HC opens clinic for opioid addicts – 06/02/2023 – Health

The Hospital das Clínicas in São Paulo has just opened the first clinic in the country for the treatment of opioid addicts, drugs with analgesic and sedative effects that, when used improperly, can lead to addiction.

The proposal is that the place receives both patients who became dependent after treatments prescribed by doctors and those who make recreational use of these substances.

Installed at Instituto Perdizes at HC, in the west zone of São Paulo, the service brings together specialists in psychiatry, psychology and pain management. The location does not have an emergency room.

Patient access is through the regulation system of the state of São Paulo (Siresp), after referrals from UBSs (Basic Health Units) and Caps (Psychosocial Care Centers). There are still openings for the months of June and July.

The initiative comes at a time when the country is registering an increase in prescription sales of these drugs. In six years, there was an increase of 465%, according to data from Anvisa (National Health Surveillance Agency).

Codeine, considered a mild opioid and generally indicated for moderate pain, accounts for more than 90% of prescriptions. Oxycodone and methadone come next.

According to experts, there has been an indiscriminate prescription of opioids by physicians who are not knowledgeable about proper pain management. At the same time, the country still has serious patients, such as cancer patients, without access to opiates.

There is also illegal use of the substance. In 2019, a Fiocruz drug survey showed that 4.4 million Brazilians had already used some opiate without a medical prescription – or 2.9% of the population.

Added to the scenario are the recent seizures of irregular batches of fentanyl, an opioid 50 times more potent than heroin and a hundred times more than morphine. In the United States, in 2021 alone, there were more than 100,000 overdose deaths associated with fentanyl and congeners.

According to psychiatrist André Malbergier, coordinator of the opioid outpatient clinic, in addition to the increase in the prescribed use of codeine and oxycodone for pain control, there is an increase in recreational consumption of these drugs, especially among adolescents.

He cites a mixture called “lean”, which combines codeine, promethazine [antialérgico que aumenta o efeito da sedação] and some drink, which can be alcoholic or soda. “They get high. And they are all legal drugs, which gives the boy a certain sense of security”, says the doctor.

Malbergier is concerned about seizures of fentanyl in Brazil. “The substance has been mixed with other drugs, such as cocaine. We are not yet trained to deal with these cases.”

Oxycodone has also increased among recreational users, but at a slower pace due to the price of the medication — a box of 14 pills costs between R$150 and R$190.

So far, the outpatient clinic has only treated patients who started abusing opioids after health treatments.

According to Malbergier, the idea is that the service’s multidisciplinary model is replicated in other parts of the country and that it also serves as a reference for doctors when prescribing opioids.

“You need to take into account if you are a young patient, if you have a personal or family history of substance abuse, if you have psychiatric factors. In all these cases, the risk of addiction is higher. Doctors are not yet able to use these criteria at the time to prescribe.”

The psychiatrist recalls that the consequences of an inadequate prescription of opioids can be very serious. “In addition to not eliminating the pain, the person will become dependent on the opioid. The limitations for a healthy life will increase.”

In Brazil, there are no numbers on how much opioids account for in drug overdose cases, but pain specialists report that there have been patients who died in these situations.

A recent case is that of a 20-year-old man from São Paulo who had an anxiety disorder. In addition to anxiolytics, he was also prescribed an opioid and, as time went by, he became dependent on the substance.

“The opioid acts on the reward area of ​​the brain. It improves the patient’s pain and stress pattern. But it is a false benefit mistake. Colleagues who do not have adequate training think they are benefiting the patient because it gives that calm, but it is an error”, says anesthesiologist Claudia Palmeira, who is part of the opioid clinic team at HC.

Palmeira also works at the non-cancer pain outpatient clinic at HC and says that he often sees patients there who have become dependent on opioids because they were not submitted to adequate evaluation criteria when they received their first prescription.

According to the doctor, even if the patient does not have predictive factors of abuse, within 30 days of using oxycodone, for example, he can already develop severe dependence and will not be able to do without the substance.

“What happens to many patients? They go to the emergency room, simulating a pain crisis [para conseguir mais opioide]. Be rich or be poor. This happens in public and private hospitals,” he says.

For her, it is very difficult for the emergency room doctor, who usually has no training in pain, to assess the risk of addiction. “The patient is there screaming, saying he is in pain, there is family pressure, he prescribes and that’s it.”

Palmeira states that there are several situations in which opioids are not indicated for pain control, for example, cases of low back pain and fibromyalgia.

“We have opioid-dependent fibromyalgia patients because the clinician, the orthopedist prescribed it. This is the big problem we have and it is similar to what happened in the USA.”

According to the WHO (World Health Organization), pain treatment should respect a scale (steps of the analgesic ladder), which includes analgesics, anti-inflammatories, adjuvant drugs and opioids (weak and strong).

Another group of concern is opioid-dependent healthcare professionals. It is the case of a 40-year-old nursing technician who is hospitalized at the institute to be treated for addiction.

She had already tried psychostimulants, such as cocaine, and at the hospital where she works, she had access to morphine. Already dependent, she began to simulate episodes of pain to get more morphine. “It combines the fact that they have a very stressful life with easy access to these medications”, says the doctor.

The treatment to take care of this dependence involves hospitalization, with substitution of the substance and gradual reduction of the prescribed amount. “They have a very bad time, they have all those withdrawal symptoms, it’s a very difficult addiction to treat.”

The withdrawal syndrome initially manifests itself with anxiety and craving for the drug, followed by tremors, nausea, vomiting, diarrhea, among others.

At the moment, the opioid clinic has an ongoing research project and is recruiting volunteers who are dependent on oxycodone, codeine or other opium-based substances. Screening takes place via email [email protected].