Physicians across the country are relaxing their prescribing practices around medical treatment for opioid addictions in a bid to bolster physical distancing by cutting down on urinary drug screens and increasing the amount of methadone they give patients to take at home without supervision.
Health care professionals specializing in drug addictions were already struggling to cope with an epidemic of overdoses that has claimed thousands of lives across Canada before the worldwide pandemic. Now, the novel coronavirus is upending years of medical tradition and adding another layer of risk.
Doctors, nurses and harm-reduction experts are concerned their clients will catch the virus and succumb to it, given the often shaky health of those who use drugs. Access to supervised consumption sites for illicit substances and detox centres is also contracting, putting people who use street drugs at greater risk of overdosing.
Health Canada last month relaxed prescribing rules for some controlled drugs, making it easier for doctors and pharmacists to give people access to opioids. The changes mean some patients in opioid agonist therapy (OAT) programs will not have to make as many trips to pharmacies and clinics. It also means some OAT patients will have more access to larger quantities of medicine like methadone that can be fatal if not taken properly.
Patients in OAT programs take controlled doses of drugs such as methadone and buprenorphine-naloxone, which is known as suboxone, to manage opioid-withdrawal symptoms and create stability in their lives. Patients, particularly those on methadone, often have to take their doses under supervision at pharmacies or clinics. Stable patients are, over time, permitted to take home a limited number of doses, known as carries, but even the most trusted generally return to the clinic or pharmacy once a week for a supervised dose.
Top doctors specializing in addictions are urging their counterparts to prescribe OAT drugs based on each person’s stability, rather than past practices.
“There’s lots of addictions physicians in this area of practice who really want to do the right thing for our patients and are willing to be flexible, creative and dynamic in order to do that," according to Vincent Lam, the medical director at Coderix Medical Clinic, an addictions facility in downtown Toronto.
Canada does not have national OAT protocols. Instead, doctors generally follow guidelines set by their province’s respective College of Physicians and Surgeons. Dr. Lam and Jennifer Wyman were among the opioid specialists who rewrote Ontario’s OAT guidelines as the coronavirus pandemic widened and Health Canada eased overarching prescribing restrictions.
“We’ve done this with a careful calculation,” said Dr. Wyman, the association director of substance use service at the Women’s College Hospital in Toronto.
The most dramatic change COVID-19 has spurred for OAT physicians is the willingness, in situations where doctors feel it is safe, to prescribe medicine such as take-home methadone to patients who are still consuming illicit drugs like cocaine, Dr. Wyman said.
“It is a judgment call," she said.
Rob Tanguay, medical lead for Alberta’s opioid dependency training program and an addictions psychiatrist, believes patients receiving suboxone, which comes with fewer risks than methadone, should be given supplies that would last between one and three months.
“There’s no need for somebody to sit in a plastic chair inside of a clinic, waiting to get the okay from the doctor to start buprenorphine-naloxone,” Dr. Tanguay said. “This is safe, its risk of overdose is extremely low, [and] quite simply [for] individuals who are struggling just to function day-to-day, making them come into a clinic every day seemed absolutely asinine."
Dr. Tanguay argues the same applies to methadone, assuming the drugs can be stored properly and physicians are comfortable granting certain patients greater access to the drug.
Campbell River, B.C., doctor Erika Kellerhals says her more stable patients have been doing all right since the pandemic started. She worries more about the others, like those who are homeless. The pandemic, she says, is “making the most vulnerable more vulnerable.”
Physical distancing is possible “if you have a home, you have money and you are able to get food in,” she said. If you are living on the street or in a shelter, it is a different story.
With movement across the United States border restricted, harm-reduction experts warn the street supply of the usual drugs is drying up, forcing users to turn to unfamiliar, potentially more dangerous drugs.
Instead of using together and risking COVID-19, some users are turning to Facetime and other video-chat services to keep a watch on each other when they take their drugs. But advocates note the most marginalized users don’t have smartphones and laptops.
Using drugs along with others comes with risks at a time when people are being told to keep apart to reduce the spread of COVID-19, especially if users share bongs, pipes and other drug gear. In Halifax, harm-reduction advocate Matthew Bonn said workers are handing out lots of the glass pipes known as stems so that users don’t share them. They are handing out more naloxone kits, too, hoping that users will have the overdose-reversing drug on hand if they OD.
But using alone can be deadly, as well. Overdoses often happen because nobody one is on hand to help or call 911 if the user starts to succumb to overpowering drugs. Social isolation can be deadly for drug users. In Toronto, well-known harm-reduction worker Zoe Dodd said users “are feeling desperate and scared.”
In Ottawa, Jeff Turnbull, medical director for Ottawa Inner City Health, said the downtown shelter is bracing for the worst. “Like everyone else in this thing, we just don’t know what tomorrow will bring.”
Enforcing social isolation among the drug users, the mentally ill and the homeless who congregate in the core of the city is next to impossible, he said.
Trey Helten, manager of a supervised drug-use site on Vancouver’s Downtown Eastside, said the site had to close its drug-inhalation tent and cut the number of injection booths in half because of coronavirus worries. As a result, some people are using their drugs outside in the alley. Others are using alone in their rooms, raising the risk of a fatal overdose.
A friend of his recently died of an overdose in a single-occupancy downtown room. In normal times, said Mr. Helten, the man would almost certainly have used his drugs at the supervised site, where he was on staff. If so, “I am almost 100-per-cent sure we wouldn’t have lost him.”
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