Therapy can't keep up with demand
Not enough authorized prescribers for drug therapy
Dr. Morris Markentin has prescribed methadone for 15 years, but the stakes have never been higher than they are now.
Opioid agonist therapy, or OAT — prescribed medications that act as substitutes for an increasingly deadly illicit supply — is one of Saskatchewan's bulwarks against record-high overdose deaths.
But clinicians say Saskatchewan's OAT regime struggles to meet the needs, medical and otherwise, of a growing base of patients, causing them to relapse.
“In this town you can phone and you can have fentanyl delivered your door within five minutes,” said Markentin, a family doctor at the Westside Community Clinic in Saskatoon. “They have a faster delivery time than Skipthedishes. We can't deliver methadone.”
Saskatchewan's coroners service says a record 329 people are suspected or confirmed to have died of overdoses in 2020, a trend driven by a wave of fentanyl in the illicit drug supply. That office has already recorded 178 such deaths in 2021.
“It's sad to say, but you become a bit numb to it,” said Regina infectious disease specialist Dr. Alex Wong.
Wong works at a clinic in Regina for people with blood-borne infections. Because intravenous drug use is the main route of HIV transmission in Saskatchewan — unique among Canadian provinces — many patients are opioid users who rely on OAT to stave off symptoms of withdrawal. But Wong said fentanyl has made stabilizing such patients even more challenging.
“There's been some patients (who died) where we've cried and it's been soul-destroying for us to hear,” Wong said. “But you have to figure out a way to move on, because if you don't, you're not going to be useful to anyone else.”
The theory behind opioid agonist therapy is simple: a person receiving methadone or suboxone won't have to roll the dice on a toxic drug supply or spend their time finding money to buy substances.
“It just frees up some space for them to not live in withdrawal and think about what's important to them,” Jeannie Coe said.
Coe, one of just eight nurse practitioners in Saskatchewan authorized to prescribe and continue OAT, said some clients even reconnect with estranged family after starting the therapy.
However, the therapy can only begin if patients can find a prescriber. And while the number of prescribers has risen in recent years, doctors say their ranks are far too thin.
“It's not anywhere remotely close to where it has to be to provide for the demand that's required,” Wong said.
The College of Physicians and Surgeons of Saskatchewan says 136 doctors were authorized to prescribe OAT as of May 2021, up from 81 in March 2018.
Some regions, particularly rural areas, have no prescribers at all, Markentin said.
“You can name off 10, 15 smaller cities that do not have OAT prescribers. We need one on every corner, and that's what we don't have.”
That means those who do offer the therapy often manage scores of patients. Dr. Sean Groves in La Ronge said he originally did not wish to prescribe OAT, seeing the toll it took on doctors who ran the program.
“They were leaving and no one would take over,” Groves said. “We didn't draw straws, but I drew the short straw.”
Now, Groves loves the work. He said it has changed him as a doctor and how he builds relationships with his clients.
“Within weeks, you can see someone's life completely change,” Groves said.
He said the shortage of resources goes beyond doctors. For OAT to truly work, patients need social workers, transportation, housing and other supports to help them stay on the medication and avoid relapse.
“If we can't get people into adequate housing, it is almost impossible to stabilize them on opioid agonist therapy, because there are so many factors that pull them back into use,” Groves said.
The number of case managers and addictions counsellors is constantly short, Coe noted.
Dr. Brady Bouchard in North Battleford believes there should be a provincewide opioid dependency network to at least knit together the resources that already exist.
He also thinks it's time to drop extra training requirements doctors have to take to prescribe OAT — which most Canadian jurisdictions have done — arguing it could be dissuading them from offering the therapy.
“I think that's the very minimal next step,” he said. “If we're going to be one of the last two jurisdictions in North America that requires an exemption, I think common sense says we're not moving with the times.”
Markentin, who leads the CPPS'S OAT programs, argues the real issue is that overwhelmed family doctors don't have time to offer the therapy. He said the training is vital given the lack of addictions medicine instruction in schools.
“We're not asking you to give us your first-born. We're asking you to do a little bit of training,” he said.
Wong believes the solution needs to be interdisciplinary clinics — one-stop shops so patients don't get lost in a web of appointments and referrals.
“To basically expect that a physician or a nurse practitioner will just prescribe (methadone) and magically transform (someone's life) — there's no question that there's value there, but you won't get anywhere near the same kind of value (as) if you actually provide comprehensive services,” Wong said.
It frees up some space for them to not live in withdrawl and think about what's important to them.