Paxton Bach, an internal medicine and addiction medicine specialist at St. Paul’s Hospital in Vancouver and co-medical director at the B.C. Centre on Substance Use, outside Kitsilano Secondary School on April 29.Kayla Isomura/The Globe and Mail
Like others working on the front lines of Canada’s toxic drug crisis, Paxton Bach is seeing a troubling shift in patterns of illicit drug use.
Over the past decade, Dr. Bach, an internal medicine and addiction medicine specialist at St. Paul’s Hospital in Vancouver and co-medical director at the British Columbia Centre on Substance Use, has noticed the use of methamphetamine skyrocket, adding another layer of complexity to the opioids epidemic.
Many people who wind up in hospital emergency departments are there with a combination of unregulated amphetamines, including methamphetamine, and opioids in their system, and deaths often involve more than one drug.
“We have a tendency to view every substance independently from one another,” Dr. Bach said. “It’s important to recognize that these are not independent phenomenon.”
Some have characterized the growing use of methamphetamine and other stimulants, together with fentanyl, as a “fourth wave” of the opioids epidemic. An initial wave was related to increased access to prescription opioids. A second wave of heroin-related overdoses emerged, in part, owing to a decrease in prescribing opioids, followed by a third wave of synthetic opioids, predominantly fentanyl.
The surge in the combined use of methamphetamine and opioids makes it more challenging to treat people struggling with the immediate and long-term health effects of drug use, addiction experts say. And it underscores the need to address the complex and worsening economic and social issues, including homelessness and untreated mental-health problems, that contribute to the problem.
According to a recent study, published in the Canadian Journal of Psychiatry and co-authored by Dr. Bach, the rate of amphetamine-related emergency department visits in Ontario increased nearly 15-fold between 2003 and 2020. The rise was most dramatic over the past 10 years, and the researchers noted polysubstance use is now common.
Their findings echo what’s happening in other parts of the country. In Winnipeg, for instance, methamphetamine-related emergency department visits jumped seven-fold between 2013 and 2017, according to a 2020 report by Manitoba Centre for Health Policy.
Since releasing that report, co-author Nathan Nickel, who is director of the centre, said the upward trend has continued. Anecdotal reports suggest the strength of the drug has increased as well, he added.
In absolute numbers, the size of the population using methamphetamine may not seem large. A March, 2020, report by the Canadian Centre on Substance Use and Addiction noted that the last available data showed roughly 0.2 per cent or 59,000 Canadians reported using the drug in the past year. But people who use it tend to have a lot of complex and frequent health care needs, said Dr. Nickel, who is also an associate professor of community health sciences at the University of Manitoba.
Amphetamine-related emergency
department visits in Ontario
Emergency department visits (left scale)
Rate per 100,000 Ontarians (right scale)
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2,500
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THE GLOBE AND MAIL, SOURCE: CRISPO JAG, LIU L, BACH P, ANSELL DR, SIVAPATHASUNDARAM B, NGUYEN F, KURDYAK P, SEITZ DP, CONLON M, CRAGG JJ. AMPHETAMINE-RELATED EMERGENCY DEPARTMENT VISITS IN ONTARIO, CANADA, 2003-2020. THE CANADIAN JOURNAL OF PSYCHIATRY
Amphetamine-related emergency
department visits in Ontario
Emergency department visits (left scale)
Rate per 100,000 Ontarians (right scale)
3,000
20
2,500
15
2,000
1,500
10
1,000
5
500
0
0
2004
2008
2012
2016
2020
THE GLOBE AND MAIL, SOURCE: CRISPO JAG, LIU L, BACH P, ANSELL DR, SIVAPATHASUNDARAM B, NGUYEN F, KURDYAK P, SEITZ DP, CONLON M, CRAGG JJ. AMPHETAMINE-RELATED EMERGENCY DEPARTMENT VISITS IN ONTARIO, CANADA, 2003-2020. THE CANADIAN JOURNAL OF PSYCHIATRY
Amphetamine-related emergency department visits in Ontario
Emergency department visits (left scale)
Rate per 100,000 Ontarians (right scale)
3,000
20
2,500
15
2,000
1,500
10
1,000
5
500
0
0
2004
2006
2008
2010
2012
2014
2016
2018
2020
THE GLOBE AND MAIL, SOURCE: CRISPO JAG, LIU L, BACH P, ANSELL DR, SIVAPATHASUNDARAM B, NGUYEN F, KURDYAK P, SEITZ DP, CONLON M, CRAGG JJ. AMPHETAMINE-RELATED EMERGENCY DEPARTMENT VISITS IN ONTARIO, CANADA, 2003-2020. THE CANADIAN JOURNAL OF PSYCHIATRY
One of the most important contributing factors to the increased use of a drug is its price, according to Leslie Buckley, chief of the addictions division at the Centre for Addiction and Mental Health (CAMH) in Toronto. When it comes to crystal meth, a form of methamphetamine, the price has plunged as small, homegrown producers have been eclipsed by large, almost corporation-like outfits that generate enormous amounts of it, particularly in Mexico, Dr. Buckley said.
The rise of fentanyl has also played a role. Often, people say they use methamphetamine to offset or complement fentanyl, whether it’s owing to an unproven perception that it provides protection from overdosing or to counter the strength of the fentanyl and allow them to function while on the drug, Dr. Bach said. Others find methamphetamine prolongs the effects of fentanyl, which is shorter-acting than heroin, he added.
“But in my world, a very common reason for the use of stimulants is survival,” Dr. Bach said. He explained some people who are homeless or unstably housed use methamphetamine to stay alert to avoid being assaulted when spending the night on the street, or in a shelter. Some also use it to cope with cold outdoor temperatures.
Dr. Nickel said he has also heard of people using methamphetamine to suppress their hunger.
“It’s less expensive to get meth than it is even to get food,” he said, adding that it’s unsurprising the drug’s use has continued to increase over the pandemic, as many health and social services were paused or temporarily scaled back during early COVID-19 waves.
The health risks of methamphetamine use include cardiovascular issues such as heart attack and stroke, as well as psychiatric problems. “Overamping,” which is analogous to overdosing on opioids, can have a range of effects, including anxiety and agitation, accelerated heart rate, paranoia and extreme discomfort. In severe cases, it can lead to psychosis.
Although there are guidelines and evidence-based approaches for treating opioid-use disorder, treatments are limited for those using methamphetamine. Dr. Buckley said some medications are in trials, but for now clinicians rely on psychotherapeutic treatments such as motivational interviewing, and treat any concurrent psychiatric disorders.
To address the acute health effects of methamphetamine, people are typically given supportive care when they arrive at hospital emergency departments, she said. This involves making them comfortable in a quiet space to help them calm down.
Earlier this month, while highlighting the growing demand for emergency services related to methamphetamine use in Toronto, CAMH called on candidates of the city’s June 26 mayoral by-election to commit to supporting solutions. Its recommendations included ensuring an increase in affordable housing, investing in the expansion of an early psychosis intervention program and investing in the creation of a stimulant hub, a central location to support methamphetamine and other stimulant users.
Even though people may appear well after the acute effects of methamphetamine have worn off, the underlying issues related to their substance use remain, Dr. Buckley said. Stimulants have a significant impact on executive functioning, which affects cognition and the ability to plan for the future, and this is often coupled with an intense desire to continue using the drugs, she said. “It’s really hard to break that cycle.”
While some politicians and pundits have linked a recent spate of random, violent attacks in Canadian cities with drug use and addiction, Dr. Bach cautioned that this oversimplifies the problem.
“It’s unfair and, I think, unhelpful to try and pin this on substances without acknowledging the greater structural inequities that are contributing to the current situation,” he said.
Dr. Nickel echoed that sentiment: “Let’s remember that these folks are dealing with some pretty difficult situations, and meth is the solution that they’re able to afford or that is the easiest to access,” he said.