Overdose

by Benjamin Perrin

  Jordan Westfall, president of the Canadian Association of People Who Use Drugs, has a similar view. “We need to really just emphasize undercutting the street market as much as possible, and that means very low-barrier access points for people already using drugs to access safer drugs. You’re interrupting the cycle of hustling that you have to do on the streets to be able to pay for drugs every day. That can mean sex work. That can mean panhandling. It can mean property crimes. All of that could be greatly reduced. It saves people; it saves our criminal justice system a lot of money.”

  Indeed, lawyers have noticed the impact when entrenched street-drug users are provided with pharmaceutical drugs instead. “I had a client whose record was unbelievable,” said Mark Gervin, a criminal defence lawyer. “He was very violent. Nothing would get in the way of him and his drugs. The amount of horrible deeds that he left in his wake in his drive to get his drugs was incredible.” Gervin estimated that this client was implicated in over 800 criminal incidents, all related to his illicit substance use.

  “He had a host of problems, including a head injury, but I didn’t see him for a while and I just assumed he was dead,” Gervin continued. “All of a sudden he was arrested for break-and-enter or something. I went to see him. I’m like, ‘Holy moly. Where have you been?’ He says ‘Well, I’m in the NAOMI project. They were giving me my heroin.’ I’m like, ‘What do you mean?’ He said, ‘Well, I didn’t need to steal anything. I got my disability payments. I got my drugs. I didn’t need nothing after that.’ And then, of course, Harper came and cut it off, and then they ended up going to the Supreme Court, and then my client got it back. I haven’t seen him now for a couple of years, ’cause he was back on the legal drugs. They were back supplying him.”

  Even the courts have taken notice when frequent offenders stop coming to court on new charges because they’re no longer having to beg, cheat, steal, or sell their bodies for street drugs. “With opioid replacements, they’re getting the high but without the danger,” said Judge Elisabeth Burgess. “They’re surviving longer and we’re not seeing them as much. They’re totally liberated now, they feel, because they show up at these clinics three times a day. They get their legal dosage and they can do other things.”

  The cost to the healthcare system of the ongoing crisis is another reason for looking at the provision of pharmaceutical opioids to those with opioid use disorder. “I’m supportive of anything we can do to stop telling people who are addicted that they have to buy what we know are toxic drugs,” Linda Lupini told me. “We’re all paying for and responding to this. So why are we not dealing with that on the front end? We’re spending millions of dollars keeping them alive so they can keep going and buying toxic drugs. What I say sometimes to the Ministry of Health is, give them clean drugs.”

  Some of the strongest support I heard for dramatically scaling up a “safe supply” for those who use drugs was from the families who’ve lost loved ones during the opioid crisis. “A dead drug user will never recover. Our first step is to keep people alive,” said Leslie McBain. “You can’t force a person into recovery. It’s dealing with what’s real. There’s always been drug addiction, there always will be drug addiction. We’re not going to end drug use or addiction.

  “Mitigating the crisis by providing people with safe drugs, if we do that, we’ll still have addiction, we’ll still have people needing to address their trauma, their pain, all those things, but they won’t be dying, and they’ll have a chance to recover. Giving up is the very opposite of what we’re doing.

  “Most people need medically assisted treatment. We’ve seen a change in that there are doctors who will prescribe Suboxone and methadone and diacetylmorphine, and these drugs that will help someone stay on track, and then taper down, and go into further treatment, which would include counselling and other supports. That’s the way to go. We need to hugely increase capacity for those things. People can find those treatments and those options, but it’s really hard.”

  Even the police are on board with the idea of substituting contaminated street drugs with medically provided opioids for illicit drug users. “If you were providing them with a clean alternative—something that they weren’t going to die from and that was given under medical supervision that would allow them to stay alive long enough to get treatment—that would lower crime as well,” said Inspector Bill Spearn. “Property crime. Things like theft from autos. You see a lot of drug-dependent sex trade workers. I mean, if they were provided with a clean opioid as an alternative to street drugs under medical supervision, then that wouldn’t necessitate them selling their bodies in order to feed their addiction.”

  “Opioid assisted therapy programs that provide addicted persons with opioid medications must be made immediately and easily accessible in therapeutic and supported settings,” said the Vancouver Police Department’s 2017 report on the opioid crisis. “The goal of this recommendation is to give addicted persons a ‘clean opioid’ (with known contents) for their addiction and to prevent addicted persons from contributing to the organized and disorganized crime-fuelled drug market through purchasing and using contaminated street drugs.”

  But rolling out “clean” opioids or “safe supply” to those using illicit street drugs has to be done thoughtfully, cautions Dr. Evan Wood. “The main issue, and this isn’t well understood, is that it has to be brought in in a way that prevents diversion; otherwise, you get more opioid-addicted people. This notion of ‘Giving out opioids is the way to get out of this mess’—that’s how we got into this mess. So more of that is not going to get us out.”

  In order to treat people with opioid use disorder, Dr. Wood wants to see witnessed injection, evidence-based recovery services, and the ability to obtain prescription opioids from a pharmacy or clinic (along with strategies to prevent people from selling what they’ve obtained). His organization has released a report that also calls for the creation of “heroin compassion clubs” so that those who use drugs could legally source a safe supply that they could purchase. But he cautions that providing access to a safe supply isn’t all that’s needed.

  “Giving somebody the clean drug is better than the alternative,” said Dr. Wood, “but just giving them the drug doesn’t solve the rest of the issue.”

  –12–

  HOW CAN WE HELP PEOPLE STOP USING?

  At 19 years old, Jordan Miller realized that he had a problem. He went to his mom, Leslie McBain, asking for help.

  “We used to say Jordan was over-partying when he was a teenager,” said McBain. “He was drinking with his friends, smoking pot. It seemed to increase over ages 15 to 19, and became a problem specifically with alcohol and cocaine. We got him into rehab. He liked it there. I mean, he did well. He came out and was good for a little while, and then he just started up again.”

  Miller had launched his own small business installing wood stoves and chimneys in the Gulf Islands along the southern coast of British Columbia. But he had a back injury on the job and went to his family doctor to get help.

  “That doctor gave him oxycodone,” said McBain. “He gave it to him in ever-increasing amounts over about seven months—even after I’d gone to the doctor, who’s also my doctor, saying don’t give this kid opioids, he’s at risk. He thanked me for the information and continued to do that.

  “Jordan went to him and said, ‘I’m addicted, I need help.’ The doctor grew angry and basically fired him as a patient. There was no offer of support or treatment or anything like that.”

  Left to fend for themselves, McBain helped her son get into detox again for a 12-day stint. She tried unsuccessfully to find a doctor who could prescribe Suboxone—a medication to help treat opioid use disorder by reducing the symptoms of withdrawal and reducing cravings. She also looked for a psychiatrist with experience in helping people like Jordan, but wasn’t able to find anyone.

  McBain’s desperate attempts to get help from professionals with the necess
ary expertise are not unusual. Many of the substance use disorder experts I spoke with highlighted the urgent need for up-to-date training for healthcare professionals to meet the needs of patients during the opioid crisis.

  About four or five months after leaving detox, Miller relapsed and started taking drugs again. “What he did was, he doctor shopped. He went to about five different walk-in clinics,” said McBain. “He was very charming and looked like a person legitimately in pain, and was able to get hydromorphone, Xanax, Citalopram, just a little array of drugs. It certainly helped him from going into withdrawal. One day he just took the wrong combination of those prescription drugs and it stopped his heart. He was alone in his apartment in Victoria and his girlfriend found him.”

  Miller died on February 4, 2014, at the age of 25.

  “It’s the worst tragedy that can befall a parent, certainly, and the family. It ripples outwards in its impacts,” said McBain slowly. “He had a girlfriend, he had an apartment, a dog and a cat, he had his business, he was sort of setting out on his adult life. It can happen to anyone.”

  McBain filed a complaint with the BC College of Physicians and Surgeons against her son’s family doctor. Soon after Jordan’s death she spoke to Dr. Evan Wood, who encouraged her, when she was ready, to consider becoming an advocate for families like hers.

  “I met two women who are both from Edmonton who had also lost sons to drug harms, and the three of us decided to start Moms Stop the Harm,” said McBain. “I think the first thing we did was create a Facebook page, and we’ve grown in the last three years from three of us to almost 500 people now, families across Canada, sadly. We provide support for families who are grieving; we try to support people who have loved ones in active addiction.”

  Moms Stop the Harm also advocates for a more compassionate drug policy. It now has chapters in every province, and is regularly consulted by various levels of government. McBain has also become the family engagement lead at the BC Centre on Substance Use, meaning she helps ensure that the organization’s work is informed by the experiences of families who’ve been affected by the opioid crisis. It was at their office in downtown Vancouver where I met with her.

  “The people who have lost a child—we see a person who’s immobilized in grief in the first months,” she told me. “They get numb, they go into deep, deep grief. They’re not able to work, they’re hardly able to often communicate with family. They find that people have a lot of stigmatized thinking around drug deaths. There’s a difference if a kid dies of cancer. There’s a different kind of reaction from family members and people around them to when a child dies of a drug overdose.”

  Since her son passed away, McBain has learned a lot more about opioid use disorder and what families can do to help loved ones in active addiction. “We tell them first of all to take care of themselves,” she said. Then, when it comes to those who are addicted: “Love them. You want them to just get the heck out of there, get out of my face, go away, do your thing somewhere else. Most families don’t know very much about addiction. I was the same. Check out what’s in your community for treatment; see what kind of physicians you can find who will treat—because the first line is your family physician, and if your family physician has a clue about addiction and how to proceed, you’re on a good path. Often that hasn’t been the case, so that’s why we really promote doctor training, medical professional training in substance use disorder.

  “The people who have loved ones in active addiction, they have their challenges and they sometimes can’t navigate their way into the system because, as Evan Wood always says, we don’t have a system—it’s fractured and we need to build one. We try to help them navigate so that they can get the support they need to stay well and help out their loved one,” McBain told me.

  “As I often say, if I only knew then what I know now, I’d like to think I could have saved my son.”

  * * *

  ——

  When most people think of substance use treatment, they think of detox—going cold turkey, abstaining altogether. The idea is that if someone is going to stop using a substance, they should just stop using it entirely. Indeed, that’s the dominant model most people have in mind when dealing with substances like alcohol. However, the problem is that applying such an approach to opioid use disorder can have deadly consequences.

  “We’ve seen for a number of folks that getting off opioids isn’t the same as getting off alcohol or some other things,” said Jennifer Breakspear. “Going off cold turkey and being abstinent and then relapsing—there are much greater risks of overdose and death.”

  Yet many treatment and recovery centres for people addicted to opioids are still based on an abstinence model. That was the case with Brandon Jansen (in Chapter 7) and Jordan Miller (at the start of this chapter), both of whom tragically died from opioid overdose—one while in detox and the other shortly after leaving it. What do leading medical experts have to say about abstinence-based treatment?

  “People who go to detox from opiates and then go back into their community lose their tolerance very, very quickly,” said Dr. Bonnie Henry. “So the probability of relapsing and dying the next time you use goes up dramatically. We’ve seen quite a lot and you’ve heard stories in the news about people who have been in recovery, and then they relapse and they die.”

  “We know that with leaving an abstinence-based rehab program, the relative risk for a fatal overdose goes up,” Dr. Paul Hasselback told me. “So it’s not something that’s been recommended.” After we spoke he sent me a study published in the British Medical Journal which found that “patients who ‘successfully’ completed inpatient detoxification were more likely than other patients to have died within a year.” I had to read that again. People who’d managed to finish their intensive detox program were more likely to die from a drug overdose than those who failed to complete the 28-day abstinence program. This so-called “treatment” was actually making things worse.

  As a result, new medical guidelines on treating opioid use disorder strongly recommend against detoxification alone, since “this approach has been associated with elevated risk of HIV and hepatitis C transmission, elevated rates of overdose deaths in comparison to providing no treatment, and nearly universal relapse when implemented without plans for transition to long-term evidence-based addiction treatment.”

  There are also major concerns that residential treatment and recovery facilities can vary widely in quality. “Right now, recovery homes, for example, are unregulated, and they can do anything they want,” said Dr. Henry, speaking about the situation in BC. “There’s no programs. There’s no standards. And they get money from the province—and some of them maybe have good results, some of them maybe not.”

  “In fact,” Surrey RCMP Inspector Shawna Baher told me, “there’s several houses that are basically, truth be known, crack houses, but they’re using the term ‘recovery home’ in an effort to try and run a flop house or a boarding house.”

  What’s heartbreaking is that families desperate to help their loved ones can end up paying exorbitant fees for so-called treatment and recovery programs that aren’t based on any scientific evidence and aren’t accountable for their outcomes. I was surprised to find that there are no clinical trials or meta-analyses showing residential treatment to be effective. In fact, relapse rates are 60% to 90%. Yet residential detox programs are often the first thing people think of when they learn that a loved one is addicted to illicit drugs. On top of that, these private programs can be incredibly expensive. “I’ve seen them cost $35,000 a month,” said McBain. “How are people affording it? Only the people who can afford it, afford it. And that tells you a lot right there. A lot of these recovery centres that are so expensive do have a certain number of beds for people who don’t have the money. There’s some sliding scale, but I don’t think these really expensive recovery centres have any more success. I’ve heard of people remortgaging their homes, us
ing all their retirement savings, things that they never expected to have to do in their life plans. That’s just such a tragedy given that a lot of the centres don’t have great success rates.”

  I’d do anything in my power to save my own child’s life. How could you not? So it’s all the more upsetting to think of those vulnerable families who’ve spent their life savings on detox programs—programs that were not only ineffective but put their loved ones at greater risk of fatal overdose during relapse. And even if abstinence-based treatment does play a role for a limited number of people, organizations that operate in this way without informing patients of the risk raise big ethical and legal issues.

  Politicians have often said we need more “detox beds,” and that if people could “just stop” using, we’d reach a solution to the crisis. If only. We know that’s not how it works.

  So what’s really needed to help people with opioid use disorder?

  * * *

  ——

  Two hours.

  According to medical experts, if someone who’s addicted to opioids asks for help, that’s the optimal time you’ve got to get them into treatment—an all-too brief window before the pull of their addiction once more overwhelms their will to escape it.

  “If you knew someone who was addicted to illicit opioids and they asked for help in getting into treatment, where would you go?” I asked.

  “I wouldn’t have the first idea where to start.”

  That’s the answer I got from Bonnie Wilson, co–program lead for mental health and substance use at Vancouver Coastal Health. And if she didn’t know where to go for help—in the very city hit hardest by the opioid crisis and in a country where finding treatment in rural areas is even more challenging—what chance would others have? Later, as I continued my investigation, I would find out.