- BIG-DICK-BUTT-FUCK
- Jan 26, 2016
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by Fluffdaddy
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For patients who fail the traditional therapies of suboxone and methadone, and there are many reasons why that may be, injectable opioid agonist therapy is an option that’s well supported by evidence – that’s where physicians and nurse practitioners prescribe an opioid that’s much safer to inject than anything found on the street, and the outcomes I’ve seen from that are much better than patients continuing to inject street drugs.
There’s been some talk and movement towards the concept of ‘safe supply’, wherein the patient gets pharmaceutical grade opioids with the intent that they will be injecting them; it’s substantially safer than injecting whatever the hell is in the fentanyl that’s out there.
What is the difference between the two please?
In my opinion, 'safe supply' or legalized opiates of some sort is the only way to improve things. In the 'before' times I don't think this was the best approach but now that Fentanyl & analogues have infiltrated all types of narcotics--powder heroin, pills, cough syrup--its the only approach I can see working. If you have to buy these products off the street, it's just a matter of time before you overdose.
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Feb 27, 2022 21:51
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May 3, 2024 15:46
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- BIG-DICK-BUTT-FUCK
- Jan 26, 2016
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by Fluffdaddy
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Thank you, that feedback does mean quite a bit to me. I did send it to my local MLA and the leader of the opposition party.
I don't know how good an idea it is to send it to my local newspaper. I would... except that my clinic is publically funded. And the current Alberta government is nothing if not vindictive. And it's not just my job on the line, but several other people, many of whom aren't doctors and can't afford to take the hit of unemployment as well as I. Maybe I'll run it by my clinic boss.
Also, the local newspapers - both are owned by the same company and now share a newsroom - are explicitly owned by Conservative donors. So though some journalists may be sympathetic, editorial is not.
'Safe supply' is where a drug user receives medication, generally meant to be consumed orally (most frequently it's hydromorphone pills) with the expectation that they will then go use it IV.
Supervised consumption (or safe consumption, or SCS) is where a user takes their own drugs sourced from wherever and injects them in a location under the supervision of medical staff, who can reverse overdose and link them with other services.
iOAT is where a patient receives a prescription for an injectable opioid - generally hydromorphone IV - and injects it under the supervision of medical staff. Broadly, it's the combination of safe supply (eliminating some risks from the drug supply) and SCS (eliminating some risks from the method of use). The other difference is that in this model physicians and NPs can prescribe IV hydromorphone, which is meant to be injected. Injecting crushed up oral meds can introduce poo poo that was never meant to see the inside of a vein, and that can be very problematic in the case of e.g. time release beads from HM Contin caps which can lacerate heart valves and increase the risk of endocarditis. Also, you can get much higher doses of IV hydromorph - I've seen up to 220 mg IV three times daily - than is practical with crushed up tabs - the highest single tab we have here is 8 mg of hydromorph which ain't that much.
Wowwwwwwwww 220mg hydromorphone IV??? No typo??
I was hooked on fentanyl for a couple years and couldn't go over 500mcg without losing consciousness (diverted from pharmacy so I know it was accurately dosed). And I did 1-2mg/day. 220mg hydromorphone is ~30x that much. Jesus Christ Lol.
Thanks for elaborating. One other question: why favor hydromorphone? Ease of dosing due to potency? From experience I'll tell you it's the most euphoric opiate, so I think people would be less likely to seek a 'better' street drug. Here in the US it's all Suboxone & methadone--neither of which have much recreational value. Addicts who aren't motivated to quit will often trade/sell their Suboxone for better drugs, slim chance of that happening with Dilaudid lol.
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Feb 28, 2022 19:34
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- BIG-DICK-BUTT-FUCK
- Jan 26, 2016
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by Fluffdaddy
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I'd always heard the injectables given in these clinics was pharmaceutical grade heroin.
I had a friend* who put it very well when he said Dilaudid is the crack of the opioid world because of the rush. So at first glance it does seem an odd choice for harm reduction, but if it keeps people alive until they're ready for treatment, that's a good thing.
*My buddy was a regular in this thread until he OD'd and died in June 2020.
I don't want to glamorize it but yeah shooting Dilaudid feels almost exactly like an orgasm. And if the ultimate goal is to reduce deaths, overdoses and illnesses associated w street drugs, I think it makes perfect sense to give addicts "the good stuff". Pure, precisely dosed, administered in a reasonably safe manner -much better than the alternative, for all parties involved.
Very sorry you and all the other loved ones in his life had to experience that loss. With time, i hope you all find some sort of peace.
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Mar 1, 2022 00:43
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- BIG-DICK-BUTT-FUCK
- Jan 26, 2016
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by Fluffdaddy
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The two primary IV ones that have been bandied about are hydromorphone and diacetylmorphine (heroin). For reasons of palatability hydromorphone was chosen, because 'literal heroin' is a tough sell to people who aren't familiar with the opioid world. Also, IV hydro is pretty widely available in the medical world because it's literally used all the time for non-addiction reasons; when they knocked my fat rear end out for a knee arthroscopy, part of the cocktail they used was hydromorphone. So part of the choice was familiarity. Also, hydromorphone is one of the cleaner opioids in terms of metabolites especially in renal failure, so there's fewer side effects.
And yes, iOAT sometimes uses enormous doses, but for the past two years the availability and potency of fentanyl and carfentanil here have been ridiculous. You literally need to dose that much sometimes to stop someone going into withdrawal. Yeah, it's certainly euphoric, but the goal of care is to prevent w/d and that's a reasonable clinical assessment to make - there's a bit of room between 'no longer dope sick' and 'high as gently caress.' If sometimes there's a bit of aggressive dosing and someone gets a little happy... enh, not the end of the world, but it's not the point of the therapy. Also, because it's dosed in the clinic, the risk of diversion is... well, not zero, but certainly lower than if it was provided at the pharmacy.
I also wanna point out that iOAT is intended as rescue therapy. The gold standard of opioid care is buprenorphine, and somewhat below that methadone. You couldn't get into iOAT without trying and failing both of those. I personally try to steer as many patients as possible towards suboxone because it's just so much drat safer. The problem sometimes is that they take it on the street and then go into precipitated withdrawal and then never want to touch it again. Well, of course it wasn't fun, you took 2 mg when you were high as hell on fentanyl and then felt like you were dying.
Just to be clear, I was simply blown away by the tolerances of some of your patients. No criticism, judgement, or moralizing intended. "armchair medicine" is always weak stuff, I'm sure that you & other medical professionals are dosing & prescribing appropriately. Suboxone is great stuff but the withdrawals were absolute hell on earth. I wasn't able to sleep a wink until day 5, and that's just the most memorable symptom.
Thanks for the thorough explanation
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Mar 1, 2022 01:01
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Feb 27, 2022 21:51
