"We’re starting to see people looking at drug use as a health issue as opposed to a criminal justice issue."
In depth: Part two in a three-part series examining the opioid crisis in the city.
Two months ago, Michelle Klaiman, an emergency and addiction medicine doctor at St. Michael’s Hospital in Toronto, remembers treating a patient who injected himself, with what he had thought was heroin, five minutes before entering the emergency department.
The man then collapsed while waiting at the registration desk, vomited on himself, and stopped breathing.
He was immediately taken into the trauma bay, where there were two attending physicians, two residents, and three nurses who helped save the man’s life, said Dr. Klaiman.
The man was resuscitated, given oxygen through a bag-valve mask, an intravenous line was placed, and he received naloxone, a safe medication that reverses the signs of overdose by blocking the effect of opioids in the brain.
She said the man was awake and alert within minutes and was able to tell them that he had injected what he thought was heroin several minutes before entering the department for an unrelated reason (abscess).
Dr. Klaiman said St. Michael’s Hospital is seeing more overdoses and projecting to use approximately 30 per cent more naloxone over the next year compared to last.
On February 22, Dr. Klaiman recalls having treated three patients during the afternoon hours of a 1 p.m. to 8 p.m. shift.
“We’re not trying to ask about where they got the drugs or where they were using,” she explained. “We ask about the quantity they used, if it was a normal amount they would usually use, and if it’s possible it was contaminated with fentanyl, which we’re seeing a lot more of right now.”
“We’re not able to test for [fentanyl], but the stories we hear from patients is that they’ll say: ‘I used the same amount of heroin I always use, so I don’t understand why I got into trouble with that dose. It must have been contaminated.’”
When asked if drug-testing would be helpful in treating overdoes at hospitals, Dr. Klaiman said urine and serum toxicology screens do not help in the immediate treatment of life-threatening overdoses.
“The results take about an hour to come back, and we need to respond immediately,” she said. “This being said, it would be useful to know local patterns.”
After doctors discuss the quality of drugs used, they talk harm reduction. They ask if the patient is using a clean needle and advise where they could find a naloxone kit if they don’t already have one.
Known by the brand name Suboxone, buprenorphine is a maintenance treatment for opioid use disorder and is used off-label in the emergency department to treat opioid withdrawal, Dr. Klaiman said.
But, there have been many cases where admitted patients leave the hospital against medical advice in order to use opioids.
“These are patients who are admitted for reasons other than their opioid use disorder,” she said. “After leaving, they may or may not return to hospital to complete their treatment. We are doing these patients a disservice, by first not adequately treating their withdrawal; and second, by not providing them with a safe place to consume their substance of choice.”
Dr. Klaiman gives an example of a patient who was admitted to hospital for treatment of endocarditis, which is a serious and potentially fatal complication of intravenous drug use requiring treatment with strong antibiotics.
“The patient went into withdrawal and left hospital to inject heroin,” she explained.
The patient returned several hours later but by that time had missed multiple doses of antibiotics.
“Had they been offered treatment with Suboxone or methadone, or a safe place to consume their substances in the hospital, they may not have needed to physically leave the building to a potentially unsafe environment,” Dr. Klaiman said.
She said opioid withdrawal is a predicted side effect of naloxone administration, which can be “an extremely unpleasant experience,” and because of that, patients are going to react differently.
Dr. Klaiman said some patients may be thankful that they did not die, while others get increasingly uncomfortable to the point where they can become “quite agitated.”
“That’s very difficult,” Dr. Klaiman said, when asked how challenging it is to assess who is more at risk than others. “We have to use the concept of universal precautions and assume that every single person is at risk.”
For the first time, hospitals in Ontario will begin tracking opioid overdoses on a weekly basis starting April 1.
“Every hospital and public health unit will have access to the near real-time data, giving experts a more comprehensive understanding of what’s happening on the ground,” Minister of Health and Long-Term Care Eric Hoskins said in a statement to Torontoist.
Councillor Joe Cressy, chair of the Toronto Drug Strategy, says the TDS has prioritized overdose prevention, harm reduction, treatment, and enforcement.
Mayor John Tory, Councillor Joe Mihevc (Ward 21, St. Paul’s West), and Cressy spoke at the first meeting for the Toronto Overdose Action Plan, held at the Metro Central YMCA. Former and current drug users at the meeting expressed the need for access to and distribution of naloxone. Cressy also heard about the importance of “good samaritan” legislation, which is currently under consideration by the federal government.
On March 20, the Toronto Board of Health unanimously approved the City’s first Overdose Action Plan.
The plan proposes that naloxone should be offered by emergency departments and other health services to those with a history of opioid use.
It also suggests exploring prescription heroin or hydromorphone as a treatment option for those addicted to opioids through the Methadone Works program.
The plan also calls for training for city staff working in service providers, such as shelters, libraries, or transit stations, on how to respond when overdoses take place.
Prisons and housing programs, such as Toronto Community Corporation buildings, were suggested by participants surveyed where naloxone should be available.
Ontario ran a pilot program at two prisons where those who were identified to be at risk for overdose were given naloxone when they are discharged—a program that is expected to be implemented to all prisons within the province, according to the plan.
Access to naloxone was expanded to pharmacies across the province in June 2016, where a prescription is no longer be needed, and there is no cost.
However, the plan reports that some participants made the important point that people may fear the stigma associated with opoiod use when naloxone is on their health record, so they should not have to show a health card.
Toronto Public Health and 46 community agencies provide harm-reduction supplies at more than 80 service locations across the city. There were nearly 139,000 client visits to these programs last year, according to preliminary data.
The plan reiterates what Hopkins told Torontoist prior to its release, which states that “plans for a drug checking program in Toronto are underway.”
The program would involve drug checking at the three injection sites and the TRIP! Project, which offers harm reduction services in the nightlife and music festival community.
However, the plan states that there were a lot of questions on the effectiveness of the intervention from survey respondents, including, how drug checking services would work, how long people would have to wait to have their drugs tested, and if people would give up part of their drug supply for testing.
In a release, acting medical officer of health Dr. Barbara Yaffe said a funding request for additional resources to help support the plan will be included in Toronto Public Health’s 2018 Operating Budget Request for consideration as part of the City’s 2018 budget process.
Cressy wants those who are on the frontlines, who know the solutions, to be part of developing them.