Stigma may be the biggest threat to solving the opioid crisis
An agonizing scream came from the corner patient room. The nearest nurses rushed in while others grabbed the Narcan. I saw the patient walk out of the room; she was sobbing but looked fine. But the flurry hadn’t stopped. I got to the room to see the patient’s boyfriend passed out on the floor. He’d overdosed on fentanyl. He knew he was playing Russian roulette with the drugs he had bought off the street, but he needed to use. We gave him the Narcan, and raised him from the dead.
Stories like this are chilling and traumatizing, but I see them regularly. I’ve spent the last few years training on the internal medicine wards and critical care units of several Toronto hospitals, where the number of patients with issues due to drug use feels like it is getting out of control. My colleagues and I have resuscitated patients who have overdosed in their own rooms, in the hospital lobby bathroom, or in a random dark corner. A friend tried to resuscitate three people in the same bathroom in the same night. Not everyone survives.
Deaths from overdoses only tell part of the story of this crisis. People who use injection drugs (PWID) are at risk for a number of severe infections, often due to unsanitary conditions and sharing equipment. PWID are one of the highest risk groups for new HIV infections, and hepatitis B and C are major problems. Injecting drugs also puts people at risk for severe bacterial infections, most of which are hard to treat and require up to two months of intravenous antibiotics. These infections can be life threatening. I’ll never forget the young woman who had a heart attack in front of me when a piece of her infected heart valve broke off and blocked the arteries that supply her heart.
Early in my training, I spoke to a number of physicians who trained or practised during the height of the HIV/AIDS epidemic in the 1980s. Many told me that at times up to half of their ward was occupied by patients with life-threatening complications of HIV. Young patients were dying at an alarming rate, and with a lack of effective treatments, I can only imagine how hopeless the situation felt.
Today, I cannot help but see frightening parallels between the HIV epidemic and the opioid crisis. The patients are similarly young and suffering from deadly diseases. They face immense discrimination when they come to hospital, causing them to lose trust in the health system. In addition, the magnitude of the opioid crisis is starting to resemble that of HIV. HIV has killed over 24,000 Canadians since 1979. From just 2016 to 2018, over 11,500 people died of an opioid-related death in Canada.
In April 2019, I spent a month training on the Urban Health Infection Unit at St. Paul’s Hospital in Vancouver. This ward was the main HIV ward during the height of the epidemic, but because HIV is under much better control, the focus of the ward has changed to people with infections due to drug use. This experience taught me what is possible when caring for PWID, and made me realize that we can do better in Ontario.
At St. Paul’s, patients are cared for by teams of addiction and infection specialists. They have access to a new supervised injection site on the hospital premises which helps patients stay connected to care even when they need to use drugs. In addition, instead of staying in hospital to complete months’ worth of antibiotics, many patients go to the Community Transitional Care Team, a converted floor of a hotel where patients live temporarily and have access to community housing and addiction resources.
One of my most challenging encounters in Vancouver was with someone whose severe opioid use disorder was out of control because she had become ill with a serious blood infection and couldn’t inject drugs. Her withdrawal and pain were so intense that she would frequently be aggressive and obstructive to medical care; initially, I thought she hated me and dreaded my interactions with her. But the unit’s intensive addictions team, who I worked with, was able to get her addiction under control by rapidly adjusting her medications. With her pain and cravings managed, she became herself again: friendly, kind, and grateful for medical care. Her humanity forced me to examine my own feelings, and the stigma I had attached to her as a drug user. Her addiction does not define her, and, like anyone, she just wanted a chance at being healthy. On my last day working at St. Paul’s, she and another patient bought a huge box of Tim Horton’s donuts for the staff. I have no idea where they got the money, but that’s the most meaningful gift I’ve ever received from a patient.
The immense stigma our society forces on PWID—which I have done myself—is akin to what we saw with HIV, and is similarly compromising our ability to effectively address this crisis. We must identify and deconstruct our prejudices towards drug use, and find new and better ways of caring for those suffering from addiction. The death toll is rising to new heights, and we are running out of time.
Thomas Dashwood is a third-year internal medicine resident at the University of Toronto. He has a special interest in the intersection of infectious diseases and social determinants of health.