London doctor prescribing opioids to selected group of users in bold response to drug crisis
LONDON, ONT. A London doctor is urging a new approach to stemming the deadly opioid crisis: Give drug users a safer supply of prescription narcotics so they don’t turn to potentially contaminated street drugs instead.
The London Intercommunity Health Centre has been quietly prescribing opioid drugs to a carefully selected group of highly vulnerable people struggling with addiction for the past three years in a bid to prevent them from seeking out more dangerous illicit drugs on the street.
“People are turning around really quickly and really solidly on the program,” said Dr. Andrea Sereda, the program’s director. “We select people who we think are highly vulnerable and at high risk of death .... We are being really careful and really thoughtful about how we prescribe these opioids.”
Sereda prescribes hydromorphone, the most common prescription opioid used by London’s injection drug users, to select patients struggling with addiction. She sees each patient in the program at least once a week for drug testing, discussions about drug use and harm-reduction, and managing any chronic health conditions or infections.
The initiative began with three women but has since expanded to about 100 people, Sereda said.
“The women were at really high risk of death,” she said. “We saw these first three patients do really remarkably well. We went from somebody who was imminently going to die of her HIV and now she’s well and treated and living independently in her apartment.”
The program is, in part, a response to the scourge of deadly fentanyl, a hyper-potent synthetic opioid implicated in a growing number of deaths here and nationwide.
While there is prescription fentanyl, a drug 100 times more powerful than morphine, much of the fentanyl that circulates on the streets is made in clandestine labs without the precise dosing and proper oversight you would find in a pharmaceutical facility.
A single hydromorphone pill can sell on the street for $60. Fentanyl sells for less and requires much less to get high.
The concept of deliberately prescribing opioids to addicted patients comes amid a crackdown on prescription narcotics in the medical community.
In recent years, the College of Physicians and Surgeons of Ontario — the profession’s regulator in the province — has issued guidelines and recommendations for the judicious prescription of opioids.
Earlier this year London’s hospitals joined forces to roll out a plan limiting the number of opioids prescribed to patients with acute pain to a maximum three-day supply. The goal is to limit the number of the highly addictive drugs in public circulation and clamp down on potential substance abuse and drug dependency.
But for vulnerable people who are severely addicted to opioids, the inability to access a pharmaceutical-grade supply of drugs is costing them their lives, Sereda said.
Sereda does not prescribe the long-acting variety of hydromorphone, a formulation London researchers have linked to heart infections and HIV transmission in injection drug users when the crushed pill/water mixture is left out and then reinjected without being heated first.
Since many of the program participants are on social assistance, drug benefits pay for their opioid prescription.
A recent Ontario study found one-third of the opioid overdose deaths in Ontario in 2016 involved people with an active opioid prescription. Of those, 60 per cent had only the prescribed drug in their system when they died.
Ward 6 Coun. Phil Squire said prescribing potentially deadly pharmaceutical-grade drugs to addicted people needs to be approached carefully and with solid scientific evidence to back it up.
“I’m concerned about it, I have to admit. I have a lot of questions about a health agency taking it upon themselves to do this,” he said. “I’m not sure what problem is being solved by doing this.”
Squire supports supervised druguse site services — places where people can use drugs with medical supervision — but said a program that allows addicted people to use prescribed narcotics on their own without the oversight a drug-use site provides is concerning.
“Opioids can kill you. If they’re not controlling how and when the people take the drugs, I would suggest that is a somewhat risky approach to take. It’s not something that I would support or suggest doing,” he said.
Squire also wonders if there are safeguards in place to prevent people in the program from also using additional illicit substances or diverting the prescription pills to the streets.
“I just worry about this. We don’t have enough information,” he said.
There have been no overdose fatalities among the group in the program in the three years it’s been running, Sereda said. The program has helped boost doctors’ ability to treat drug-using patients with HIV who might not otherwise have seen a physician. Other issues, including sex work and incarceration, have been decreased among the program participants, Sereda said.
“The emergency safer supply program is a door into a system that has systemically excluded these patients in every way. It’s a door into health care,” she said.
The program is not a substitute for addiction treatment medicine, including methadone or suboxone, but it is an opportunity to meet high-risk individuals where they ’re at and possibly open doors for future treatment when they’re ready, Sereda said.
“We don’t claim to be treating opioid use disorder. What we’re doing is reducing the harms of people who continue to use street drugs,” she said.
After a spate of overdose deaths across the region in early April, police and public health officials pointed to a possible bad batch of drugs as the culprit.
The region’s top public health official says harm reduction measures, including safer supply programs, should be on the table.
“Having a much more predictable dose makes a big difference, and of course reduces the risk of spreading HIV or hepatitis C or contracting other infections,” said Dr. Chris Mackie, chief medical officer of health at the Middlesex-london Health Unit.
“It’s something that’s got to be considered. We have been made aware of the work that is happening at the London Intercommunity Health Centre. They’re not alone. This sort of approach is being used around the world.”