key: cord-1022670-4f5obcvv
authors: Krausz, Reinhard M.; Wong, James S. H.; Westenberg, Jean N.; Choi, Fiona; Schütz, Christian G.; Jang, Kerry L.
title: Canada’s Response to the Dual Public Health Crises: A Cautionary Tale
date: 2021-02-11
journal: Can J Psychiatry
DOI: 10.1177/0706743721993634
sha: 7de5eca76b447fe15de4f46ea396acdd70aea15c
doc_id: 1022670
cord_uid: 4f5obcvv

nan

The overdose crisis in Canada shows little sign of sustained abatement despite nearly a decade of attention by health care, government, and regional activists. Statistics from 2019 show some promise with a decline in rates of fatal overdose, suggesting that all this effort may have paid dividends, sadly, only to rebound in 2020. Nationally, more than 17,000 opioid-related deaths occurred since 2016. 1 Preliminary results from the Ontario coroner's office indicate an approximate 25% increase in opioid-related fatalities from March to May 2020, compared with the same 3-month period in 2019. 2 In Alberta, the number of opioid-related calls to emergency medical services rose from 620 in the first quarter of 2020 (January to March) to 1,485 in the second quarter (May to June), the highest ever seen in a quarter. 3 Dr. T. Tam, Canadian chief public health officer, confirms similar trends for the entire country.

To address the overdose crisis, the federal government has highlighted access to treatment, harm reduction, awareness, prevention and fighting the tainted drug supply as key areas of response. One of the most intense discussions concerns the notion of "safe supply" as a promising solution. The Federal Government is supporting a "safer drug supply" project led by the Parkdale Queen West Community Health Centre in Toronto, Ontario. Prime Minister Justin Trudeau says his government is "moving forward aggressively" to ensure a supply of pharmaceutical alternatives to toxic street drugs.

The situation in British Columbia (BC) has progressed further. A safe supply program has already been implemented for months. Directly in response to the dual public health emergencies of the opioid overdose crisis and the COVID-19 pandemic, new clinical guidelines in BC were released in March 2020 to provide pharmaceutical-grade opioids, stimulants, and benzodiazepines to people who use drugs (PWUD), with the aim of reducing their exposure to a toxic drug supply, risk of withdrawal, and exposure to COVID-19. 4 The BC Government's decision to allow the prescription and distribution of a supply of psychotropic substances ("safe supply") serves as a landmark decision and a paradigm shift in drug policy. It is a bold step toward legalization of access to and possession of pharmaceutical-grade opioids in response to an ongoing 5-year crisis. Medications include oral hydromorphone, long-acting oral morphine, dextroamphetamine, and methylphenidate. The initial prescriptions are recommended to be for at least 23 days to support physical distancing and self-isolation. To be eligible, clients must be at risk of COVID-19 infection or are COVID-19 suspected/positive, have a history of ongoing active substance use, and are at high risk of substance use-related harms. The medications are prescribed by nurses, nurse practitioners, and physicians. This approach aligned with the concepts and demands of activists and politicians across Canada, seeing the BC government as the initiator and pilot of this new approach.

The opioid crisis was recognized as a public health emergency in April 2016 due to the increasing number of opioid-related deaths. 5 Measures taken to address the alarming number of overdoses include increasing access to naloxone, improving overdose prevention education, and enhancing surveillance of overdose data. Evidencebased, effective opioid agonist treatment (OAT) has been gradually increasing in accessibility, but retention rates remain low in BC. 6 Psychosocial interventions such as cognitive behavioral therapy when provided with OAT have been shown to generally improve treatment outcomes. 7 The scaling up of harm reduction interventions has played an important role. Nevertheless, the annual death toll in BC reached a peak of 1,547 in 2018, followed by a decline to 984 in 2019. 8 Despite these measures, between January and July 2020, there have been 909 fatalities, nearly equaling the yearly total of 2019 and on pace to setting a new record that coincides with the onset of the pandemic. 8 Clearly, BC and other provinces are experiencing a dual public health crisis. July 2020 was the third consecutive month in which the number of illicit drug toxicity deaths in BC surpassed 170. These recent monthly totals surpass the previous high of 161 reported in December 2016. Ontario experienced a 38.6% increase in the number of opioid-related deaths in the second quarter of 2020 compared to the first quarter of 2020: from 448 to 621 (Supplementary Figure 1 ). 2 The number of overdose deaths in Saskatchewan is also the highest in 10 years (Supplementary Figure 2) . 9 The COVID-19 pandemic poses tremendous challenges for the treatment of opioid use disorder. 10 The high prevalence of comorbidities, such as anxiety and depressive disorders, cardiovascular and pulmonary diseases, HIV, and other chronic illnesses among PWUD put them at increased risk of COVID-19 infection. [11] [12] [13] PWUD are also vulnerable to the hardships of physical distancing, which may put individuals in treatment and recovery at increased risk of withdrawal and relapse, as well as reduce their ability to access harm reduction services such as supervised injection sites and support services. 14-16 COVID-19 may also increase risk of overdose. Those self-isolating cannot receive or administer naloxone if overdose does occur. 13 Similarly, drug markets are being impacted by shortages, leading to increased prices, variability in drug purity, and likelihood of contamination with synthetic high-potent opioids. Difficulties in addressing the needs of this already-disadvantaged group intensify in times of crisis and this has led to a relaxing of rules and regulations for patients to receive treatment. It is remarkable how limited the resources and engagement allocated to the overdose crisis are in comparison to the billions allocated to the pandemic.

A decriminalization and legalization debate has come along with this new drug policy program that is strongly supported by advocacy organizations 17 and the BC Center for Substance Use, 4 a BC government-funded center advising the government. Common sense suggests that possession of small amounts of safe but currently illicit substances would significantly decrease purchase of potentially toxic drug supplies from criminal sources. Moreover, the Canadian Union of Police Chiefs, the Premier of British Columbia, and the Public Prosecution Service of Canada are jointly calling for alternatives to criminal penalties for simple possession cases.

Decriminalization of drug use and possession is a major topic of discussion worldwide. A significant movement in North America is advocating for removing prosecution for possession and use of psychotropic substances which is a major reason of incarceration in the United States. In 2018, more than 1.6 million arrests were made related to drugs; 86% were made for possession only. The drug policy alliance advocates for elimination of penalties for use, possession, and low-level sales. 18 In November 2020, Oregon became the first state to decriminalize the possession and personal use of drugs. 19 Portugal decriminalized drug possession in 2001. Around this time, Portugal also increased the availability of drug treatment. In 1999, there were 6,040 people in OAT. 20 This increased to 14,877 people by 2003. More than a decade later, the prevalence of drug use has remained about the same; however, arrests, incarceration, disease, overdose, and other harms are all down. 21 The Portuguese experience suggests that decriminalization helps to reduce the risk of substance use but has no influence on substance use in general and its prevalence as well as the mental health challenges coming with it. Scientific studies on effects of decriminalization are scarce even in countries like Portugal; nevertheless, support from international organizations is growing. 22 The decision in BC on "safe supply" is the first time a government has adopted such an approach. This could be innovative and courageous on the one hand, or alternatively a decisive step in the wrong direction. The Achilles Heel of safe supply is its over-reliance on concepts related to "harm reduction," while neglecting the necessary therapeutic context concerning the underlying mental health issues of addiction in the first place. It makes sense in this context, that the need for psychiatric expertise and involvement is questioned and the health care community is experiencing a major crisis. This is a very sensitive issue, one where mistakes cost lives. The stakes have become greater with the onset of the pandemic, rendering it vitally important to identify and explore existing evidence and recent experiences in detail to allow an accurate assessment for everybody involved.

The promise of safe supply is compelling, but it is important to outline what the conditions of success and failure might be and what data could be used to gauge its effects. For instance, the success criteria for safe supply policies would be when the rates of nonfatal and fatal overdose decline. A successful program is when increasing number of PWUD enter the program and there is a concomitant decrease in overdose and death among them. Publicly available data show that this condition has yet to be met ( Figure 1 ). 8 Moreover, an aim of safe supply is to reduce the spread of COVID-19 among PWUD. However, limited data indicate that the Downtown East Side (DTES) of Vancouver has not been spared from the pandemic. The Vancouver Centre North health region, which includes the DTES, has had one of the highest proportionate jumps in positive cases in August and antibody testing has revealed that actual case counts could be far higher. 23 Another indicator of success would be when patients stable in OAT ask to be put on safe supply. Such a request would suggest that the appeal of hydromorphone is greater than methadone or buprenorphine. It is also worth noting the low retention rates in current OAT programs offering mainly methadone or buprenorphine throughout Canada. The finding that a majority of patients leave OAT in the first few months indicates that the current programs do not meet these individuals' needs or miss critical components like counseling. 24, 25 Currently the largest indicator of failure of the proposed safe drug supply policy is the narrow focus on safe supply itself and that it remains unsupported. This is clearly demonstrated by the guidelines that state:

These guidelines are not intended for treatment of substance use disorders but rather to support individuals with substance use disorders to self-isolate or social distance and avoid risk to themselves or others.

It will be argued that these guidelines are interim and that other services may exist, but if government and health care providers are serious about addressing addiction, then mental health must always be part of any guideline.

Substance use disorder is very often a concurrent condition with traumatic experiences and severe, persistent mental illnesses. In the acute care system, the majority of patients nowadays suffer from both concurrent mental illness and often high-risk substance use. 26 Much of the research has been conducted in Canada, and in particular Vancouver, the very epicenter of Canada's crisis. The risk of substance use is rising with concurrent trauma and mental illness. 27 A patient with complex concurrent conditions is the new normal in acute care psychiatry, and all conditions need to be treated to stabilize someone. Just distributing medications does not help with treating psychosis, and that is also true for highrisk substance users.

To our knowledge, there is currently a BC Centre for Disease Control project underway where linked administrative health data are utilized to explore the impact of the BC safe supply guidelines. It examines whether safe supply has led to decreases in overdoses and deaths, and on issues related to its implementation.

Decades ago, many European countries including Germany, the Netherlands, Switzerland, and Denmark dealt with similar spikes in heroin use, overdoses, and high rates of HIV and Hepatitis C infections, which spread through the sharing of needles. For example, in the 1980s, Zurich Switzerland had an "open drug" scene best known by the nickname "Needle Park." Rates of HIV infection soared and the number of drug overdose deaths climbed in several major cities. The Swiss took a very pragmatic approach to address the problem and, in 1994, passed one of the most progressive and controversial drug policies in the world, which included heroin-assisted treatment. 28 Persuaded by evidence that intensifying policing would not solve the problem, Swiss authorities opted for a strategy of institutionalizing specialized health services to reduce harms as part of a comprehensive 4 pillars policy that also includes prevention of drug use, treatment of drug dependence, and policing of drug crimes. Most importantly, there was an expansion of treatment range and coverage, which was supported in several public votes.

The promise of prescribing high potent psychotropic substances is attractive to PWUD in search of a nontoxic supply, thereby offering a viable option to street drugs. Access to a safe drug supply needs to be combined with counseling and other mental health supports where patients could be seen on a regular basis in a clinic or treatment program. Now more than ever, mental health professionals must work in collaboration to provide essential support, promote recovery, reduce risk of overdose, and minimize COVID-19 transmission. Other essential features of a truly comprehensive program for dealing effectively with dependence on substances such as opioids are listed below.

Prevention of fatal overdoses requires safe injection facilities and in the best case a clinic which offers diacetylmorphine and hydromorphone-assisted treatment like the Crosstown Clinic in Vancouver. These clinics also have the longest retention rates and the best general psychosocial supports. In order to avoid diversion of drugs from safe supply, professional dispensing is required. Somebody seeing the patient on a regular basis, who has contact with the patient and can initiate additional support in a housing facility, a pharmacy, or a clinic is necessary. In any OAT clinic, "carries" are part of the procedure if appropriate, but there is a context for interventions.

The effective reduction of overdose fatalities requires the creation of quality treatment programs addressing a broad range of issues related to substance use disorders including individual preferences. Countries unaffected by an overdose crisis like in Canada invest appropriately in such programs. Switzerland, for example, experienced a severe crisis around open drug scenes in the 1990s, but sadly, the lessons learned have been ignored in Canada. Moreover, in order to increase retention in treatment programs, there is an obligation to adapt to individual needs, preferences, and expectations. Psychosocial interventions such as case management are effective at improving important treatment-related outcomes such as identifying needed services, facilitating linkage with services, promote participation and increasing retention in services. 29 Given the well-documented effectiveness of heroinassisted treatment for long-term injection street opioid users within the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) trial, 30 it is puzzling why this treatment is still not available widely throughout Canada, and why health providers do not adopt new highly effective treatment options more readily. Immediate access to safe drug supply is critical, but it should be provided in quality treatment programs. The combination of heroin-assisted treatment and other comprehensive supports provided the turning point in Zurich, when Switzerland faced its enormously challenging opioid crisis and open drug scenes in the 1990s. There is every reason to expect such a change in policy would find equal success in Canada in the 2020s.

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RMK reports grants from the Canadian Institutes of Health Research, Bell Let's Talk, HSBC, Health Canada, InnerChange Foundation, Coast Mental Health, travel reimbursements from the Mental Health Commission of Canada and Canadian Center for Substance Abuse, personal fees from The United Nations Children's Fund, and is the Chair of the World Psychiatric Association section of Addiction Psychiatry. JSHW, JNW, FC, CGS, and KLJ declare no competing interests.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Reinhard M. Krausz, MD, PhD, FRCP(C) https://orcid.org/ 0000-0002-6208-4364 Jean N. Westenberg, BSc https://orcid.org/0000-0002-4720-8402

Supplemental material for this article is available online.

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