trying to save lives of those hit hard by covid and the overdose crisis
drug users continue to fatally overdose in record numbers, due to a poisoned street supply and pandemic restrictions. there are differing opinions on how to save their lives.
12 minute read
sam gill, clinical nurse leader a the rapid access addiction centre st st. paul's hospital. "i think more people are struggling and need the help," gill said.
francis georgian
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by: lori culbert
christopher composes bluesy funk music in his notebook while waiting for treatment at an addictions clinic in st. paul’s hospital. he’s tired of chasing a fentanyl high and grateful for the second chance he’s being offered by the medical staff.
“i wouldn’t be alive without it,” christopher, 40, said of the rapid access addiction centre, while sitting in its withdrawal management room. “it gives hope. it’s like a beacon of light in an otherwise dark world.”
at the clinic, which opened in 2016, substance users are offered replacement drugs and other social supports as a first step toward stabilization. it’s christopher’s second visit to the centre, where he’s looking for kadian — a brand of slow release oral morphine — to try to curb his body’s craving for fentanyl.
“people like me can still be contributing members of society if we can get better,” he said.
at this clinic operated by providence health care, as well as similar ones run by health authorities, clients are assessed by nurses and doctors, and often leave with prescriptions for replacement therapies such as suboxone and methadone. the centre also offers social workers, peer navigators and connections to other social supports off-site.
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ultimately, the aim is to transition clients to longer-term treatment in the community, which could include their family doctors, methadone clinics, and treatment centres.
“it’s holistic care,” said sam gill, the facility’s clinical nurse lead. “it’s really about removing barriers for people. our patients face so many barriers.”
rather than enduring long waiting times at more traditional drug treatment centres, clients can come off the street and walk up a metal staircase at the back of st. paul’s to get to the clinic without needing an appointment.
since opening five years ago, the clinic has created intake files for more than 10,000 people, although some might be counted twice if they returned after a period of absence. the numbers dipped during the early part of the pandemic, but are now above pre-covid rates.
“i think more people are struggling and need the help,” gill said. “the pandemic affected people’s mental health, and to cope they’ve increased their substance use.”
covid changed everything
last year was, of course, when covid-19 changed everything in the world of health care, including access to drug treatment services. and that unfolded as a parallel toxic drug crisis caused a record-setting number of overdose deaths.
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as covid-19 vaccinations rise and new infections decrease, the provincial government and health authorities are racing to re-engage drug users with the treatment system, to try to reduce those devastating overdoses, which right now are killing an average of six people a day in b.c.
but within the addictions-care system, there are debates about the best treatment to offer substance users, given the extreme potency of today’s street drugs. are fewer detox services needed, for example, if more clinics like the rapid access addiction centre offer opioid replacement drugs? does b.c. have enough physicians and pharmacists willing to provide this type of addictions medicine?
b.c.’s minister of mental health and addictions told postmedia that some changes around provincial drug treatment policies will be announced next month.
in the vancouver coastal health region, some residential addiction treatment services reduced capacity or temporarily closed due to the pandemic. some
physicians and clinics stopped seeing drug users in-person, which resulted in a decrease of both new clients and of followup appointments with existing clients, the health authority said in response to questions posed by postmedia.
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“for those with addiction, in-person and outreach services are necessary for retention in care; virtual services alone are not sufficient,” vch’s statement said. “
while most services are now seeing clients in-person, visits may still be at reduced levels to comply with covid-19 safety plans; catch-up of those lost to followup has also not fully occurred.”
however, even before the dual epidemics hit drug users disproportionately hard, the number of people in vch seeking drug detox help had already begun to fall.
detox admissions in vch fell from 4,814 in 2017 to 3,352 in 2020, a decrease of 30 per cent. the decline began before the pandemic hit and worsened with the arrival of the virus.
similarly, detox completion rates went down 25 per cent over those four years, with the drop beginning in 2019 and continuing through the pandemic.
a shift in approach
while detox is important for those struggling with alcohol or other drugs such as benzodiazepines, vch officials have moved away from offering it to opioid users, said dr. mark lysyshyn, a medical health officer. that’s because if opioid users relapse after a period of abstinence — which is quite common — then they have lost their tolerance to today’s potent street drugs.
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“there are some people with opioid use disorder that it is appropriate to use detox for, but there’s very few, actually. … the reality is, that puts them at super high risk for when they relapse without any tolerance. literally, their first dose of street drugs after that can kill them,” lysyshyn said.
“so we’re trying to expand access to opioid agonist therapy … but we still need to continue to expand those options.”
opioid agonist therapy is the type of treatment offered at the rapid access addiction centre to fight addictions to opioids such as heroin, fentanyl, oxycodone or percocet. it uses replacement drugs like methadone and suboxone, to prevent withdrawal symptoms while reducing a person’s cravings for opioids, but also decreasing or eliminating the euphoric high associated with street drugs.
between 2017 and 2020, when detox admissions were falling, the number of people going on a variety of different opioid agonist treatments increased by roughly the same amount in vch, from about 4,500 to 5,500.
these are difficult treatments for people to manage, as they often have to go to a pharmacy every day to take their doses, so some relapse. as a result, lysyshyn said, the goal is to try to reduce barriers to these alternative therapies but also continue to offer harm reduction services for those who continue to use.
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rethinking addictions medicine intensified as street drugs changed and became more deadly.
in 2017, the b.c. centre on substance use released newopioid use disorder guidelineswhich “really revolutionized substance use care,” said dr. rupinder brar, an addictions consultant at st. paul’s hospital and a canada addiction medicine research fellow.
while detox can be a “great first point of entry” for people looking for a path out of addiction, she said, evidence shows those who go to detox alone face a significantly increased risk of fatal overdose and hiv transmission.
“we have learned in addiction medicine that detox alone isn’t the answer. … relapse rates are about 90 per cent,” she said. “so what we really started to do at vch is increase access to low-barrier outpatient services like opioid agonist therapy.”
it is a message that health officials are trying to get out to substance users and the people who provide them services, lysyshyn said, to counter long-standing beliefs that going into weeklong residential detox is still beneficial to opioid users, who often view it as a much-needed reprieve from the chaotic life of addiction.
‘every option available’
postmedia, though, spoke with a half dozen experts with diverse experience with either opioid use or helping those with addictions, and most argue that while opioid agonist therapy plays an important role in the drug treatment system, so does detox. they say the province must invest in more, not fewer, detox services if lives are to be saved during the overdose crisis.
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“when considering the overdose crisis, we need every option available that’s going to save lives,” said nadia tchoumi, spokeswoman with the downtown eastside’s union gospel mission. “we have heard from people who want detox but were not able to access it. … we would support greater access to detox.”
mission staff appreciate the extra efforts taken by vch during the overdose crisis, but say not all their residents want replacement therapy and the pandemic emphasized the need for detox on demand.
“we’re talking about community members who are the most vulnerable, and it’s easy for them to fall through the cracks,” tchoumi said. “what i’m hearing from our staff is even if there was an increase in 50 detox beds, it could make a major difference.”
detox was once the gateway to get opioid users into treatment. now, putting them directly onto replacement drugs means many service providers or family doctors must help them through the very, very difficult withdrawal stage, sometimes without the tools to do so, said keir macdonald, ceo of phoenix society, which runs 70 drug treatment beds and supported post-treatment housing in the fraser health region.
“we continue to see people coming into our programs still in a very vulnerable state. they may have just been started on suboxone or methadone, are still actively in withdrawal, and unstable,” macdonald said.
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“i would be enhancing detox, not limiting access, and i believe that is still a great place to engage people in the substance-use system of care. if anything, we should be providing more (support) services from a detox location.”
detox admissions in fraser health fell by half, from 2,800 in 2017 to 1.400 in 2020. that downward trend continued in the first five months of 2021. detox completion rates hovered around 60 per cent over those four years. there are 180 people on fraser health’s detox wait-list. the average wait time for admission right now is two to three weeks.
rachel thexton, who is in long-term recovery from opioid addiction, is passionate about ensuring the right kind of treatment is available for those who need it. she believes that includes
opioid agonist therapy
such as suboxone in addition to detox.
“withdrawal from opioids is one of the worst things a person can experience, psychologically, mentally and physically. and in my opinion, anyone who has any type of addiction that’s gone long term — which is mostly anyone trying to withdraw from opioids — they need help in detoxing,” she said.
“so as much as i am an advocate — a huge, huge advocate — for suboxone and harm reduction … i do believe detox is key.”
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guy felicella, who is also in recovery from opioid addiction, went into detox more than 100 times and was always accepted back without judgment — a crucial step, he said, in his path to being healthy today. felicella, now a peer clinical adviser with the b.c. centre on substance use, said detox offered him a break from the streets and a safe place to stay — but it was only successful if he could move directly into treatment, which was usually not the case because of major backlogs.
he believes the province needs to fund more residential “stabilization units” where people can detox for as long as they need, and many more long-term treatment beds.
changes coming: minister
sheila malcolmson, b.c.’s minister of mental health and addictions, said the budget for drug treatment and support services has increased since the ndp’s election in 2017. that includes, she said, more money for evening and weekend detox programs for people who can’t drop their regular lives to go into the traditional seven-day detox program.
the province’s plan is to vastly improve treatment services by 2028, malcolmson said. “if we are successful as a ministry and the government, then someone presenting to their health-care provider with addiction or mental health challenge gets just the same access to care as if they presented with a broken arm or skin cancer.”
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in the short-term, though, she acknowledged there is “more work to do” to support drug users during the escalating overdose crisis, and hinted at changes that would be announced next month:
• there has been a 475 per cent increase in people using a safer supply of drugs between february 2020 and march 2021 (for a total of 6,500 people), but the premier has asked her to reduce barriers so the numbers accessing prescribed untainted drugs or alternatives can grow.
• asked if the government would eliminate the restrictive requirement to have pharmacists witness daily opioid agonist therapy doses, she said the ministry is looking at removing barriers so more people can access this type of care.
• she said policies will be updated to encourage more doctors and nurses to prescribe opioid agonist treatments.
vch now has more than 525 doctors who prescribe replacement drug therapies, which has more than doubled over the last five years. about 2,700 physicians work in the vancouver coastal health region, and while not all provide care to drug users, advocates argue many more doctors across b.c. need to offer these alternative treatments to their patients.
for years, prescribing these drugs was heavily regulated and few physicians wanted to get involved. now, some of those obstacles have been removed, said vch’s lysyshyn. efforts are being made to reduce the stigma around addiction and to get more doctors and nurse practitioners willing to prescribe, especially in the suburbs and rural areas, he said.
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withdrawal so much more difficult
brar, a longtime addictions doctor, said that in almost a decade of practising in the downtown eastside, she has seen “an incredible shift” in the illicit drug supply. the heroin that dominated the street scene a decade ago has been supplanted by synthetic drugs like fentanyl, and more recently the introduction of benzodiazepines, which have further complicated responding to overdoses.
the extreme potency of the drug supply is believed to be a main reason that detox completion rates have fallen over the last four years, she said.
“it is concerning that the successful completion rates aren’t what they used to be, it’s become very challenging to compete with the increasingly toxic drug supply that’s out there. and we’re doing the best we can, but i’ve seen that someone’s withdrawal has changed so tremendously,” brar said.
the strength of today’s street drugs is also likely to blame for the rate of “no shows” — people who request a spot in detox but then do not show up when one becomes available, a wait that averages seven days — more than doubling from 17 per cent in 2017, to 35 per cent in 2019.
miranda compton, vch’s regional program director of addiction and prevention, said there is sadly no “quick fix” for the multi-faceted drug treatment system.
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“we don’t think of detox as the be-all-end-all of the system. it’s a component of an increasingly, by necessity, complex system of services that creates different pathways depending on the person’s substance use,” compton said.
“i do want to stress there are gaps in the system that we’re working actively with the province to fill.”
the good news, compton added, is the province has given health authorities money to fill some of those gaps, by expanding programs for alcohol and stimulant addictions, creating more long-term recovery support, and building a new detox facility planned for east vancouver.
“there’s a lot of work underway, but it’s an immense challenge,” she said. “this toxic drug supply, especially the toxicity in this past year, it doesn’t leave any room for error.”
after the emergency health crisis was declared in 2016, overdose death rates improved slightly by 2019. but in 2020, fatalities skyrocketed again, largely as a result of pandemic restrictions, and the high death tolls have continued this year.
“(this) made our jobs way more complex, and i think it also then requires us to rethink almost everything that we do, because
we’re going to have to recover from this,” compton said. “we have had people disconnect from care. and we have had an increase in people’s level of stress and anxiety in their lives.”
