In 2018 we find ourselves battling an opioid crisis that has been years in the making. Opioids are drugs that act on the nervous system to relieve pain and were originally derived from opium but now also include synthetic preparations. In the mid-1990s, their use by physicians was heavily promoted by the pharmaceutical industry, leading to greater prescribing for both acute and chronic pain. Patients using opioids can develop a dependency or addiction. There are two sources of opioids: those that are produced by the pharmaceutical industry and those that are illicitly produced. Recently, the illicit supply has become so contaminated with fentanyl (a very powerful opioid) or fentanyl-like substances that many people are at risk of an unintended acute and potentially fatal poisoning. Peterborough has not been immune: in one week last month, there were six poisonings treated in the PRHC Emergency Department.
Preventing the harms of opioid use can start upstream by preventing the initiation of substance use in the first place. This work often falls to governments and public health. Iceland has been able to shrink rates of use by young people over the last 20 years from 42 percent of 15 to 16 year olds reporting inebriation to only five percent. Rates of smoking tobacco have dropped to three percent among youth. It’s taken a broad initiative by communities and parents but the impact has been breathtaking.
The health care sector plays an important role in prevention too. Physicians and other prescribers can help reduce harms by very judicious use of opioids for the management of pain: new evidence-informed guidelines and standards now outline practical ways to use these drugs in ways that protect patients from becoming dependent. And better pain management resources, like pain clinics, will help provide safer and sometimes better options to opioids.
We need to accept that a percentage of patients prescribed opioids will develop an opioid use disorder, and we need to offer earlier and better help. Many stand to benefit from improved identification and treatment of their dependencies. This can be accomplished by integrating the treatment of opioid disorders into primary care, and by enhancing access to both community withdrawal to assist people to transition into treatment services. Our LHIN has recently invested in these services, with a new Rapid Access to Addiction Medicine, or RAAM Clinic funded for Peterborough.
I am a strong believer that none of this will be successful unless we also address the stigma of addictions. People with addictions are discriminated against unfairly, and this stigma further harms them, acting as a barrier to care. As an example of what needs to be done, the recent expansion of Naloxone kit provision through the Emergency Department at our local hospital included anti-stigma training for all implicated personnel. This type of approach bears repeating.
Which is one reason why harm reduction must be accessible, non-judgemental, and comprehensive. We know that some harm reduction strategies, like needle exchange, are extremely cost-effective. We have seen how supervised consumption sites (SCS) save lives in large urban centres both in Canada and internationally. We now have widespread access to Naloxone, a rescue medicine to reverse an overdose and buy time until first responders arrive. Added to these, Peterborough may also soon be hosting an overdose prevention site (OPS), funded by the province as an interim measure while longer term permission is sought from the federal government for an SCS.
SCS are places where people can bring their drugs to use safely, in the presence of health care workers who can respond if there is an overdose. OPS are usually temporary versions, with very few barrier to encourage those who are fearful or feeling very stigmatized to access them. So far, we are seeing signs of success in Ontario. In London, overdose deaths have been averted because of the services available at their temporary overdose prevention site. A Toronto Drug Strategy review of safe consumption sites has found that they save lives, help get people into treatment, reduce public drug use and do not cause any increase in crime. For all these reasons and more, it’s a strategy worth trying and one that we should all support.
By Dr. Rosana Salvaterra, Medical Officer of Health, Peterborough Public Health
For more information about Dr. Salvaterra, her bio is available on this webpage: