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a killer high

This story is part of A Killer High: A Globe examination into the rise of fentanyl in Canada

The number of emergency department visits for opioid overdoses in Ontario soared 72 per cent over the past decade, many of which could have been avoided had follow-up treatment programs been available for patients struggling with addiction, a Globe and Mail investigation has found.

Figures obtained by The Globe show that patients who overdosed on opioids were taken to emergency departments 2,853 times during the fiscal year ending March 31, 2014, up from 1,660 times in fiscal 2005.

While the numbers are tiny compared with the nearly six million annual emergency visits to Ontario's 151 hospitals, they are symptomatic of a much bigger problem: Canada's epidemic of prescription painkiller abuse and the toll it is taking on the health-care system.

The emergency department visits represent just the tip of the iceberg, medical experts say. Many overdose victims make every effort to avoid going to a hospital, where they often feel stigmatized as junkies. Those who do end up in an emergency department are typically given an antidote to reverse the symptoms of a life-threatening overdose and sent home. They receive no follow-up treatment, the experts say. Patients who seek treatment for their addiction to opioids often relapse after lingering on long waiting lists. And in many rural and remote communities, there are no treatment programs.

The Globe investigation found that neither Ottawa nor the provinces are taking adequate steps to stop doctors from indiscriminately prescribing highly addictive opioids to treat chronic pain. Canada ranks No. 1 in the world and Ontario is the country's biggest per capita user of prescription painkillers. In 2015, doctors in Ontario wrote 8.1 million prescriptions for opioids, enough for nearly every person between the ages of 15 and 64.

Illicit fentanyl, largely a product of organized crime, is behind a spike in overdoses in Canada, many of them fatal. Fentanyl was developed as a prescription painkiller, but gained popularity as a street drug after OxyContin was removed from the market in Canada in 2012. OxyContin was popular not only with people who became addicted after their doctors prescribed it, but also with heroin users, because it could be snorted like cocaine or injected like heroin for a quick high. Fentanyl is up to 100 times more potent than morphine. The equivalent of two grains of salt can kill a healthy adult.

Clinics that dispense methadone or buprenorphine, drugs that suppress withdrawal symptoms, do not offer primary care to patients, many of whom are dealing with complex psychological conditions. As a result, the drop-out rate is high. And treatment programs that are abstinence based do not accept patients taking methadone or buprenorphine.

"There's a very pervasive sense that addiction is not the responsibility of the health-care system," said Meldon Kahan, medical director of the Substance Use Service at Women's College Hospital in Toronto. "A lot of doctors feel it is not their responsibility to treat addiction."

Dr. Kahan is spearheading a project – the first of its kind in Ontario – that integrates treatment and primary care under one roof for people addicted to opioids and other substances, including alcohol. Hospitals in seven communities across Ontario are participating in the project, including Sudbury, London, St. Catharines and Ottawa. Patients who arrive in an emergency department because of a drug overdose are revived with the antidote and given a couple days' supply of buprenorphine until they can be seen by doctors in one of Dr. Kahan's rapid-access addictions medicine clinics, where they receive primary care from a physician.

Michael Franklyn, an addiction doctor in Sudbury, is leading the project for his city in the hospital's detox centre. He said the program is making a difference in a city where illegal drugs are a huge problem. Sudbury is the drug gateway to Northern Ontario because of its geographic proximity to highways and it was once dubbed the "OxyContin tablet capital." These days, the city is mainly dealing with the illegal diversion of pharmaceutical fentanyl patches. But police say it is only a matter of time before illicit fentanyl powder shows up on the streets.

The 14 patients in the Sudbury program, who are dealing with alcohol or opioid addictions, have been to emergency nine times since January, when the clinic opened. In the 90 days before the clinic opened, by comparison, these patients were in emergency 24 times. Not only is the clinic reducing costs for the hospital – each emergency department visit costs roughly $400 – the clinic is a much better option than emergency for his patients, Dr. Franklyn said.

"Every interaction they have had has been negative," he said. "The attitude is, 'You are a junkie, you're wasting my time.'"

One patient at the clinic, a 25-year-old man who asked that his name not be used because of concerns his addiction will prevent him from getting a job, had been to emergency 10 times during the 90 days before the clinic opened. He had overdosed on pharmaceutical grade fentanyl patches, purchased illegally on the street. Since he started going to the clinic, he said, he has not been back to the emergency department.

For the first time since he started using opioids recreationally a few years ago, he feels like he can overcome his addiction.

"I can see the light at the end of the tunnel," he said.