One of the paradoxical but predictable consequences of the ongoing war on drugs has been the proliferation of synthetic opioids like fentanyl and carfentanil. These synthetics have effectively replaced illicit heroin in parts of North America and are increasingly being found in other illegal drugs like cocaine and methamphetamines. This means people who use drugs can no longer predict what product they are buying and a single dose of heroin, cocaine, or crack can be lethal. Fentanyl is 50 times more potent than heroin; carfentanil is 5,000 times more potent. Fentanyl and other synthetic opioids were implicated in 69 percent of opioid-related deaths in Canada in 2017, when 2,757 people died of fentanyl overdoses. In April, five people died in two days due to fentanyl-laced cocaine in Ottawa, a city that has safe consumption spaces and low-barrier addiction treatment.
I have experienced this devastation first-hand. I am currently completing addiction training in Boston where treatment options and harm reduction services are even more limited than they are in Canada. Right now, I continually check the chart of one particular patient to see if she is still alive. She has been hospitalized with IV-injection-related infections repeatedly over the past six months and continues to struggle with her opioid use. She tried buprenorphine-naloxone, one of our first-line agents for opioid addiction treatment, but continued to experience intense cravings. She is now on methadone, but due to a bloodstream infection that travelled to her heart, we are struggling to increase the dose. At her current sub-therapeutic dose of methadone, she continues to use street opioids, which in Massachusetts now means fentanyl.
In medicine, we would say this patient has “failed” treatment. This suggests that it is her fault, as if she is simply not trying hard enough to let the medications help her. I can assure you, she is trying. In fact, my patients on treatment for opioid use arguably “try harder” than many patients I work with as a general internist. They show up weekly for their buprenorphine prescriptions or daily for their methadone treatment. I have patients who travel two hours each day just to get their methadone. In these cases, it is clear that the treatments are failing the patients, rather than the other way around.
My patient is only in her early 30s. She has had open-heart surgeries, multiple courses of antibiotics for skin and bone infections, is now living with hepatitis, and faces constant danger living on the streets of Boston. She does not wish to die, and she would like to stop using fentanyl, but she has a severe addiction. The only thing I have to offer her, other than my compassion, are two medications which have failed her multiple times in the past. She will likely die as a result of our inadequate treatment options for her disease.
This makes me angry. I know there is more I could be doing to help her. If she lived in Canada, I could direct her to a safe consumption space, which would keep her safe while using and prevent infections. However, even in Canada, and especially in Ontario right now, these programs are at risk. While the overdose deaths continue to rise, and approximately one person dies each day in Toronto alone, Premier Rob Ford is cutting funding to safe consumption spaces. This is nonsensical, and more people will die as a result. We need more, not fewer safe consumption spaces, and we need other innovative services like drug testing and prescription heroin.
Recently, drug testing has been offered at INSITE, a safe-consumption space in Vancouver, where it has become hugely popular, with people who use drugs lining up for testing. The service allows people who use drugs, as well as medical providers, to learn what is in their products. For example, etizolam, a highly potent drug chemically similar to medications for anxiety, has been cut into heroin and fentanyl and is suspected in recent overdoses in Vancouver. Drug testing allows for the real-time identification of these toxic synthetics, maybe before a post-mortem has to be conducted.
We also need to expand other evidenced-based treatments for severe opioid use disorder (OUD), including the prescription of injectable heroin and hydromorphone. Randomized controlled trials have proven that prescribed heroin is safe and beneficial for patients with severe OUDs for whom first-line treatments have failed. I saw the benefits first-hand while working in Ottawa’s injectable opioid program. Almost all the patients enrolled continue on treatment and are still alive today, more than a year later.
Prescribed heroin has been available in other parts of the world for years. The United Kingdom has had unsupervised heroin prescribing for over a century. Supervised prescription has been available in Switzerland since 1994, and as a standard treatment since 1999. More recently other European countries including Denmark, the Netherlands, and Germany have also instituted supervised heroin prescribing. Across these European countries, prescribed heroin is used for approximately one to 12 percent of treatment-refractory people with OUD. In Canada, supervised heroin is only available at one clinic, in Vancouver, and intravenous hydromorphone is only available in one program, in Ottawa. Prescribed heroin or hydromorphone is not available anywhere in the U.S.
Perhaps if these treatments were available for my patient I would not be forced to keep checking whether or not she is still alive. I am dreading the day when her chart goes from “active” to “inactive.” In the meantime, I will continue to offer the inadequate treatment options that are available. But I know she deserves better.