“We’ve never had a proper addiction care system in North America, maybe worldwide. We don’t have a system of care here like people with other illnesses enjoy and can access,” said Marshall Smith, senior advisor for recovery initiatives for the British Columbia Centre on Substance Use and chair of the British Columbia Recovery Council. “We got here because we didn’t give a shit about people with substance use disorders.”
“A lot of money, a lot of resources initially went to harm reduction initiatives and very little went into treatment,” said Inspector Bill Spearn. “Almost four years into the crisis we’re finally just starting to see some of the treatment options come online, but it’s not proportionate to the problem. People who use drugs and are addicted to drugs have a medical problem and, really, throwing them in jail is not going to solve this problem.”
According to a 2017 Vancouver Police Department report on the opioid crisis, “Research has provided evidence-based options for treatment that reduce overdose deaths, reduce the negative impacts on communities, and reduce costs.” Its chief recommendation was to provide “treatment on demand” for people with opioid use disorder. Interestingly, the police force didn’t recommend stricter laws or more money for enforcement. Instead, they wrote, “we must invest in creating effective addiction treatment and realize the widespread public safety and public health benefits that would result.” Even the police are saying that the answer isn’t more law enforcement, it’s greater compassion.
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New national guidelines for treating opioid use disorder were published in the Canadian Medical Association Journal in March 2018. They broke ground, in the midst of the opioid crisis, by strongly recommending “opioid agonist treatment” as a first-line treatment, specifically the use of a prescription medication called Suboxone. Suboxone, which comes in pill form, is a combination of buprenorphine (a partial opioid agonist that prevents opioid withdrawal and cravings) and naloxone (which reverses the effects of opioids, as we saw in Chapter 9). I asked Dr. Mark Tyndall how Suboxone works.
“For the person who says ‘I’m going back to school’ or ‘I’ve got a job’ or ‘I need to be straight,’ Suboxone is a great drug,” he told me. “You won’t get high from it, but it will stop you from withdrawing, and we can stabilize you. And there’s good literature to suggest that for a lot of people that’s very effective. But there’s also good literature to suggest that, if you’re not ready for it, then it won’t work for you. Many people—and I’d actually say most people who are on these programs—are on and off them. It’s just the way addiction goes.”
By preventing withdrawal and reducing the cravings, Suboxone can help regular users stop using contaminated street drugs or misusing prescription opioids. They can get further supports, like individual or group counselling or residential care.
“I’m a huge fan of Suboxone,” said Marshall Smith, who is himself in recovery from addiction. “I think of Suboxone like a scalpel: in the hands of a trained surgeon, it’s a life-saving instrument. We use Suboxone all throughout our treatment centres and in the recovery homes that I directly supervise. I’ve seen phenomenal outcomes.”
Suboxone is now available in BC through prescription from any physician and is covered by pharmacare, which isn’t the case in all jurisdictions. Many doctors are still learning about it, so their training and education is crucial in ensuring that this first-line treatment is made widely available.
Fortunately, Rapid Access Addiction Clinics have begun springing up in cities like Vancouver and Victoria. These clinics, I discovered, are the places to go during that two-hour window after someone with opioid use disorder asks for help. Depending on the clinic, people can either walk in on their own or get referred by doctors, nurses, or social workers. The clinics provide evidence-based treatments like Suboxone or methadone on a short-term basis to help stabilize patients before transferring them to a healthcare provider in the community. Importantly, a health card isn’t needed to access these services, and they’re free.
Compared with more traditional and well-known opioid agonists like methadone, Suboxone is considered a better option overall for most people with opioid use disorder. Those being treated with Suboxone have a significantly lower risk of fatal overdose than those on methadone, both during and after treatment. As well, Suboxone has fewer and less serious side effects; it’s easier to take on an ongoing basis because once the person has stabilized they can get a prescription to take it at home; and there’s no concern about its being diverted to the illicit market since it doesn’t provide the effects people seeking illicit drugs desire.
“The other secret is that a lot of people who are on methadone continue to use illicit drugs,” explained Dr. Tyndall. “A methadone patient can take a day off and say ‘I got some money today. I’d rather use heroin. I’m not going to pick up my methadone.’ And their methadone would have worn off, and they get to use heroin for the day. Suboxone doesn’t work that way. It sticks around more.”
But Suboxone isn’t a magic pill to make everything better. It doesn’t make the underlying reasons for someone’s addiction go away. Instead, they can come back fiercely to the surface.
“They feel very normal on Suboxone. The discussions I’ve had with people, they feel too normal,” said Dr. Tyndall. “Like you have nothing. You’ve blown all your relationships. You live in a shabby SRO [single room occupancy] somewhere with cockroaches on the wall, and now you’re not high anymore and you’re not withdrawing. You’re just bored and irritated and all the trauma that you started drugs for starts coming back again. If the options I give them are Suboxone or nothing, when I know they’re going to buy fentanyl and any one of those times they could die, I think we have to do better than that.”
There are other important limitations of Suboxone. For one, it can be extremely dangerous to use Suboxone with alcohol or other drugs like benzodiazepines (medications such as Ativan, Xanax, or Valium). So someone who has opioid use disorder and other substance use issues may not be able to use it at all. And although Suboxone and methadone can be helpful in stabilizing people, it can be difficult to effectively taper off these medications. Most attempts to taper down are unsuccessful. Still, researchers believe that “there are increased odds of success when doses are reduced gradually with longer periods of stabilization.” As Bonnie Wilson told me, “There are individuals who are wanting to get off opioid agonist therapy. Get off the methadone, get off the Suboxone. We haven’t done enough with the rest of our system to really support that.”
While it was encouraging to hear that Suboxone is effective at helping some people stop using illicit street drugs and reduce their risk of a fatal overdose, Dr. Tyndall had raised serious concerns about its efficacy for many entrenched illicit drug users. These first-line treatments just aren’t effective for approximately 10% of people with opioid use disorder. And more than half of those who start treatment with Suboxone or methadone discontinue it in the first year and relapse. Many are unwilling or unable to stop the self-medicating effects from opioids. That’s where “safe drugs” again come in: they can help reduce the risk of fatal overdose.
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Medical experts say that with the right treatment and follow-up, people with opioid use disorder can have sustained long-term remission. Some can benefit from moving between the evidence-based treatments described in this chapter (such as medications like Suboxone and methadone to reduce cravings and withdrawal symptoms so that they can use less drugs or abstain altogether) and those mentioned in the preceding chapter (such as opioid medications like diacetylmorphine and hydromorphone to help them stop or reduce their use of contaminated street drugs). The new guidelines for opioid use disorder say that residential treatment and psychosocial treatment (such as cognitive behavioural therapy and contingency management) may help some people and can be one part of a long-term addiction management approach, alt
hough they also note that there isn’t strong evidence in that regard. In short, there’s no one-size-fits-all approach. Treatment has to be patient-centred and responsive to individual needs. After all, every person in long-term recovery has their own unique story.
Controversially, a significant majority of Canadians recently polled want people who use illicit drugs to be forced into treatment against their will. But government- or court-compelled treatment for people with opioid use disorder is a horrible idea. “I don’t think we have any good evidence that court-ordered treatment management, rehab, therapies of that nature have a role to play in long-term sustainability,” said Dr. Paul Hasselback. “We’ve seen that in the past. We know it doesn’t work for alcohol-related dependency. There’s no reason to believe it’s going to work here, and the interventions are not long enough to actually be sustainable.” And as Dr. Ronald Joe told me, “Other jurisdictions have tried involuntary treatment. It doesn’t work very well. In China, for instance, they’ve actually since changed it from an involuntary to a voluntary system now as a result of the fact that it didn’t work. Most jurisdictions in the world would have a paradigm that addictions treatment is voluntary. A person voluntarily takes it on versus being forced to take it.”
And when it’s on a voluntary basis, the long-term benefits of treatment can be significant, not just for the individual, but also for their family and for society as a whole. The U.S. National Institute of Drug Abuse estimates that every $1 spent on addiction treatment saves the healthcare and criminal justice systems up to $12. Try getting that kind of return on the stock market.
Other assistance may be needed for those trying to recover from opioid use disorder, such as housing and employment support. Yet it’s often family members who are left to advocate for their loved ones to get them the help they need. “I know a mom in Victoria whose daughter wanted to die because she was so addicted—she couldn’t get the drugs and she’d get sick and all these terrible things,” said Leslie McBain. “That mom, who’s now one of our leader moms, pushed for about a year and a half to get her daughter the treatment she needed, the housing she needed, the counselling she needed. But the slog—navigating that for her was a full-time job. That would never happen with any other disease. It wouldn’t.”
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One critique I’ve heard about the medicalized model of addiction treatment is that it doesn’t address the underlying reasons why someone has opioid use disorder—reasons that we now understand to be a combination of genetic and “environmental factors,” such as trauma.
But one organization that’s championing a greater recognition and role for wellness in helping people with opioid use disorder is the First Nations Health Authority. As Dr. Shannon McDonald, its acting chief medical officer, told me, “Everything we do at the First Nations Health Authority is done with a holistic perspective. We are always looking at people’s physical health but also their mental, spiritual, and emotional health within the context of their particular environment. When we deal with anybody, especially in mental wellness and substance use, we always have to look at it in the context of their whole life. We often talk about not having a drug problem in our community, but as having a pain problem,” said McDonald. “Sometimes it’s physical pain. It could be individual trauma, something in their life that they’re struggling to cope with. It could be family, community, nation, historical trauma. All of those things contribute to an individual’s relationships with opioids or other substances as they move forward.
“[With] people who’ve had severely traumatized lives, to just turn around tomorrow and say ‘Here. Take pill X instead of substance Y’ without dealing with the underlying issues of poverty and racism and trauma, we’re never going to get any closer to a solution.”
I could see Dr. McDonald’s point. I’d heard a related concern expressed by Marshall Smith.
“I think that we’re in the midst of an addiction crisis, and I know that a lot of people like to focus on the actual drug itself,” he said. “No matter what the substance is that people are using out there, this is a people problem. This is a crisis of community. It’s a crisis of connection. It’s occurring in people and in their lives, and so through my viewpoint the solution lies in people, not in drugs, and other processes.”
While first-line opioid agonist treatments like Suboxone or methadone can help stabilize people with opioid use disorder, and providing a “safe supply” of clean drugs like diacetylmorphine or hydromorphone can help keep them alive and reduce criminality and health risks, there’s also a need for a long-term response that helps people in a more holistic way. Although our immediate objective during this crisis must be saving lives, our long-term goal should be helping people deal with the underlying pain, trauma, and other reasons that either caused them to begin using illicit drugs in the first place or are barriers to their sustaining recovery so that they can live full lives, free of the enslavement of substances. And that will take a major societal effort—one that Indigenous communities that have been hardest hit want to see become a reality.
In addition to recommended medical treatments, the holistic approach championed by the First Nations Health Authority for Indigenous people involves making culturally based treatment options available. That includes access to counselling, engagement with Elders, and traditional practices to support those with substance use disorders on their healing journey. “On the land” treatment is an innovative approach being used in Indigenous communities across Canada to help people get respite from often hectic, chaotic lives that can be consumed by substance use. Participants live on the land together and are provided with emotional, mental, and spiritual support. They engage in traditional practices and cultural activities. This helps restore and strengthen connections to their culture and identity that have been horribly damaged by colonization as well as racism and discrimination against Indigenous people. It’s also an opportunity to develop deep, long-standing relationships with fellow participants, Elders, and facilitators.
There’s also a recognized need for a holistic response to the underlying causes of their addiction and the obstacles to their recovery, among them homelessness, unemployment, and mental health issues. Many people I interviewed spoke of the need for “wraparound” services—not only medical care based on the latest research but also support with such related needs as housing, vocational training, and counselling. That would constitute a much better and more cost-effective approach than how we deal with these social issues today, which is to silo them off and ignore the obvious interconnections between them.
“Allowing people the dignity of a home, potential for employment, support services to deal with their trauma as well as medical services to deal with substance use is going to take us a lot further than putting people in jail for short periods of time,” said Dr. McDonald. Unfortunately, instead of addressing the underlying challenges people are facing in their lives, our abiding societal response to illicit substance use has been just that—to punish people who use illicit drugs and brand them as criminals.
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WON’T DECRIMINALIZATION MAKE THINGS WORSE?
I never once saw Jim smile. When I met him he was in his late forties—twice my age at the time. He was unemployed, just trying to get by in downtown Toronto. He had grey, dishevelled hair and his clothes were well-worn and dated. One day a police officer stopped Jim and asked him for his identification (that’s never happened to me and probably never will—white professionals like me don’t get carded).
Jim riffled through his pockets and out dropped a little piece of plastic wrap. The officer picked it up. It contained a small amount of crack cocaine. Jim was charged with illicit drug possession.
When I was a second-year law student at the University of Toronto, Jim was one of my first clients at the Downtown Legal Services clinic. I had one shoplifting case under my belt and an assault trial scheduled in a few months. Another
client had paranoid schizophrenia and was facing stalking charges. The work at the clinic was exhilarating, terrifying, and humbling all at the same time. We were trying to help people who were in trouble with the law but couldn’t afford a lawyer or get legal aid. On days when I had court appearances I’d wear a suit to school just to try to look the part.
My first step was to read through the offence to see what the Crown prosecutor had to prove and find out how much hot water Jim could be in if he was found guilty. The Controlled Drugs and Substances Act is federal legislation that makes it a criminal offence to possess illicit drugs such as heroin, cocaine, methamphetamine, and fentanyl. A first-time offender with a small amount faces a maximum fine of $1000 and up to six months in jail. That doubles for a subsequent offence. If the Crown prosecutor decides it’s a more serious situation, they can indict the accused; the law provides for a maximum penalty of seven years’ imprisonment. There are separate offences for trafficking and possession for the purpose of trafficking, both of which have a maximum penalty of life imprisonment.
In first-time drug possession cases like Jim’s, Crown prosecutors seemed to want people to plead guilty and pay a fine: a quick and easy resolution for the prosecutor. But for the accused it meant a criminal record that prevented travel outside of Canada and made it even harder to get a job. And for the impoverished clients who qualified for our legal clinic, paying a fine was out of the question. It didn’t offer them any support, and it wasn’t going to do anything to stop them from using again. It just punished them and set them up for even more legal troubles—kicking them when they were already down. In retrospect, the entire process seemed less than pointless.
Fortunately for Jim, owing to mistakes the police had made he was able to avoid both a fine and a record. From a legal perspective it was a win, but for him it just meant that this time he’d be left alone. I never heard from Jim again. I wonder what happened to him.
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