In response to the opioid crisis, Canada embarked a few years ago on a safer supply program in which doctors prescribe pharmaceutical opioids to addicts to keep them from using contaminated street drugs. If this approach works well for some patients, others will outright resell the pills, obtained at public expense, to buy drugs on the street that put them at risk, discovered The duty.
Marie writhes in pain while waiting for the pharmacy doors to open. She is in need. Like every morning. “When I started using, no one warned me how sick you get when you’re in withdrawal. The shit, the vomiting, all that. »
The young thirty-something with a drug-ravaged face crosses the downtown Montreal branch, not far from Place Émilie-Gamelin, as quickly as possible to get to the prescription counter. “Is he kidding me or something? » she says, sighing loudly to the pharmacist. She asks about the condition of a friend, also in need, who is in line behind her with his face covered in sweat despite the winter cold setting in.
Meanwhile, the pharmacist opens some Kadian pills [morphine orale à libération lente] and mixes the precious little balls into an applesauce that Marie devours in three spoonfuls directly at the counter. Marie quickly feels the benefits of the drug, which last for 24 hours. But it’s not enough. The Kadian is only the bottom layer that allows it to survive. It will only “make her sick”, as she says.
Mary — to whom The duty granted anonymity to avoid trouble — so comes out of the pharmacy with his daily dose of Dilaudid: eight capsules of 8 milligrams each. Enough to knock out a horse. For reference, for a person who has post-operative pain, doctors will generally prescribe taking a pill of 1 to 2 milligrams every six hours. Marie has a total of 120 milligrams in her hands every morning.
She has barely left the pharmacy when she is handing out pills here and there. She owed three to a guy, sold two to a girl who begged her to give him credit for a few hours. She buys a puff of freebase, which she smokes immediately, while waiting to find a “syringe kit” to inject Dilaudid. In the neck, because it no longer has any veins. It won’t even give him buzzbecause his tolerance is too high.
Marie doesn’t hide it, she sells her Dilaudid tablets almost every morning. At $5 or $10 each, depending on the mood of the day. “It sells very, very easily,” she assures. She keeps at least three for herself and sells the rest to “survive”. It allows him to eat, to pay himself “a puff », to buy cigarettes or clothes. Except that she finds herself in withdrawal. “I end up with not enough medication, and I have to use the money to buy fentanyl because it’s stronger,” she explains casually.
I end up with not enough medication, and I have to use the money to buy fentanyl because it’s stronger
A “mixed” pharmacist
At the pharmacy where she works, Isabelle — who requested anonymity so that the identity of her employer and her customers cannot be established — sees around twenty drug addicts who come to collect their daily doses. They often line up outside the pharmacy in the east of the city waiting for it to open, often sick from withdrawal. “When I see the line in the morning, I tell myself that I’m the local “dealer”,” sighs Isabelle.
She expected to see the doses decrease over time, but she noticed, on the contrary, that they only increased. She regularly gives 10 or 15 tablets of Dilaudid 8 milligrams. Recently, she served a patient who had a prescription for 30 pills. A dose that exceeds anything she has ever seen. Concerned, she called the attending physician, but he maintained the dose. “It’s way too much, he’s sure to resell them,” she says.
She has even seen a patient resell her Dilaudid directly in the pharmacy. “We kicked her out, but what do you want to do? » she asks, shrugging her shoulders sadly. “It’s prescribed, I’m not going to tell them no. And then, they know that with this, they will be able to buy food, clothes or crack. It’s a bargaining chip. And then, their lives may have improved a little thanks to that. »
She also notes that the generic Dilaudid is not popular. To the point where the pharmacy where she works doesn’t even have any anymore. “If you give them the credits, they have a fit. Patients don’t want it because it sells less well on the market. That’s how much…”
Isabelle is not against safer supplies. But she has the impression that we have “opened Pandora’s box”. She is “mixed”. “There are some where it works well, and I know that they are not going to resell them and that it will help them not to go and buy drugs elsewhere. There are others who abuse it. I think we should remain reasonable in the quantities. »
Lack of supervision
Pharmacist-owner David St-Jean Gagnon, who has worked with drug addict clients for 15 years, agrees. “I find that the doses are extremely high. And we have no way of really knowing whether the patient is taking his pills completely or if he is selling some of them. These are still patients who are covered by RAMQ, so I find it a little ethically disturbing. »
He is convinced that the safer supply helps many people, but he would like the taking of opioids prescribed through the program to be better regulated. “It seems like we’re just giving them that and letting them loose in society.” The Kadian, for example, is taken under the supervision of the pharmacist. Could Dilaudid be too? he asks himself.
He is well aware that resellers will always find a way to do it. He gives the example of methadone — an opioid-based replacement medication used for a very long time to treat addiction — which must be consumed in pharmacies. Which doesn’t stop some people from making themselves vomit when they go out to sell the mixture to the most desperate. “It’s a shocking example, but that’s what’s happening on the black market in relation to all that. And there, we have Dilaudid which is added in there. The fact that it is in tablets, I find that it is super easy for patients to resell and make money with it. »
Worried doctors
Dr. Marie-Ève Morin, a family doctor who has worked in addictions and mental health for 20 years, believes in harm reduction, in general. In addition to her work as a doctor at the La Licorne clinic, she founded Projet Caméléon: she tours music festivals to distribute sterile consumption materials and suggests that consumers have their drugs tested before consuming them.
But when she saw the quantities of Dilaudid prescribed by her colleagues, she said she was “perplexed”. “It’s not that I don’t believe in it, but I wonder where we’re going,” she confides in her office decorated with unicorns and skulls, which give the impression of visitor to be at a tattoo artist than in a doctor’s office.
According to her, the prescription of pharmaceutical opioids should be temporary, while the dose of traditional treatments – methadone or buprenorphine – is fixed, which allow patients to become functional again by stopping using. She believes much more in these classic addiction treatments, which have proven themselves over the years and saved countless lives, than in the safe supply program. “We are now prescribing enormous doses of methadone and we continue to give Dilaudid, so tolerance continues to increase. »
She also considers that the safer supply “does not at all encourage people to break the habit of injection”. She repeats that injection, whatever the substance, “is not trivial” and carries risks. On this point, she joins a group of doctors specializing in addictions from Ontario, who recently came out publicly to denounce the risks of this program and the resale of opioids which fuel the market.
“It is not because there is more Dilaudid in circulation that there is less fentanyl,” assures the DD Morin. We still have deaths from fentanyl overdose among patients who are on the safe supply program. We say it among doctors: we are tired of feeling like dealers when patients come to try to negotiate their dose. »
To read tomorrow: A program that, despite its challenges, saves lives