Opioid crisis | “I prefer it to be me, your dealer”

Prescribing drugs to save lives by replacing street drugs: a solution to the opioid crisis? Quebec doctors try the blow, while in British Columbia, a public policy is born.

Lila Dussault
Press

To save their patients from opioid overdoses, which continue to wreak havoc in Quebec, doctors have started to prescribe drugs to replace contaminated drugs sold in the street, a way of doing things born out of the pandemic.

“At the beginning, I was not the most enchanted by this new approach, says D^D Marie-Ève ​​Morin, family doctor specializing in addictions in Montreal. But I have lost so many patients by overdose this year that I realized that we have no choice but to go towards this, and that’s okay. ”

Deaths from probable cause of overdose increased by 25% in Montreal over one year, between March 2020 and March 2021, according to the most recent data from the National Institute of Public Health of Quebec. Enough for doctors to decide to act.

“At the start of the pandemic, we feared that the drugs on the illicit market had changed,” recalls Louis-Christophe Juteau, family doctor at the Dopamed community clinic in Montreal, and head of the drug addiction medicine service at the Center hospitalier. from the University of Montreal (CHUM). The apprehension was justified. From the summer of 2020, when overdoses reached peaks in Quebec, doctors began to prescribe drugs to replace those, counterfeit and contaminated, which circulated in the streets.

The practice has since spread.

Prescribing drugs, instructions for use

Doctors, however, do not distribute just anything, anyhow. The practice is even the subject of public policy elsewhere in Canada (see below). It all started with pan-Canadian guides, developed during the pandemic for medical professionals to treat homeless people with COVID-19. “These patients had to isolate themselves in closed places, and there were times when we had to prescribe substances temporarily to replace drugs,” says Dr.^r Juteau.

Since then, in Quebec, tablets such as hydromorphone (an opioid analgesic marketed under the name Dilaudid) have mainly been prescribed to heroin addicts, alongside other opioid substitution treatments, such as methadone.

Street drugs are increasingly contaminated with fentanyl, a synthetic opioid more potent than heroin. New even more dangerous substances have also appeared on the black market in Quebec since 2020, such as isotonitazene. No matter what they use, addicts no longer know what substance they are dealing with.

” [Consommer]is playing a bit of Russian roulette, ”says Jason.^*. Addicted to opioids for the past ten years, the 26-year-old is on methadone treatment and is recovering from a recent overdose. “Of course when you’re not feeling well [à cause du sevrage], you don’t think about that. ”

The three doctors consulted by Press claimed that prescribing Dilaudid to patients kept them away from street drugs while facilitating trust, contact with medical teams and improving living conditions.

“When physicians change their practice, it is not necessarily distribution, but it is for the purpose of patient engagement, to avoid an overdose. », Adds the D^D Julie Bruneau, doctor at the CHUM and holder of the Canada Research Chair in drug addiction medicine.

Overcome your apprehensions

After being released from the hospital after his last overdose, Jason was prescribed two Dilaudid pills per day by his family doctor, Dr.^D Marie-Ève ​​Morin. He will have to go to the pharmacy every day to get them. “She told me, word for word: ‘I’d rather it be me, your dealer”” Jason said. Press spoke to him just before he went there for the first time.

“It makes me feel secure knowing I have this,” he said. It was in my ideas to find a source [de drogues illicites] and arrange for myself. The young man explained that withdrawing from methadone made him sweat cold and feel so sick that he sometimes cried when he went to the pharmacy to get his prescription. “Astheure [avec la prescription de Dilaudid], it would stress me out a lot less to start a job, ”added Jason, who is currently receiving Employment Insurance benefits and wants to return to the workforce.

“From a moral point of view, considers the D^r Juteau, faced with an overdose epidemic, it’s up to us, to the doctors, because we have the tools to do it, to get our hands dirty to reduce the number of deaths. ”

* Fictitious first name

Safe Drug Prescriptions: Too Little, Too Late?

Vancouver – Six people die of an overdose in British Columbia every day – far more than from COVID-19. As 2021 is on track to become the deadliest year in this province, a safe drug prescription program is emerging.

“It’s not an overdose crisis, it’s a poisonous drug crisis!” », Corrects from the outset Jean Swansson, city councilor for the City of Vancouver, in an interview with Press at the end of August.

The one who has sat on the City’s municipal council for more than three years has lost many acquaintances in her entourage due to overdoses. She has since been a strong advocate of safer drug distribution, or safe supply, in English.

British Columbia is experiencing an unprecedented opioid crisis in Canada. Nearly 1,800 people died of overdoses between January and October 2021, according to the most recent figures from the province’s coroner’s office released on December 9. In October, 201 people lost their lives, the highest death toll on record in a single month.

Remember that the province declared a state of public health emergency in 2016 because of this crisis, which has only worsened since the start of the pandemic.

In response to the wave of deaths, British Columbia implemented the first public health policy on access to safe prescription drugs in Canada last summer.

Prescriptions That Save Lives

Like across the country, street drugs – not just heroin – are increasingly contaminated with extremely potent synthetic opioids, such as fentanyl.

As part of this new British Columbia policy of so-called prescriptions safe supply, synthetic opioids can now be officially prescribed to seriously addictive patients to replace their usual illicit use. Other drugs, such as stimulants, may be added in later stages.

This avenue differs from that taken by physicians in Quebec, who also began to prescribe certain doses of synthetic opioids to their patients already in treatment (see above).

” The safe supply, for me, it is a public policy endorsed by governments and which responds to a crisis, explains the D^D Julie Bruneau, doctor at the CHUM and holder of the Canada Research Chair in drug addiction medicine. While I think here [au Québec], we are no longer in alternative treatments. ”

This approach also has its opponents in the west of the country. ” The term safe supply, it’s very busy. Even in British Columbia there are a lot of voices in the medical population who say they don’t want to be pushs of pills, ”says Dr.^D Bruneau.

Not enough, according to some

Either way, it is too little, too late, according to some. While the policy had only just been implemented, Press went to East Hasting Street, a disadvantaged place in northeast Vancouver, to see how she was received.

On the spot, sidewalks, alleys and parks abounded with destitute, intoxicated or homeless people. The overdoses here weren’t just numbers. “Last night I saw a guy die of an overdose just outside my window,” told Press Andy Pinchbeck, a neighborhood resident.

“I don’t think much of the program [d’ordonnances de drogues sûres], also said Hugh Lampkin, coordinator of the organization VANDU (Vancouver Area Network of Drug Users). You can only have drugs for three days. It’s so unrealistic! ”

An opinion shared by city councilor Jean Swansson: “It’s too bureaucratic for a lot of people. You have to make an appointment with a doctor, you have to go to his office, you have to wait… every step of the way, you lose someone. ”

In Montreal, Martin Pagé, director of the organization Dopamine (which helps drug addicts), believes that distributing prescription drugs is not enough.

“Too many people in British Columbia and Canada are in mourning because they know people who have died from illicit drug use,” lamented in an interview with Press Sheila Malcolmson, British Columbia Minister of Mental Health and Addictions and responsible for establishing this new policy. We are determined to find new ways to save lives during this crisis. ”