View attachment 46881 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.”
Column 1 Column 2 Emergency care and hospital admissions are costly. Evidence-based care for opioid addiction in the community is not. And compassion is free.
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.
And compassion is free.
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.
Column 1 Column 2 Treatment must be evidence-based. Period... we should stop doing what doesn’t work and we should really stop doing what kills people. The evidence is very clear that an abstinence-only admission to care is the No. 1 factor associated with death.
An interview with Dr. Virani:
View attachment 46883 Dr. Hakique Virani has been on the front lines of Alberta’s battle with fentanyl. In the first half of this year, 145 Albertans died of fentanyl overdoses and Dr. Virani’s clinic in downtown Edmonton sees dozens of fentanyl cases weekly. A physician who also teaches at the University of Alberta, the 38-year-old specializes in addiction medicine. He spoke with The Globe’s Justin Giovannetti about Alberta’s leading public-health crisis.
What does the fentanyl crisis currently look like?
To use one word: bad. This is the worst problematic opiate use we have ever seen in Alberta. We are essentially seeing a death a day. The deaths are occurring in every socioeconomic demographic and every age group, you name it, people are using fentanyl and are at risk of overdose death. It’s urgent and the No. 1 public-health problem in Alberta.
On the front line, we see people who were formerly well-functioning and had jobs, such as professional athletes and bankers, as patients. For whatever reason, they were exposed to opiates, either after a prescription from a doctor for an injury or through from recreational use, and that use has escalated very quickly into dysfunctional use that is associated with social dysfunction: job loss, apprehension of children, criminal activity. The changes in the human brain that occur with chronic opiate exposure are such that there is a complete loss of control. I don’t think it’s banal to say that it really could happen to anybody.
Is there a possibility that this fentanyl crisis flames out over time?
If there was, I wouldn’t be so shocked to see the magnitude of the problem now. It’s predictable that fentanyl and heroin would arrive in Alberta because we’ve done a very poor job of addressing this problem with evidence-based intervention. I don’t think it’s natural that this has flared up or will flame out. It’s a function of our failure to address an issue that was simmering, bubbling and is now boiling over.
What do you make of the Notley government’s response so far?
I’m not going to say that it’s unfortunate that we have a new government, but what is unfortunate is that there is a delay in acting when you take over a file. You try to learn things, you have to trust your bureaucracy to inform you about the situation, but we’re at a [crisis] point now. We first saw this, ground zero, with the Blood Tribe, where this problem turned from insidious to overflowing. That was in January, we’re almost at the end of the calendar year now and we don’t have a great handle on the distribution of the antidote naloxone yet, we certainly don’t have access to treatment figured out and we don’t have supervised injection sites in Alberta, which might have tempered this problem.
I would characterize the government’s response as inadequate but I’m cautiously optimistic that their ideology is consistent with the evidence.
There is an argument for abstinence-based treatment in Alberta. How would you improve the treatment system as it currently exists?
Treatment must be evidence-based. Period. We must do more of what works. In a system where resources are always necessarily scarce and we are dealing with other medical needs, including needs in mental health and addiction, we should stop doing what doesn’t work and we should really stop doing what kills people. The evidence is very clear that an abstinence-only admission to care is the No. 1 factor associated with death. At the level of the President of the United States there has been recognition that offering abstinence-only treatment is not okay.
This is not someone’s failure to exercise conscious volition over drug use, but this comes after fundamental changes in their neurobiology. Their only fault is that they had a human brain. This isn’t something that they want to do. They have no control over the drug use and if they are exposed [to the drug] one time after an abstinence-based treatment they can die. It’s a science versus ideology debate, not a science versus science debate.
The antidote naloxone only works when a user has someone with them when they use fentanyl. You’ve raised a need for supervised injection sites. Do you think those sites are possible in Alberta?
I think after the federal election on Oct. 19 more things are possible in every province. There has certainly been a more open dialogue around the idea of supervised injection sites. The evidence around Vancouver’s Insite is not mixed; it’s clear. It works at reducing the dysfunction associated with injection drug use and it works with preventing death from drug toxicity.
The original story in the Globe and Mail about Alberta's government being accused of indifference towards the increase in fentanyl abuse and fatalities:
Alberta’s main opposition parties say Premier Rachel Notley’s government has responded with indifference as deaths from fentanyl abuse have surged in the province and turned into a public-health crisis.
Ms. Notley’s New Democrats have defended their response to the fast-acting opioid by pointing to the creation of a committee to review mental health care in the province. However, members of the Wildrose and Progressive Conservative parties say resources need to be allocated immediately to overtaxed health and police services. In the first half of the year, 145 Albertans died from fentanyl.
“They have been indifferent to fentanyl so far,” said Mike Ellis, a former Calgary police officer and Tory MLA. “I don’t want to say that the government is doing nothing. They’re reacting and supporting victims through Alberta Health Services, but that proactive approach to dealing with vulnerable people and drug dealers is completely missing.”
Alberta Justice Minister Kathleen Ganley has reached out to the Alberta Association of Chiefs of Police and is seeking recommendations on ways to combat fentanyl, her office said Monday. The request came after she met with 11 police chiefs last week. However, Ms. Ganley’s spokeswoman added the Health Ministry is leading the province’s prevention and harm-reduction strategy.
David Swann, Alberta’s interim Liberal Leader and co-chair of the province’s mental health review, says health-care and human-services systems are stretched to the maximum and he will be tabling a report in December that calls for the redoubling of efforts.
“The fentanyl issue is a symptom of some deep problems in our culture and government systems that are not working as effectively as they should be to look after people with mental health issues and addictions,” Dr. Swann said. “There is a tremendous need and we are all struggling to find new resources and new ways to deal with this.”
A pill of fentanyl costs about $20 on the streets of Alberta’s major cities and is 50 times more potent than heroin. While the drug has been tied to prescription abuse in Eastern Canada, the variant found in the Prairies is believed to be produced by organized crime. What sets fentanyl apart from other opioids is how toxic it is – two milligrams are enough to kill the average person in less than 15 minutes.
Jason Nixon, the Wildrose Party’s Whip, has raised concerns that the NDP government could be cutting funding for addiction treatment in its October budget.
“My first concern is with the money for detox centres and addiction. The way we’re reading the budget, there’s a $13-million cut,” said Mr. Nixon, who is former director of the Mustard Seed, a homeless shelter. “There are concerns amongst people working in addictions that cuts are coming, but that might be from a lack of adequate information from the government.”
Questions to Alberta’s Health Minister were not returned by press time. Addiction treatment centres reached by The Globe and Mail said they were concerned their budgets could be cut.
“We need more funding for treatment and education – they are the most cost-effective ways of dealing with the problem,” said Janine Copeland, clinical director for the Alberta Adolescent Recovery Centre. “At present there are reports of budget cuts in mental health and addiction. I’m not hopeful when I hear that kind of stuff.”
While Alberta’s provincial health authority has activated an emergency command centre to combat fentanyl abuse and has committed to making an antidote available to the public, Ms. Copeland would like to see the government shift its focus from harm reduction to addiction treatment.
The Calgary-based organization held a workshop last week about fentanyl that was so popular it has scheduled another for January. An addiction support group outside Edmonton called Parents Empowering Parents has seen a similar demand for information about the drug and is hosting a workshop on Tuesday.
“We should be working on the basics of prevention, treatment and education,” said executive director Lerena Greig. “Let’s face it, our children are dying. We’ve been talking about this fentanyl issue in Alberta since May and I’m not really sure what the solution is.”
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