British Columbia鈥檚 other public-health emergency has slipped from the headlines lately, as eyes focus on the COVID-19 outbreak.
But the opioid crisis that has claimed at least 5,605 lives in sa国际传媒 since 2015 races on relentlessly.
Last week, paramedics responded to 35 potential overdoses in Victoria alone, nine of them on Wednesday when social-assistance cheques were issued. That same day, two men were found dead in their tents at the homeless encampment in Topaz Park.
The convergence of two public emergencies on an already vulnerable population is one of the reasons a small number of doctors who specialize in addiction medicine are prescribing a safe supply of drugs for their patients.
鈥淪afe supply is controversial and has it own risks, but I鈥檓 in favour of anything that will prevent overdoses and save lives,鈥� said Dr. Bill Bullock, Island Health鈥檚 medical lead for addiction medicine for the south Island.
People who use opioids or stimulants are buying from dealers on the street and they don鈥檛 know what they鈥檙e getting, Bullock said.
鈥淭hey鈥檙e using a supply that鈥檚 unsafe because it鈥檚 contaminated with fentanyl and other things like synthetic cannabinoids and benzodiazepines. People who think they鈥檙e buying heroin or methamphetamines are getting adulterated materials and that鈥檚 what鈥檚 responsible for the majority of the overdoses.鈥�
Safe supply, which Bullock prefers to call pandemic prescribing, is a harm-reduction strategy that replaces unsafe drugs with a known quantity of prescribed medication.
It also allows people who use illicit drugs to keep their distance from other people to reduce their risk of contracting or spreading COVID-19 鈥� something they can鈥檛 do if they are out trying to score and using in groups.
Safe supply is different from treating someone with methadone or suboxone, he said. 鈥淭hose are addiction treatments to try and help people not use drugs. But for people who are continuing to use, a safe supply will provide them with drugs that would enable them to use without a high risk of overdose.鈥�
In March, the sa国际传媒 Centre on Substance Use issued guidelines that give physicians and nursing practitioners more tools for prescribing substitute medications that people can use instead of street drugs.
The guidelines aim to protect people from several risks, including overdosing on increasingly toxic street drugs, contracting or spreading COVID-19 by going out frequently to buy drugs, or suffering from withdrawal when staying home and self-isolating.
鈥淭his is for folks that aren鈥檛 engaged in treatment currently, or they are engaged in treatment, but that treatment hasn鈥檛 been effective,鈥� says Cheyenne Johnson, the centre鈥檚 co-interim executive director.
The guidelines also incorporate Health sa国际传媒鈥檚 temporary exemptions to the Controlled Drugs and Substances Act that allow pharmacists to renew prescriptions by phone and deliver medications to a patient鈥檚 home, so people don鈥檛 have to make as many trips to the drugstore and are able to self-isolate during the pandemic.
Bullock said prescribing a safe supply of drugs is best done in a situation where the patient is known by the doctor.
It should only be done by people who have special expertise in addiction medicine, he said, noting only a couple of dozen doctors specialize in that area in Victoria.
鈥淚t鈥檚 not like going to the store. The very first thing is a very thorough history-taking and physical examination. The physician needs to understand their patient and their background, what it is they鈥檙e using, what their history is of attempts to either stop or modify their use, and what medications they鈥檝e tried in the past.鈥�
It can take a couple of hours to assess one patient, said Bullock. The first line of treatment for opioid-use disorder is suboxone. If聽that鈥檚 not successful, the physician can prescribe methadone, he said.
鈥淏ut if someone is continuing to use, in spite of treatment with opioid agonist therapies, or if they鈥檝e declined opioid agonist therapies, they may be a candidate for pandemic prescribing,鈥� said Bullock.
Pre-pandemic, many people on methadone would go to the pharmacy every day for a dose that the pharmacist watched them take.
Some people, generally those who are working and have stable housing, are given 鈥渃arries鈥� or a take-home supply so they don鈥檛 have to go to the pharmacy every day and have a locked box where they can store several days鈥� worth of methadone.
That鈥檚 harder to navigate with the COVID pandemic.
With safe supply, addiction doctors are writing prescriptions for hydromorphone or long-acting morphine to replace heroin and fentanyl, said Bullock, adding that most of the heroin that鈥檚 purchased now is more fentanyl than heroin.
鈥淏ut prescribing something like that has its own risk, because one can still overdose on legal opioids or the drug could end up in the hands of someone with low tolerance. The amount a regular user might take several times a day would kill a non-user in one dose,鈥� said Bullock.
Most addiction-medicine physicians are in favour of the concept of safe supply. They believe that if people are going to use drugs, they should have drugs that are safe to use. The issue is in the execution, said Bullock.
鈥淧hysicians are very concerned with safety and doing something in a way that鈥檚 not going to create harm,鈥� he said.
Doing safe supply properly requires a team approach with follow-up by nurses and pharmacists as members of the team, he said.
Doctors can mitigate risks by prescribing for short periods and following up with their patient, or having a street nurse check in with the patient regularly, he said.
鈥淏ut that鈥檚 in short supply right now. People are getting this kind of prescribing now, but it鈥檚 not happening on a large scale,鈥� he said.
Dr. Ashley Heaslip, medical lead for PHS Community Services in Victoria, said it is happening in the inner city, where she works as part of a team with nurses, mental-health workers and other front-line workers.
鈥淭hat wraparound servicing has meant that the prescribing that we鈥檙e doing is done within that full picture for the individual,鈥� she said. 鈥淎nd that really does encompass that full continuum of care that people do best within.鈥�
As well, Heaslip said, she and a number of physicians have formed an on-call group 鈥� the Victoria Inner City COVID Response 鈥� to support nurses working with people at Topaz Park or in temporary housing at hotels and motels in the city.
She said there has been significant demand for safe prescriptions during the pandemic.
鈥淎s we can imagine, when you鈥檙e a patient sitting in the middle of this dual crisis and there is an option on the table for achieving some sense of safety within it, I think any of us would walk toward that sense of safety,鈥� she said.
In addition, she said, doctors are hearing from patients and the people responding to overdoses that the drug supply is becoming more toxic, and that overdose symptoms are worsening.
Heaslip stressed, however, that safe supply alone won鈥檛 solve the overdose crisis without long-term housing options, mental-health supports and a host of other services.
鈥淪afe-supply prescribing is a piece of that puzzle, but it is not the puzzle itself,鈥� she said. 鈥淭here are lots of other elements that are incredibly important to ensure that people have the opportunity to live their best life.鈥�
Bullock said he鈥檚 hopeful that things will improve as people without stable housing are moved into hotels over the next two weeks.
The peer-support group is working non-stop in Topaz Park. Island Health workers haven鈥檛 had a day off in a month and a half. Nurses and physicians haven鈥檛 had a break in two weeks, said Bullock.
鈥淓verybody is doing the best they can and trying really hard to help each other out.
鈥淭he government has stepped up and the city has stepped up and everybody is really trying to help the situation.鈥�
