could sell it for profit. In some parts of the United States, the nonmedical use of OxyContin has replaced the use of heroin. Prevalence studies in the United States estimate that over 300 people have died of OxyContin overdoses over the past two years in 31 states. 

There are no statistics available that quantify the extent of the problem in Canada. Anecdotal reports indicate it is being seen more in recent years, generally in conjunction with other substances that are being abused. Recent anecdotal evidence also suggests the abuse of OxyContin is most prevalent in Newfoundland. 

An important aspect of this work is verifying how widespread the misuse of OxyContin is throughout Newfoundland and Labrador. Initial data gathered by the Task Force indicates that the quantity of OxyContin tablets prescribed and dispensed in this province have increased by 400% from 2000 to 2003. This rapid growth is not unlike other provinces in Canada; however, Newfoundland and Labrador is showing an increasing trend in the prescriptions for the higher strengths. 

There has been an estimated 10 fold increase in the quantity of OxyContin 40mg tablets prescribed and an eight fold increase in the quantity of OxyContin 80mg tablets prescribed, versus a three fold increase in the quantity of 10mg and 20mg tablets. This trend is inconsistent with the rest of Canada and indicates that physicians in this province are prescribing more of the higher strength product than in other parts of the country. This initial data indicates a 600% increase in the number of milligrams (mg) of OxyContin prescribed by physicians and dispensed by pharmacists throughout this province. 

Initial data analysis also shows a marked increase in the prescribing of other products containing oxycodone. From 2000 to 2003, the quantity of oxycodone containing products has increased by approximately 200%. The Task Force continues to collect and validate statistics related to OxyContin sales, utilization and prescription practices from a number of sources. More information will be contained in the final report. 

There has been a change in the philosophy of treatment for pain syndromes with the development of new and different pain relief drugs. Narcotic drugs, which were once carefully avoided, have been established as part of the treatment programs for pain syndromes (acute and chronic, cancer and non-cancer). Preliminary discussions with experts in the field of pain management have indicated that part of the problem with the volume of narcotics being prescribed for use in various pain syndromes is that there is inadequate access to alternative non-pharmacological modalities. This is further complicated by the fact that incidents of thefts, robberies, false prescriptions, and double doctoring have given a certain notoriety to the use of OxyContin, even for legitimate patients. 

Dr. Simon Avis, Chief Medical Examiner for the province, indicates that since 1997, accidental drug overdoses have been identified as the cause of death in 14 cases. Oxycodone was the leading cause of death in six of these 14 individuals. Dr. Avis noted that in five of these six deaths, other substances, including alcohol, marijuana and other narcotics were found. Dr. Avis is awaiting toxicology reports on another three overdose deaths in 2003 and he recently received confirmation that a 1997 death was due to an accidental overdose of oxycodone. Since 2001, the police have confirmed that oxycodone, specifically OxyContin, was the leading cause of accidental overdose deaths in six individuals.

In 2003, the Recovery Centre reports that 89 out of 934 admissions were for OxyContin abuse. This is an increase of 9.5% from the previous year. Since September 2003, 15-20 admissions of approximately 80 admissions per month are for OxyContin abuse.

Officials with Portage, an out of province inpatient treatment facility for youth and young adults, indicates they have ten individuals from Newfoundland and Labrador in the Portage program for treatment of OxyContin abuse.

Information from the police, school officials and other concerned individuals, indicates some disturbing trends for youth and young adults, including:

• access to OxyContin is available for many high school students 

• for some youth and young adults, OxyContin abuse is associated with increased criminal activity, including theft, shoplifting, and prostitution

• a range of negative health consequences associated with OxyContin abuse, including malnutrition, skin infections, and an increased risk of Hepatitis C and other infections, that have potential lifelong implications.

EDUCATION AND PREVENTION
Newfoundland and Labrador's small population makes it easier to reach target populations. The education and prevention strategies recommended by the Task Force focus on: 

• youth in junior and senior high schools, 

• physicians and pharmacists, and

• the general public. 

Schools 
As a first step, the Ministers arranged for the delivery of education and awareness sessions in senior high schools in St. John's, Deer Lake and Corner Brook. Addictions and law enforcement personnel jointly delivered these sessions and provided information on the dangers associated with the abuse of OxyContin in the context of healthy decision-making. 

Feedback from these initial sessions indicated they were useful to students. Further feedback indicated that follow-up discussions in classrooms would increase the effectiveness of the presentations. A working group of the Task Force is developing follow-up questions that will assist teachers in these classroom discussions. 

The Task Force plans to continue working with other junior and senior high schools in the province on the dissemination of this information. Pamphlets and website information developed by the provincial government are available for youth, teachers, and parents.

Officials with the Department of Education are following up with the school boards to determine if links to the government's website on OxyContin can be placed on the websites of school boards or schools.

The Task Force recommends that law enforcement and Addictions Services personnel, within the regional health and community services and integrated boards, work with schools and school board personnel to continue the OxyContin education sessions in the junior and senior high schools in the province. It is further recommended that these sessions be incorporated into a comprehensive, sustained drug awareness strategy that includes education for parents.

Physicians and Pharmacists 
Physicians and pharmacists are the first contacts for individuals who require prescription narcotics. They are the primary sources of information for many individuals regarding the safe and effective use of prescription medications. 

The Task Force recommends that a joint continuing education program related to OxyContin be developed and offered to all physicians and pharmacists in the province. Health professionals are in agreement that these sessions will focus on managing and treating pain, non pharmacological methods of treatment, the use of narcotic medication in treatment, and the issues associated with prescribing narcotics within the Newfoundland environment. A number of sources have been identified to assist with the content, delivery, and materials associated with these sessions. Purdue Pharma has offered to make their education material available to this working group and assist with the cost of delivering these sessions. 

General Public
Over the past few months, the media has focused a great deal on the use of OxyContin in the province. Individuals who have been misusing or abusing OxyContin, professionals, and other concerned individuals have been interviewed as to the realities and dangers of abusing this drug. Public forums hosted by concerned community groups provide another venue for the general public to be made aware of the dangers of OxyContin misuse and abuse.

In December 2003, the government of Newfoundland and Labrador created a website to make information available to parents and youth on the dangers of OxyContin misuse and abuse. This website also provides contact information for those individuals who want to speak with addictions counsellors. 

The Task Force recommends that the dissemination of information on OxyContin through the website, forums and other opportunities continue. Discussions are ongoing regarding the most effective ways to inform parents about the potential signs of drug use and the dangers associated with OxyContin abuse. 

DETOXIFICATION
Research indicates several avenues of detoxification for individuals undergoing OxyContin withdrawal. Although considered a safe method, the abrupt cessation of the drug (the non-medical approach) is reportedly uncomfortable for the individual. This discomfort is due to a range of withdrawal symptoms and sensations, which typically have a duration of 3-5 days. With respect to medical detoxification, information sources suggest a range of options, including the use of clonadine, decreasing doses of OxyContin (tapering), and methadone (an opioid substitute from which individuals are subsequently weaned). There are considerations with each of these options that will be explored by the Task Force. 

The current situation with respect to detoxification for OxyContin includes:

Nonmedical Detoxification
The Recovery Centre in St. John's offers a non-medical withdrawal management program that addresses all substances, including narcotics such as OxyContin. In addition to providing a supportive environment, the Recovery Centre offers education, counselling and referrals to appropriate addictions treatment services. Individuals aged 16 years and older can avail of these services. The non-medical approach appears to be a deterrent for some individuals who opt for pharmacological assistance with withdrawal. 

Medical Detoxification
There are no structured medical detoxification programs for OxyContin or any other substances in this province. Individuals requiring medical attention may be admitted to a hospital bed for opiate withdrawal, however, there are no set guidelines. Based on information provided by physicians, there does not appear to be a consistent approach for treating OxyContin withdrawal. Attempts at opiate tapering have shown varying outcomes. 

Although each of the above approaches has its strengths, it appears that the optimal response would be a combination of the two approaches. Improved connections between the medical and non-medical systems would offer short-term pharmacological assistance supplemented by a supportive therapeutic environment. 

The Task Force recommends that the Recovery Center continue to be used to assist individuals requiring supported non-medical detoxification from OxyContin. In addition, links between the medical system and the Recovery Centre need to be strengthened. The Task Force is continuing to research pharmacological approaches for OxyContin withdrawal so that a standardized protocol can be developed. The Task Force continues to explore options specific to adolescent needs. 


TREATMENT
The Canadian Centre for Substance Abuse (CCSA) indicates treatment outcome studies for OxyContin are lacking. However, CCSA indicates that best practice for the treatment of opioids includes a period of detoxification followed by traditional behaviorally oriented therapies (individual counselling, group therapy, and/or inpatient treatment). 

Adults
Outpatient treatment is offered to adults by Addictions Services staff, under the Health and Community Services or Integrated Boards, located in every region across the province. The Humberwood inpatient facility in Corner Brook provides a program for gambling, alcohol and other drug abuse that is based on the Bellwood program in Ontario. Humberwood provides a 21 day inpatient program that is comparable to other short-term, residential treatment programs for adults requiring that type of treatment. Individual needs are assessed and further recommendations are provided, including the option of an extended stay and follow-up counselling in their own region. 

The Task Force recommends that outpatient services continue to be offered to individuals through the Addictions Services offices across the province. It is further recommended that adults requiring inpatient treatment be referred to the Humberwood facility in Corner Brook.

Youth
Adolescent House, located in St. John's, and regional Addictions Services offices throughout the province offer outpatient addictions treatment for youth. It is recommended that youth requiring outpatient counselling continue to avail of Adolescent House or Addictions Services within the province. 

It is also recommended that youth requiring inpatient treatment should continue to use the Portage program, located outside the province. Every effort will be made to ensure a smooth process for youth who need this inpatient service. Work will begin immediately to ensure the necessary preparation, assessment and aftercare plans are in place for youth attending Portage. The Task Force continues to explore appropriate detoxification and treatment options for youth. 

HARM REDUCTION
Police intelligence and other data sources indicate that the majority of OxyContin being used illegally is obtained within the province through legitimate prescriptions. Therefore, harm reduction strategies need to focus on limiting inappropriate prescribing of and access to narcotics, reducing drug trafficking and stopping the diversion of legal narcotic drugs for illegal purposes. 

Collaboration among government departments and various agencies is needed to ensure success in the implementation of strategies to manage these problems. The Task Force is pursuing a number of long term strategies but in the short-term it recommends the following approach be implemented.

Tamper Resistant Prescription Pads
Representatives of the Task Force have met with officials of the Newfoundland Medical Board, the Newfoundland Pharmaceutical Association, the Newfoundland and Labrador Medical Association, and the Pharmacists Association of Newfoundland and Labrador to discuss the use of tamper resistant prescription pads for narcotics. All stakeholder groups agree that this is a viable short term option that will lay the foundation for the longer term strategies being considered by the Task Force.

Discussions with Purdue Pharma indicate they are willing to work with the appropriate stakeholder groups to provide expertise and financial assistance to support this initiative. 

The Task Force recommends that tamper resistant pads be implemented for narcotic prescriptions within the province. Details of this implementation are to be worked out jointly by officials with the Department of Health and Community Services, the police, and the professional associations and regulatory bodies representing physicians and pharmacists.

NEXT STEPS OF THE TASK FORCE
The Task Force will continue to work on implementing the recommendations previously identified. The final report due March 31, 2004 will address the following long term issues.

Nature and Extent of the Problem
The Task Force continues to collect and validate statistics related to OxyContin sales, utilization and prescription practices from a number of sources. Further information will be contained in the final report.

Education and Prevention

• Schools - In the long-term, regular and consistent information is widely considered the best practice with regards to drug information. Information on healthy choices, decision-making and drug use is integrated into the school health curriculum. The Task Force is assessing how appropriate information regarding OxyContin can be integrated into the school curriculum or other programs accessed by youth. The DARE program, a drug education program available to elementary schools, offered by the Royal Newfoundland Constabulary and the Royal Canadian Mounted Police may be able to reinforce this information. 
  

• Physicians and Pharmacists - The continuing education sessions offered to physicians and pharmacists will provide a foundation for the harm reduction strategies being considered by the Task Force. Other types of education interventions such as Academic Detailing will also be explored. Academic Detailing refers to a program in which health care professionals such as pharmacists and physicians provide one on one unbiased, evidence-based drug information to prescribers.
  
  

• General public - Information will continue to be made available to the general public on the use and abuse of OxyContin as well as the work of the Task Force. 

Detoxification 
The Task Force is continuing to gather information on the range of medical and non-medical options available to those who require detoxification. The long-term strategy is to offer a coordinated approach to detoxification between the medical and nonmedical facilities to meet the needs of those individuals who may require some pharmacological support to assist with the detoxification process.

Treatment 
Outpatient treatment continues to be available to youth and adults through programs located throughout the province. Adults can obtain inpatient treatment via a facility located in the province. Discussions with Portage officials and the province are focusing on ensuring that the pre-treatment preparation, including detoxification, and follow-up supports needed by youth and their families is provided in a consistent and coordinated manner. In the long-term, the Task Force is exploring the feasibility of an inpatient treatment program for youth in the province. 

Harm Reduction

• Changes to Legislation - As a long-term strategy, the Task Force is continuing to discuss any changes that may be needed to relevant legislation which supports the access to and sharing of information among regulatory bodies and law enforcement officials. Discussions are ongoing with Justice officials to determine what information can be accessed, by whom, and under what conditions it can be shared.
  
  

• Reducing the Inappropriate Prescribing and Use of Narcotics - The Newfoundland and Labrador Prescription Drug Program has had success in reducing inappropriate access to some narcotics, such as OxyContin, by introducing coverage protocols based on accepted pain management guidelines. As a long term strategy, the Task Force is exploring how this success may be broadened to all narcotics prescribed in the province outside the Newfoundland and Labrador Prescription Drug Program.
  
  

• Access to Alternative Treatment Modalities for Pain Patients - Preliminary discussions with knowledgeable individuals in the field of pain management have indicated that part of the problem with the volume of narcotics being prescribed for use in various pain syndromes is that there is inadequate access to alternative non-pharmacological modalities. The Task Force will continue to explore this issue over the next two months. 
  
  

• Prescription Drug Monitoring Program - A number of groups have publicly stated that the proposed Pharmacy Network would assist in addressing this problem. The Task Force will be closely examining the former Prescription Monitoring Program with respect to its outcome and the reasons for its limited impact. The feasibility and usefulness of an alternate monitoring program, including the option of a monitoring program developed and contained within the proposed Pharmacy Network will be further explored. 

CONCLUSION
The Task Force continues to research best practices and work on the implementation of short-term strategies while identifying the long term issues and strategies needed to effectively address the issue of OxyContin and other related narcotics abuse in the province. 

The Task Force would like to offer individuals, families, community advocacy groups and stakeholders an opportunity to provide input into the deliberations of the Task Force. The Task Force has set aside time for those who wish to present their ideas and recommendations to the Task Force. We look forward to hearing from you. Please contact Beverley Clarke, Task Force Chair, at 752-4831.