CRISIS IN THE SHADOWS
In convergence of pandemic and opioid-overdose emergency, doctors prescribe a safe supply of drugs
British Columbia’s other public-health emergency has slipped from the headlines lately, as eyes focus on the COVID-19 outbreak. But the opioid crisis that has claimed at least 5,605 lives in B.C. since 2015 races on relentlessly.
In one week recently, paramedics responded to 35 potential overdoses in Victoria alone, nine of them on one day when socialassistance cheques were issued. That same day, two men were found dead in their tents at the homeless encampment in Topaz Park.
The convergence of two public emergencies on an already vulnerable population is one of the reasons a small number of doctors who specialize in addiction medicine are prescribing a safe supply of drugs for their patients.
“Safe supply is controversial and has it own risks, but I’m in favour of anything that will prevent overdoses and save lives,” said Dr. Bill Bullock, Island Health’s medical lead for addiction medicine for the south Island.
People who use opioids or stimulants are buying from dealers on the street and they don’t know what they’re getting, Bullock said.
“They’re using a supply that’s unsafe because it’s contaminated with fentanyl and other things like synthetic cannabinoids and benzodiazepines. People who think they’re buying heroin or methamphetamines are getting adulterated materials and that’s what’s responsible for the majority of the overdoses.”
Safe supply, which Bullock prefers to call pandemic prescribing, is a harm-reduction strategy that replaces unsafe drugs with a known quantity of prescribed medication.
It also allows people who use illicit drugs to keep their distance from other people to reduce their risk of contracting or spreading COVID-19 — something they can’t do if they are out trying to score and using in groups.
Safe supply is different from treating someone with methadone or suboxone, he said. “Those are addiction treatments to try and help people not use drugs. But for people who are continuing to use, a safe supply will provide them with drugs that would enable them to use without a high risk of overdose.”
In March, the B.C. Centre on Substance Use issued guidelines that give physicians and nursing practitioners more tools for prescribing substitute medications that people can use instead of street drugs.
The guidelines aim to protect people from several risks, including overdosing on increasingly toxic street drugs, contracting or spreading COVID-19 by going out frequently to buy drugs, or suffering from withdrawal when staying home and self-isolating.
“This is for folks that aren’t engaged in treatment currently, or they are engaged in treatment, but that treatment hasn’t been effective,” says Cheyenne Johnson, the centre’s co-interim executive director.
The guidelines also incorporate Health Canada’s temporary exemptions to the Controlled Drugs and Substances Act that allow pharmacists to renew prescriptions by phone and deliver medications to a patient’s home, so people don’t have to make as many trips to the drugstore and are able to self-isolate during the pandemic.
Bullock said prescribing a safe supply of drugs is best done in a situation where the patient is known by the doctor.
It should only be done by people who have special expertise in addiction medicine, he said, noting only a couple of doctors specialize in that area in Victoria.
“It’s not like going to the store. The very first thing is a very thorough history-taking and physical examination. The physician needs to understand their patient and their background, what it is they’re using, what their history is of attempts to either stop or modify their use, and what medications they’ve tried in the past.”
It can take a couple of hours to assess one patient, said Bullock. The first line of treatment for opioid-use disorder is suboxone. If that’s not successful, the physician can prescribe methadone, he said.
“But if someone is continuing to use, in spite of treatment with opioid agonist therapies, or if they’ve declined opioid agonist therapies, they may be a candidate for pandemic prescribing,” said Bullock.
Pre-pandemic, many people on methadone would go to the pharmacy every day for a dose that the pharmacist watched them take.
Some people, generally those who are working and have stable housing, are given “carries” or a take-home supply so they don’t have to go to the pharmacy every day and have a locked box where they can store several days’ worth of methadone.
That’s harder to navigate with the COVID pandemic.
With safe supply, addiction doctors are writing prescriptions for hydromorphone or long-acting morphine to replace heroin and fentanyl, said Bullock, adding that most of the heroin that’s purchased now is more fentanyl than heroin.
“But prescribing something like that has its own risk, because one can still overdose on legal opioids or the drug could end up in the hands of someone with low tolerance. The amount a regular user might take several times a day would kill a non-user in one dose,” said Bullock.
Most addiction-medicine physicians are in favour of the concept of safe supply. They believe that if people are going to use drugs, they should have drugs that are safe to use. The issue is in the execution, said Bullock.
“Physicians are very concerned with safety and doing something in a way that’s not going to create harm,” he said.
Doing safe supply properly requires a team approach with follow-up by nurses and pharmacists as members of the team, he said.
Doctors can mitigate risks by prescribing for short periods and following up with their patient, or having a street nurse check in with the patient regularly, he said.
“But that’s in short supply right now. People are getting this kind of prescribing now, but it’s not happening on a large scale,” he said.
Dr. Ashley Heaslip, medical lead for PHS Community Services in Victoria, said it is happening in the inner city, where she works as part of a team with nurses, mental-health workers and other front-line workers.
“That wraparound servicing has meant that the prescribing that we’re doing is done within that full picture for the individual,” she said. “And that really does encompass that full continuum of care that people do best within.”
As well, Heaslip said, she and a number of physicians have formed an on-call group — the Victoria Inner City COVID Response — to support nurses working with people at Topaz Park or in temporary housing at hotels and motels in the city.
She said there has been significant demand for safe prescriptions during the pandemic.
“As we can imagine, when you’re a patient sitting in the middle of this dual crisis and there is an option on the table for achieving some sense of safety within it, I think any of us would walk toward that sense of safety,” she said.
In addition, she said, doctors are hearing from patients and the people responding to overdoses that the drug supply is becoming more toxic, and that overdose symptoms are worsening.
Heaslip stressed, however, that safe supply alone won’t solve the overdose crisis without long-term housing options, mental-health supports and a host of other services.
“Safe-supply prescribing is a piece of that puzzle, but it is not the puzzle itself,” she said. “There are lots of other elements that are incredibly important to ensure that people have the opportunity to live their best life.”
Bullock said he’s hopeful that things will improve as people without stable housing are moved into hotels over the next two weeks.
The peer-support group is working non-stop in Topaz Park. Island Health workers haven’t had a day off in a month and a half. Nurses and physicians haven’t had a break in two weeks, said Bullock.
“Everybody is doing the best they can and trying really hard to help each other out.
“The government has stepped up and the city has stepped up and everybody is really trying to help the situation.”