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.
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Amen!
Why are providers not working with people like myself?
I have been free from OUD for a decade and am on SUBOXONE. I went back to college and graduated as an addiction counsellor. Now, I’m almost done my Honours in PSYC.
The reason I opened up was to help others. Not just those with SUD’s, but the doctors who had provided me the crazy amounts of narcotics. I think I had enough for an oral equivalence of 600 mg of MOP a day!
I have advice, I know all the tricks and you would be shocked by how much doctors do not know about opioids.
For example STRENGTH IS NOT THE SAME AS LIKABILITY.
There are practical, easy ways to ensure that narcotics are used for pain and not being diverted or over consumed.
Only one provider ever asked me for my thoughts!?!
I also have a special interest in the intersection of infectious diseases and social determinants of health. I hadn’t considered the relationship between the opioid crisis and HIV/AIDS before. But living in a city in Ontario where the emphasis of the Health Unit, in particular its medical officer of health, is mainly on the opioid crisis, and seeing so many people who are not HIV positive needing opioids or narcotics, at a moderate level – say, Tylenol 2 or 3, leaves me feeling that the needs of some people are being disregarded in favour of those addicted to opioids due to HIV or AIDS.
I also see that perhaps in part because of this “crisis” in sw Ontario, that the Health Unit is not paying enough attention to other aspects of its mandate when it comes to infectious diseases, such as Tuberculosis. I was let down last year when I was falsely suspected of having TB, due to inaccurate clinical symptoms being put on the form someone filled out about me. No one caught the error, No one could be bothered. What would happen if that happened to someone with HIV or AIDS? They would probably start a “healthy debate” about it. As someone with emphysema, and not with symptoms of TB, born in England, attended private school, had caring parents who enjoyed nutritious food served at the table, later emigrating to Canada, marrying, giving birth to 2 children (pregnant 2.1 times), having that end, moved to attend university, moved again to attend university, still no career, ended up in the first university city unknown, uncared for, replaceable. Now a senior, thrown to the wolves, no one caring enough (about me, or the work they do) to do it right. And now, no one taking responsibility. I no longer have a prescription any more for Tylenol 2 or 3, that I had at one time for a broken ankle before I moved to this city, and now with a healed broken femur but left with a bad knee and other chronic conditions, I am required to make do with Tylenol 1. Yes, I have an interest, too, in the intersection of infectious diseases (or being suspected of having one) and the social determinants of health as seen by narrow-minded health professionals judging me by how I ended up.
Thanks for this thoughtful piece about bias. I believe it speaks to a fundamental flaw in the philosophy of medical care: if you don’t have the “answer” for a successful treatment outcome, you have “failed”. Medical training indoctrinates us to avoid failure; therefore, we find ways to avoid patients whose conditions we are ill-prepared to help with. We end up blaming the patient, moralizing the conditions, and finding quick but ultimately ineffective “solutions” that solve our problems but not the patients’, such as early discharge, thoughtlessly increasing doses of opioids, setting patients up so their behaviours become intolerable enough that we can fire them. This was the case when HIV was new. This is the case with addiction. This is the case with chronic pain. I think it speaks to the necessity of upping our compassion quotient, particularly when faced with a lack of “answers”. And, of course, educating ourselves appropriately where there are effective means of providing good care to complex conditions. Like addiction. Like chronic pain.
It seems you are a hypocrite. Addicts are, and rightly so, treated as people with an illness. That aside, chronic pain patients on opioids are stigmatized by nurses, pharmacists, doctors and medical regulators as addicts.
So great to see you sharing your experiences at SPH, Thomas! Hope to see you there in the future.
Kinnon
Wonderfully written, compassionate and important