Doctors across Ontario are prescribing potent opioids to patients who may otherwise overdose and die on the street supply — and they are calling on other clinicians to do the same.
They’re part of the growing safe supply movement, made up of prescribers and harm reduction advocates in Canada who are calling for access to pharmaceutical opioids as an alternative to the illicit market that has become tainted with bootleg fentanyl and carfentanil.
“We have to be willing to step outside of our comfort zone and out of the medical establishment comfort zone and say that we need to keep people alive,” said Dr. Andrea Sereda, a family physician at the London Intercommunity Health Centre in Ontario.
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For the last three years, Sereda has been prescribing take-home hydromorphone tablets to select patients who are currently relying on the illicit market, most of whom are homeless and inject drugs. The effort, which she refers to as “emergency safer supply,” started with three people and has since grown to 100.
Sereda says the results have been positive. None of the patients have fatally overdosed, half of them have found housing, and they have weekly contact with healthcare providers.
“It’s not just a prescription for pills, but it’s a relationship between myself and the patient and a commitment to make things better,” Sereda told Global News. “That involves me taking a risk and giving them a prescription, but it also involves the patient committing to doing things that I recommend about their health and us working together.”
Safer supply is not a replacement for methadone or suboxone, said Sereda. It’s an option for the subset people for whom methadone and suboxone don’t work, and it serves as a bridge for people who may not be ready for those treatments.
Hers is one of the only programs of its kind in Ontario, and she hopes to see more like it. Similar efforts include prescription injectable opioid programs in Vancouver for a subset of patients for whom opioid substitution therapies such as methadone and suboxone are ineffective. Last year, another Vancouver clinic began prescribing hydromorphone tablets for patients who consume them on site with medical supervision.
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Dr. Nanky Rai is one of two physicians at the Parkdale Queen West Community Health Centre in Toronto who began prescribing hydromorphone tablets last November to patients who rely on the illicit opioid market. She now prescribes to around 10 patients and she has seen an improvement in their quality of life.
Rai said she was spurred to ramp up this type of prescribing in part because of the number of people she knew who were dying from opioid overdoses linked to the contaminated drug supply.
“I’ve had people who, literally, their urine is just all carfentanil,” said Rai in an interview. “That’s really what terrified me into action. Before that, I was doing it slowly building things up. If we don’t catch this, we’re never going to be able to prescribe any drugs that are meant for human consumption that could actually compete with and address what carfentanil is doing to peoples’ bodies — for those who stay alive.”
Rai also said that the focus on slashing opioid prescriptions as a solution to the overdose crisis has been harmful for some. Not only has cutting people off of their prescriptions forced many patients to turn to the dangerous street supply, it has also impacted those who need pain control for things like medical procedures, who now have more difficulty accessing them.
Rai said that she looks forward to having her prescribing program evaluated in the future. “We recognize that we’re building as we go,” she said. “But we can’t wait in order for more research to be done in order to stop people from dying.”
Addiction experts say that primary care providers have an important role to play in the face of governments that are slow-moving or unwilling to embrace certain harm reduction measures. Sanctioned supervised consumption sites exist only in B.C., Alberta, Ontario, and Quebec. And Alberta and Ontario have recently frozen or withdrawn funding for a number of sites.
But the overdose crisis has become even more urgent as death rates continue to rise across Canada. Nationwide overdose data released earlier this week by the federal government show there were at least 4,460 opioid overdoses in Canada in 2018, up 10 per cent from the year before.
New figures released this week from Ontario’s public health agency show that 388 people in the province died of an opioid overdose last summer, down slightly from the 414 deaths during the same time the year before.
“If 11 people a day were dying of any other reason, whether it was tainted lettuce or Ebola or a virus like SARS, I think we would be mobilizing at the community to do things differently to stop that epidemic,” said Sereda. “And I think just because it’s affecting a highly-stigmatized group like drug users doesn’t mean that doctors shouldn’t come together for that collective action on this issue.”
The federal government has expressed openness to safe supply measures. In May, Health Minister Ginette Petitpas Taylor said it had approved injectable hydromorphone to treat opioid addiction. However, it is not covered under the Ontario Public Drug Plan, as it is under the equivalent program in B.C.
On Thursday, a group of more than 400 healthcare providers and researchers released an open letter to Ontario Premier Doug Ford to add high dose injectable hydromorphone to the plan so that it can be prescribed in a cost-effective way. The letter also called for the implementation of programs that provide safer drugs.
A spokesperson for the Ontario health ministry told Global News in an email that the province “takes the ongoing opioid crisis very seriously and is committed to helping people struggling with addiction to get the help that they need, when they need it.”
The province is also reviewing the federal injectable hydromorphone announcement, but that “no decisions have been made with respect to Ontario’s support for hydromorphone treatment.”
Former Liberal health minister Jane Philpott, who is currently an independent MP, was instrumental in implementing a number of federal measures to address the opioid crisis in Canada such as easing restrictions around opening supervised consumption sites.
Although health care is under provincial jurisdiction, Philpott told Global News in an interview that the federal government can be a champion for certain harm reduction approaches.
“As physicians and this entire system becomes more comfortable with the concept of safe supply,” said Philpott, “one of the things the federal government has already done and can do even more is make sure that the work that’s being done is well-documented and well-researched so that we can start to understand what best practice looks like.”