Vincent Lam is an addictions-medicine physician and an author. He is the medical director of the Coderix Medical Clinic, an addictions clinic in Toronto. His new novel, On the Ravine, will be published later this month.
There is a parable in which a group of blind people encounter an elephant for the first time. They each touch it and share their impressions. One person, holding the trunk, declares that an elephant is like a snake. Another, who feels the ear, disagrees – saying an elephant is like a fan. Grasping the elephant’s leg, a third person says that elephants resemble trees.
Opioid addiction, a field in which I have worked for the past decade, could be said to be like this elephant. And I have been many of these blind people, having encountered opioids from different points of view during my career. After a decade working with people whose lives are affected by opioid-use disorder, I can begin to map the creature.
What I was initially taught – that although I was prescribing opioids, I didn’t need to worry about addiction – turned out to be entirely wrong. As medical students in the late 1990s, we were told that if we prescribed opioids such as OxyContin – which was introduced in 1996 – for “legitimate” pain, they were “safe.” We need not worry about our patients becoming addicted.
When I became a staff emergency physician in 2001, it was perfectly normal to prescribe Percocet tablets to someone with a twisted ankle, or a badly strained back. Somehow we believed that a magical divide existed between these “safe” opioids that doctors prescribed for the “right” reasons, and those that people used for the “wrong” reasons. We practised as if there was no link between the Percocet prescriptions we wrote for musculoskeletal injuries when working in the minor area of the emergency department, and the patients we revived from heroin overdoses in the resuscitation area of the same department.
In fact, the illicit market in opioid pills flourished with the increased supply from prescriptions we doctors were writing. A subset of people became addicted. Some progressed from pills to heroin, and later to fentanyl. In 2006, the U.S. Justice Department found that the manufacturer of Percocet and OxyContin, Purdue, was aware of the “significant” abuse of OxyContin after its introduction, and even “in the face of this knowledge” continued to market it as a less addictive alternative to other opioids. A U.S. study conducted in 2008 and 2009 found that 86 per cent of urban injection-drug users had first used prescription opioids. In 2022, Canadian provincial and federal governments settled with Purdue for damages of $150-million, and continue to pursue 40 other opioid manufacturers and distributors with legal action. So much for those “safe” opioid prescriptions.
I loved the variety and urgency of emergency medicine, but after over a decade of work, during which I would become involved in a fragment of each patient’s life, and never see them again, I also began to feel fragmented. I wanted a practice wherein I could develop relationships with patients over time – what we call “continuity of care” – and follow people’s stories to a better place, while also addressing urgent problems.
In the early 2010s, I shifted my medical work toward addictions medicine. I remember some of the first patients whom I assessed in acute opioid withdrawal: They were agitated, anxious, having hot and cold flashes, pain throughout their bodies, abdominal cramping, sometimes vomiting and diarrhea. I was amazed that after a week or two of treatment with medications such as methadone and buprenorphine, a previously distressed, suffering person could sit comfortably and discuss their treatment plans. I sometimes double-checked their name to be sure I had the right patient in front of me – so drastic was the improvement. These treatments are also opioids. Opioid dependence, wherein opioids become necessary for a person to simply feel “normal” and not suffer withdrawal, is part of what drives addiction.
Despite continuing research into other classes of medications, opioids are still the mainstay of treatment for opioid addiction at this time, and those that are used for this purpose are called opioid agonist therapies (OAT). In terms of saving lives, nothing else has proved nearly as useful. A 2021 meta-analysis, a type of study that combines results from multiple studies to give us a bird’s-eye view, examined 15 randomized controlled trials of methadone and buprenorphine, and found that the chance of dying from any cause was roughly halved during times when a person with an opioid addiction was receiving one of these treatments, as compared with times when they were not receiving them.
Thus, a key lesson about opioid addictions: At this time, the best medications we have for treating opioid addiction are opioids. If this observation were a part of the elephant, it might be the trunk – the part of the anatomy that comes to mind first. The irony of the treatments being so closely related to the compounds that underpin the problem is paralleled by people’s individual experiences: Many people initially use opioids to escape anxiety, pain and distress. Once addicted, people become further afflicted with anxiety, pain and distress in the absence of opioids. The solace that opioids provide transform into the stricture of their necessity. OAT medications don’t break this bond, but they stabilize it, making it possible to take daily medications – or, now, an option that is injected monthly under the skin.
The molecules that have the most street value are short-acting – such as oxycodone, hydromorphone, heroin and fentanyl. They change a person’s experience of the world in the moment, whether by providing euphoria, or relieving discomfort. The more they are used, the less effective they are, requiring ever higher doses, higher potencies, and entailing greater risks of overdose and death.
The molecules that have been shown most convincingly to reduce the deaths of people who suffer from opioid addiction are long-acting, with effects in the body that last for days. They hold the physiology steady, thus relieving withdrawal. In some patients, OAT keeps things steady for years – in some cases, they offer this benefit for the remainder of the patients’ lives.
Methadone and buprenorphine are our standard treatments because they have the strongest data. There is also evidence, though less robust, supporting the use of slow-release oral morphine in a 24-hour formulation.
Injectable opioid agonist therapy (iOAT) – providing people with heroin or hydromorphone to inject in a setting with health care staff on hand for safety, and without these opioids leaving the facility – has proven to be a reasonable alternative for some patients. It recognizes some patients’ goals of experiencing euphoria. It may reduce illicit opioid use and criminal activity. It is not clear that this offers any advantage over standard OAT in terms of reducing overdose and death, though.
(iOAT needs to be distinguished from safe injection sites or safe consumption sites, where people bring their own drugs and use them while staff watch over them, ready to resuscitate them with naloxone. Note that as crucial as this rescue medication is, its role is to reverse overdoses. It often puts people into terrible withdrawal – and doesn’t treat opioid-use disorder in a continuing way.)
One of the pitfalls of the current discourse around the opioid crisis is the error of taking evidence that supports one thing, and claiming it as scientific support for something else. Advocates for public supply of addictive drugs (PSAD), a.k.a. “safe supply,” often cite evidence for the supervised consumption model, iOAT, as support for the practice of distributing opioids whose use will not be supervised. Precisely because both the problematic substances and the treatment approaches are opioids, these detailed differences are crucial. Glossing over them and conflating evidence for one thing with support for another is like saying a snake is actually equivalent to an elephant’s trunk.
As important as these details are, if someone were to study every contour and wrinkle of an elephant’s trunk and conclude that that trunk defines all there is to know about the elephant, they would be as mistaken as the person who believes that understanding the pharmacology of opioids is a sufficient basis for understanding opioid-use disorder.
As I began to know the patients in my practice, and to gradually build trust, I soon learned that the elephant is much larger than the trunk. If there are four legs upon which the elephant of opioid addiction stands, they are trauma, co-occuring mental-health disorders, pain and isolation.
Many patients, once I begin to earn their trust, tell me stories of childhood abuse or neglect, often of sexual abuse. I began to practise trauma-informed care with all my patients, assuming that if they had not yet told me of a formative traumatic history, there was nonetheless a good chance it was part of their history, which they may or may not wish to share. The patterns I observe in my practice reflect our knowledge: Five different types of childhood maltreatment – physical abuse, sexual abuse, emotional abuse, physical neglect and emotional neglect – are associated with the development of 10 different substance-use disorders, including opioid-use disorder.
Most have other mental-health issues apart from addiction – anxiety, depression, personality disorders, sometimes psychosis. In the U.S., 18.7 per cent of adults with mental-health disorders use opioids, compared with 5 per cent of adults who do not have a mental-health disorder. Many patients tell me they did not begin using opioids “for fun” or in order to “feel high,” but because it gave them relief from mental distress. Unfortunately, opioids are fickle, providing these benefits in the short term and making them more elusive in the long term.
Chronic pain is commonplace. An injury often initiates the story of a person’s opioid addiction – a motor-vehicle collision, or a workplace injury. I have patients whose lives were saved by complex surgeries and intensive-care units, who were discharged home without adequate access to rehabilitation but with a prescription for opioids. One study in a Level 1 trauma centre showed that 79 per cent of trauma patients developed chronic pain four months after their injury, and the 26 per cent of those patients who were still using opioids had more pain, life interference, depression and anxiety than those who were not. I have many patients who sustained a minor injury such as an injured back or limb, who could not afford either to take time off work after their injury to recover properly, or to pay for physiotherapy and occupational therapy that would have supported safer return to work. However, they were able to see a doctor and fill an opioid prescription.
Many of my patients live satisfying, rich lives with meaningful work and valued relationships, and they are your neighbours and co-workers. However, too many feel stuck within the amplifying spiral of poverty, precarious housing or none at all, involvement with the law, lack of opportunity, and isolation. Their drug of choice may be an accessible comfort, but if it was a workable choice in the long term, they wouldn’t be seeking my help.
In the parable of the elephant, the blind people – each grasping a different piece of the elephant – say the others are wrong, even accuse one another of being deceptive. The field of addictions treatment is notable for such conflicts. Anyone who has followed this issue has come across a variety of terms being used to describe the problem: opioid crisis, opioid-overdose epidemic, fentanyl crisis, overdose crisis, poisoning crisis, toxic drug-supply crisis. As with the elephant, whichever part of the creature each observer has laid their hands upon informs both the words they choose to describe the problem, and the solutions they recommend. Meanwhile, a person experiencing addiction may inhabit such dissonance, saying of their substance of choice, “It makes me feel whole,” and also, “This has destroyed my life.” Both of these statements may be true in their own way, just as different parts of the elephant may seem to contradict one another when examined in isolation.
One of the tendencies of public discourse is that it lends itself to simple, narrow narratives, and grasps at what seem like quick fixes. The PSAD narrative – that simply providing pharmaceutical-grade short-acting opioids to people will save lives – has captured the imagination of the media and dominated recent public attention around addictions treatment. The narrative is appealing, although after six years of PSAD being practised in Canada, there is no clear evidence that it actually reduces overdoses and deaths. Simplicity allows politicians to fixate on PSAD, which can also serve as a device to galvanize their constituents. However, the framing of PSAD as a partisan issue is akin to different political parties taking opposing stances on specific chemotherapies or cardiac medications.
What to do if we wish to move an elephant or, in this case, if we seek to address the opioid crisis? One needs to appreciate that opioids are only the point of the tusk. The elephant is all the ways in which our society is traumatized, fragmented and failing to provide care, the places where opioids provided temporary solace but not a workable long-term solution. Of course, pointing out broader causes comes too late if one is gored by an elephant tusk, or dies of an opioid overdose. So, the challenge is twofold: how to both address the dysfunctions, of which opioid addiction is one acute symptom, and how to care immediately for Canadians, both to prevent and treat opioid-use disorder.
It is vital that we embrace high-quality outpatient and in-patient addictions health care such that it provides continuing support to Canadians. It is the exception rather than the norm that medicine definitively “fixes” things: some broken bones, some infections. Yet the narratives around addiction responses – “intervention,” “getting clean,” even the terminology “rehabilitation” – suggest time-limited, definitive solutions. For most conditions, whether it is heart disease, diabetes or cancer, treatment is about changing trajectory, and improving quality of life over a time horizon of years. The same is true of addictions.
Chronic outpatient addictions care needs to be accessible and patient-centred. OAT may have the strongest evidence, but until 2018, methadone was uniquely hamstrung by Health Canada, which required that physicians have special federal permission to prescribe it. This, along with uniquely legalistic regulation of OAT care in many provinces, which aligned with the interests of profit-focused outpatient clinics that benefit from high-frequency patient visits and urine sampling, often made this treatment onerous for patients and focused it entirely on pharmaceutical care. OAT needs to be broadly accessible in hospitals and outpatient settings, paired with funding and programs for case managers and counselling, with more flexible and patient-centred practices. Too often, people who use drugs also forgo crucial in-hospital care, because of stigmatizing experiences and a lack of OAT care in hospital. No one should be excluded from a vital surgery for the lack of OAT in that hospital.
Although the tusk of the elephant is sharp, the massive legs of this problem must also be addressed. One in five adult Canadians do not have a family doctor. This, when by the age of 40, one in two Canadians has had a mental illness, and having a mental illness doubles the chance of a substance-use disorder. Patients will say they were “self-medicating” with opioids – an indication that our system is often failing. We need a plan to guarantee access to primary care – family doctors and nurse practitioners – without which most of our health care system is inaccessible. We need public funding for non-pharmaceutical care by non-physicians, including counselling and physical therapy. These services already exist but are affordable only to the affluent or well-insured. For everyone else, a prescription is easier to get.
We need multidisciplinary, publicly funded systems to rehabilitate painful conditions and return people to work, rather than leaving workers to sort it out on their own with opioid pills, and a setup for an addiction. Australia, a country that is historically and culturally similar to Canada, has integrated, publicly funded pain-management programs in every state. In 2021, Australia’s age-adjusted rate of all drug-induced deaths was 6.6 per 100,000. In the same year, Canada’s age-adjusted rate of total apparent opioid-toxicity deaths was more than triple the Australian figure for all drugs, at 21.2 per 100,000, a staggering difference.
Given the strong links between adverse childhood experiences and substance-use disorders, we need to support families – by providing universal paid parental leave, community supports for struggling parents, and accessible prekindergarten child care. We need to respect the deep value of family, and also the wounds that can grow within. All families, my own included, reckon with mental-health challenges, conflicts, trauma or its repercussions, and times when someone wishes they had done more – or had not done something. This is what it is to be human. Humans need to be able to turn to their communities and institutions for support. Canada and the U.S. are both world outliers amongst rich countries in terms of how little public support is provided to young families, and outliers in opioid-related deaths. We have to help families access useful tools, the resources to get through tough times, and workable responses to problems.
In addressing the trap of homelessness and isolation, we know how we could be doing better. The two-year “At Home/Chez Soi” study provided a highly supported housing program to traumatized, marginalized Canadians, many of whom were experiencing substance-use disorders and mental-health challenges. This cost-effective intervention had a range of positive outcomes, including improvements in quality of life and activities of daily living, and a reduction in emergency-department visits and criminal involvement. We need the political will to offer this to vulnerable Canadians.
People who use drugs as well as their allies and advocates should be part of the conversation, just as there are organizations that advocate for people with other conditions. They strengthen discourse, although conversation does not always mean agreement and disagreement does not mean that there isn’t common ground.
Clinically speaking, this means that even if I think that someone’s life would improve if they stopped using illicit drugs, some of my patients will want to continue using their preferred drugs along with methadone or buprenorphine – and I need to, we need to, accept and work with that decision. People take OAT in order to have less withdrawal, to be able to work, re-engage with their families, reduce the risks associated with criminal activity, or to reduce the risk of overdose and death despite still using illicit opioids. Similarly, some patients with heart disease take cholesterol-lowering medications while eating cheeseburgers, and some people with asthma smoke cigarettes.
Much of my value as a physician is to bring a medical and scientific perspective to problems. The ethos of science is that it is always incomplete, questioning itself, raising more questions than answers, sometimes discounting old orthodoxies, at other times trying bold new experiments and abandoning them when they do not stand up to critical evaluation.
It’s not as if we have evidence for everything we do, but some things entail less risk. We don’t have much evidence for mutual support groups in opioid addiction, so if people tell me they find meaningful connections there, I encourage them to attend; if they tell me it’s not a good fit for them, I tell them to look for connections elsewhere. On the other hand, understanding how the elephant is put together obliges us to think about lateral or less obvious consequences of our actions. When we know that increasing the supply of opioids on this continent led to decades of opioid-use disorder, and now when front-line clinicians like me are seeing new cases of opioid-use disorder instigated by hydromorphone diverted from PSAD programs, we have to ask: If lives are saved by PSAD – and we don’t yet know if they will be – how many other lives will we unintentionally harm by increasing the market supply of opioids, despite attaching the label “safe”?
None of this is black and white – methadone and buprenorphine are also diverted, and this happens more in countries where either OAT or other opioids are not as readily available. However, we know that short-acting opioids are more desirable. The elephant is a complex animal, and I am supportive of iOAT, in which publicly supplied heroin and other opioids could be consumed on-site by people who have not been helped by standard treatments, because the potential benefits and risks would accrue to the same person. Observed dosing is a safeguard against expanding the size of the illicit opioid market.
Our broad attitudes also matter. When I was an emergency physician, years ago, I would routinely refer patients to psychiatry, only to be told that their main problem could not be deemed psychiatric until their urine was clear of illicit substances. Our health care system has started to move toward ending the exclusion of a major health issue – substance-use disorders – from care, and it needs to do so with far greater urgency.
Coming to grips with the elephant means circling it, examining all of its parts, accepting that the impressions we form from holding the tusk may not be wrong, but need to be re-evaluated when we run our hands over the elephant’s tail. Hopefully, anyone in a position of authority who ever believed that addictions are a matter of “willpower” or “morality” has already dispensed with this. Other problems in perspective are more subtle but equally pervasive and problematic – including the notion that addictions are some special category of health problem that is not in the purview of the health care system, the notion that addictions are some kind of isolated issue, or the notion that we don’t know what to do about them. We have a great deal of knowledge, and we need to put it to better and greater use.
For each of us, the elephant in the room is: How can I listen, what can I try to understand, and what can I do?
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