By: Dr. Mike Beazely
Addressing Challenges
Throughout the 2000s, regulators and prescribers began to address the diversion of the then opioid of choice, OxyContin (sustained-release oxycodone tablets) manufactured by Purdue Pharma. This led to predictions of a resurgence in heroin in the unregulated market. That did occur, however a more potent, synthetic opioid, fentanyl, rapidly began to replace heroin, first as a drug contaminant, then as a drug of choice. Heroin, fentanyl, morphine, oxycodone are all opioids and can all be used to treat pain or for their euphoric effects, and all opioids can cause respiratory depression and death.
So why has unregulated fentanyl caused so much more harm than heroin or OxyContin? Opioids differ with respect to potency: how much of the drug is required for an effect, or a toxic effect. Fentanyl’s potency makes it much more dangerous because it doesn’t take very much of the drug to shut down your brain respiratory centre, resulting in opioid-induced respiratory depression (OIRD, more commonly known as an opioid overdose).
The presence of fentanyl as the primary opioid of choice led to the current “opioid crisis”, further compounded by the stress, isolation, and disruptions experienced during the COVID-19 pandemic. We have now spent almost a decade reading news headlines about year-over-year increases in opioid overdoses and deaths.
Acknowledging Successes
What isn’t reported on nearly as much as the negative aspects of the opioid crisis are the success stories. Success stories in the opioid crisis!? Along with record numbers of cases of overdoses, we have record numbers of opioid overdose reversals with the antidote, naloxone.
Less than 10 years ago, the public and health professionals, if they had heard of naloxone at all, thought of it as an emergency department drug. Now naloxone can be obtained free of charge from most pharmacies, public health units, and other service providers. Less than 10 years ago, there were two pharmaceutical treatments for opioid use disorder: methadone and buprenorphine-naloxone. We have now trialed other opioid agonist treatments such as extended-release morphine as well as safer supply programs for hydromorphone, heroin, and fentanyl.
Prescribers still use opioids but have become much more measured, balancing the risks of over-prescribing opioids (which led to the current crisis) with using opioids for both acute and chronic pain. We have implemented a number of new treatment and harm reduction strategies and have even experimented with drug decriminalization in some jurisdictions.
The knowledge gained from these preliminary/pilot programs will allow us to better understand what works, what doesn’t, and who benefits. And throughout, physicians, pharmacists, nurses and nurse practitioners, social workers, therapists, frontline service providers, and peers, and others have worked tirelessly, often under-recognized, under-appreciated, and under-paid, to address the challenging needs of people with opioid use disorder or who use opioids.
Avoiding Distractions
Recently, there has been increased discussion in the news about several harm reduction initiatives, particularly “safer supply” programs. Traditional opioid agonist therapy (OAT) was implemented to provide longer-acting pharmaceutical opioids to those with opioid addiction, with the eventual goal of tapering the opioid and achieving abstinence. Traditional OAT is successful for many opioid users, but not all. Recognizing that traditional OAT does not work for everyone, and the alternative is the use of unregulated fentanyl, often contaminated with other harmful substances, safer supply programs are designed to provide pharmaceutical-grade opioids to avoid the harms associated with the toxic unregulated drug supply. As with OAT, safer supply opioids have worked for many individuals, but not all.
Similar to OAT, or any prescribed opioid, there is a risk of diversion of safer supply opioids to others. A common criticism of safer supply programs is that we should be investing in treatment, not harm reduction. Such statements almost universally come from individuals with either a superficial knowledge of substance use or those who wish to create an artificial, black and white, often political debate. In the real world, treatment and harm reduction (and prevention and enforcement) all play a role in addressing substance use issues. This is the reason why most municipal drug strategies were built on a “four pillar” approach that integrates prevention, harm reduction, treatment, and justice and enforcement.
Translating Knowledge
The extensive knowledge gained about opioid and substance use during the opioid crisis keeps refining our responses. Although it can seem frustratingly slow, in the context of changing practice in the field of medicine, the changes around how we address the opioid crisis have actually happened quite quickly. However, most novel interventions to address the opioid crisis (e.g. safer supply programs, rapid access addiction clinics, supervised consumptions sites, drug checking services, etc.) have been implemented in larger urban centres, often in specific neighbourhoods with high densities of people who use drugs. In addition to understanding the benefits and harms of those programs, we also need to think about how novel interventions, piloted in major urban centres, can be implemented in places like Huron County that has a population spread thinly across a large geographic area.
Let’s consider drug checking programs. The Kitchener supervised consumption site launched a drug-checking service last year after receiving funding to purchase a Raman spectroscopy drug checking device. People who use drugs but also supports and family members can access the drug checking service, even if they don’t plan to use the supervised consumption site. Can this be replicated in rural Ontario? Well, probably not. The device costs tens of thousands of dollars and requires a dedicated service provider to operate and we would need several locations.
So, are rural Ontarians excluded from this harm reduction service? Partially. However, by working together and taking a four-pillar approach, service providers, social workers, peers, people who use drugs, and police, can help us understand how toxic drugs are trafficked to rural regions (in the case of Huron County, often from London and Kitchener). And although we can’t provide real-time drug checking, we can flag new drugs and contaminants at urban drug checking services and disseminate that knowledge to rural service and health care providers and residents. In fact, this work is ongoing, and we hope to produce more information sheets. See below for two examples: one is about protonitazepyne, an older opioid that didn’t make it as a pharmaceutical drug but has been synthesized as an unregulated drug. The other is about xylazine, a relatively new contaminant found in unregulated opioids
Additional Resources
About the Author
Dr. Michael Beazely is the Gateway CERH Research of Rural Substance Use and a professor at the University of Waterloo’s School of Pharmacy. Prof. Beazely’s research includes the evaluation of undergraduate pharmacy education with respect to substance use and ongoing educational tool development for practicing health professionals. He is interested in assessing interventions by community pharmacists aimed at reducing harms associated with substance use and understanding the intersection between drug use and ongoing pharmaceutical care. The Beazely lab at the University of Waterloo studies the role of growth factors in neurons. This work will expand our understanding of neuronal function and dysfunction in mental health conditions, including schizophrenia and depression, as well as susceptibility to substance use disorder.
Disclaimer
The views expressed in this opinion article are solely those of the author and do not necessarily represent the views or opinions of Gateway CERH. We believe in providing a platform for a diverse range of perspectives, and this article is intended to stimulate thoughtful discussion.
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