Dr. Hakique Virani is a specialist physician in public health and preventive medicine and in addiction medicine, and is an assistant clinical professor at the University of Alberta Faculty of Medicine.
A recent Globe article describing Alberta’s failure to respond to the fentanyl crisis demonstrated that, over the past months, media may have a better grasp of this problem than the authorities charged with solving it. A decade ago experts began calling for action on a prescription opioid crisis. Three years ago, we encouraged authorities to revisit their decision to allow “generic OxyContin” in Canada.
Now, families in every social demographic are grieving the loss of hundreds of Albertans to the fentanyl epidemic. At each of these times, we have we heard platitudes like, “This is a complex issue that requires comprehensive solutions aimed at the root causes of this problem.”
The problem is big, and it is tragic. But it is not complex. Here’s how simple the solution is.
There are three evidence-based interventions that are proven to reduce opioid fatalities:
1. Naloxone, the antidote for opioid overdose, is cheap, safe, and effective. After Health Canada sent 200 doses of naloxone in kits to the Blood Tribe for overdose prevention in March, 2015, Alberta Health launched its expanded naloxone distribution program, and only had to commit $300,000 to do so. It has saved lives already, but its effectiveness has been limited by the narrow reach of needle exchange programs. In Calgary, two-thirds of fentanyl overdoses are occurring in suburban homes.
Given naloxone’s safety, there is no legitimate argument against making naloxone freely available to anyone who wants it. Such an approach is supported by the World Health Organization, citing evidence that in populations where naloxone is distributed at a rate of 1 per 1,000 people, opioid overdose deaths are reduced by almost half.
2. Canada has been a pioneer in demonstrating the safety and effectiveness of safe injection sites. The data are clear. Safe injection sites save lives, and cheaply. They also provide patients with an entry point from which to pursue more definitive addiction treatment. The Supreme Court of Canada knows this, and accordingly, ruled against the Stephen Harper government’s attempt to shut down InSite in Vancouver. Safe injection sites should have been available in Alberta long before the fentanyl crisis.
Thankfully, on the front lines in Alberta, the majority of treatment-seeking individuals using fentanyl are not injecting drugs. But that is changing. If we fail to employ the other solutions rapidly, the burden of injection fentanyl use will continue to rise, bringing with it severe co-morbidities. The arrival of heroin and fentanyl after our failure to deal with a prescription opioid crisis was predictable. So will be the escalation of higher risk injection drug use.
3. Medication-assisted treatment with medications like buprenorphine is a highly cost effective population health approach to treating opioid addiction definitively and reducing overdose deaths. This treatment also reduces the population demand for opioids, which is associated with a decrease in new opioid users. These facts have caught the attention of President Obama, who, two weeks ago, issued an order that federal agencies with health-care responsibilities would, within 90 days, identify and address barriers to medication-assisted treatment for opioid addiction. The opioid problem in Alberta is worse than it is in the United States, and calls for improved access to medication-assisted treatment have gone on for closer to 90 months than 90 days here. It is long past time to act.
The opioid problem in Alberta is not a problem of scarce resources. The interventions described above are inexpensive. The interventions currently available – residential treatment, intensive counselling, and inpatient detoxification – on the other hand, are expensive. More concerning is that abstinence-based treatment of opioid addiction is associated with relapse rates approaching 100 per cent and an extremely high risk of overdose death. Parents, children, siblings, friends, and neighbours of fentanyl casualties know this reality all too well.
Alberta urgent-care centres and emergency departments are seeing close to 250 individuals a month with opioid poisoning or withdrawal (compared to fewer than 100 in 2012). Emergency care and hospital admissions are costly. Evidence-based care for opioid addiction in the community is not.
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