Illustration: The Globe and Mail. Sources: Getty Images
Dr. Vincent Lam is an addiction-medicine physician, and the medical director of the Coderix Medical Clinic. He is a Giller Prize-winning novelist whose latest book, On The Ravine, explores Canada’s opioid crisis.
A dozen years ago, when I started caring for people with opioid addiction, I assessed a patient in the throes of withdrawal. He had tried to “just quit everything” without medical help. He was hunched over, drenched in sweat. His distorted face reflected the pain racking his body. I prescribed 30 milligrams daily of methadone, a starting dose, and asked him to return soon.
A few days later, seeing his name on my patient list, I went to the waiting room and called him. A man stood up with a smile, and for a moment I was confused – I thought it was the wrong person. Then I realized it was the same man. My first thought was that methadone had so transformed him that he was hard to recognize. Then I realized it was not methadone that had transformed him. Rather, the first version of him I met – suffering from terrible withdrawal – was the one that was hard to recognize. His illness was the distortion. Treatment brings people back to themselves.
A couple of weeks later, his medication adjusted to a level at which his withdrawal was gone, he asked me, “Okay, doc, what now?” I told him that stabilizing on treatment is like moving into a house. You must furnish it with things that make it your home: healthy relationships, school or employment, enjoyable activities that aren’t drugs. These make the house of treatment and recovery a home. This is what I still tell patients, although nowadays it feels more difficult and fraught.
When I started working in addiction medicine, people used heroin. This has been replaced by a cocktail of fentanyl mixed with other substances. From January, 2016, to December, 2023, 44,592 Canadians died of an apparent opioid overdose. The rise of fentanyl in North America, the COVID-19 pandemic, a housing crisis and a mental-health crisis have disproportionately affected vulnerable Canadians, including those who use drugs.
During this time, our treatments have evolved. The first-line treatment in the CRISM national guideline is now buprenorphine, a medication for which we have new rapid induction methods and monthly injectable treatment options. Many patients still choose methadone. It still works well, though now addressing the physiological imbalances created by the current drug supply often requires methadone doses that are double what we commonly used a decade ago, and it can be challenging to adjust people’s doses to these levels, if chaotic life circumstances interrupt the weeks-long process. As before, people become addicted to short-acting opioids such as fentanyl and hydromorphone. Long-acting opioids – primarily buprenorphine and methadone (both forms of opioid agonist therapy – OAT) – stabilize physiology and lives. These have the most robust body of scientific literature, and cut mortality by almost half.
In 2021, more than one in four deaths of Canadians between the ages of 20 and 40 were related to opioids. Between 2019 and 2021, the annual years of life lost to opioid-related deaths doubled from 3.5 to 7.0 YLL per 1,000 Canadians. News stories have detailed deaths of teenagers and even toddlers. My waiting room contains, in addition to patients, its share of ghosts.
One would hope for a coherent national response. Instead, the political finger-pointing and media attention revolve around hot-button issues such as prescribed alternatives (aka safer supply), supervised-consumption sites and decriminalization – all harm-reduction measures. These serve nicely as political wedge issues because they are controversial and challenge societal norms. Harm-reduction work is incredibly important; Insite, North America’s first supervised-consumption site, has reversed more than 11,000 overdoses in the past 20 years. However, harm reduction has so dominated the public discourse that one could be excused for thinking that it is the only available response to a crisis solely defined by the toxic drug supply. Many who practise addiction medicine would counter that an increasingly toxic drug supply (the illicit drug market has always been toxic) is one contributing factor amongst many and that while harm reduction has a very important role, as with alcohol, stimulant and other addictions, the path forward is through treatment and recovery.
Recently B.C. Premier David Eby asked for Ottawa’s help in modifying the province’s decriminalization policy, while Ontario Premier Doug Ford vowed to fight Toronto’s application for decriminalization “tooth and nail.” Such polarization seems de rigueur in today’s political climate, but most notable to me is what everyone nominally agrees upon and then fails to meaningfully discuss: In every political tussle over harm reduction, it seems obligatory for politicians to mention they support the treatment of addictions, and then attach no meaningful commitments to this claim. It’s as if everyone agrees they want to build a house, there is broad agreement that the house should be solid and waterproof, but since discussion is then consumed by a passionate argument over paint colours and lighting choices, no one addresses the engineering of the house. When Toronto’s application for decriminalization was rejected by the federal government, Mayor Olivia Chow emphasized what matters: “Well, let us focus on the solutions. It’s the treatment program, backed up by shelter and housing, with good mental-health support. That’s how we can prevent some of these deaths.”
The four pillars of a societal approach to addiction are treatment, prevention, enforcement and harm reduction. Recovery-oriented treatment must be the central pillar. Why? Firstly, because whether they are addicted to alcohol, opioids or other substances, that’s what almost all my patients tell me they want: to recover and get back to their lives. Only a small number want to keep using substances as a lifestyle choice. Care that prevents addiction, such as comprehensive pain management and mental-health services, is desperately needed in Canada, and this is also important in supporting the treatment of addiction. Enforcement to deter importation, production and sale of dangerous drugs is important to reduce their availability, but when people who use drugs encounter the law, this should be connected to treatment. Rather than inserting people into a cycle of incarceration and criminalization, we need to help them to recover. Meanwhile, it is crucial that harm-reduction programs, which aim to reduce illness, suffering and death while people are using drugs, channel people toward treatment and recovery. When I was an emergency doctor, I performed cardiac resuscitations on people who’d suffered heart attacks so they would survive to receive treatment to open blockages in their hearts. A patient who needs multiple cardiac resuscitations and does not receive definitive treatment will soon die. Similarly, while overdoses need to be reversed, that effort will only have lasting impact if it leads people toward treatment.
We need to properly situate addiction treatment within the health care system, and the nominal support of politicians for addiction treatment needs to shift to meaningful commitment. I would love to see someone campaign on access to addiction care, integration of the full scope of addiction care within the broader health care system, and support of patients’ engagement in their communities.
Access to addiction care around all substances needs to be available to all Canadians, which means not only providing services but reaching out to those who need it. Liquor stores should be required to prominently advertise addiction treatment, as should cannabis retailers. Many people connect with their illicit drug dealers on social media – so treatment should also be targeted to people online. Alberta’s Virtual Opioid Dependency Program – which offers patients same-day virtual assessment, a prescription for an opioid agonist therapy, and connections to physical clinics – should be emulated in other provinces but with a broader scope that also initiates treatments for other addictions. Meanwhile, we should remember that online access will not reach patients who are unhoused and have no internet, and online care may not be optimal for developing meaningful therapeutic relationships. We also need low-barrier access to high-quality in-person care.
Delivering the full scope of care means that hospitals need to step up. In too many emergency departments in this country, the most available option after a life-threatening emergency such as severe alcohol withdrawal or an opioid overdose is to send the patient to a detoxification facility with no medically trained staff. Meanwhile, in the next room, patients with other life-threatening conditions are routinely admitted to hospital. This reflects both bias and distorted thinking, that somehow addiction is a health problem that is not worthy of hospitals and health professionals. Astoundingly, in the Greater Toronto Area, no general hospitals have dedicated addiction-medicine in-patient beds. Only the Centre for Addiction and Mental Health has a limited number of difficult-to-access beds. In 2020, of patients who presented to Ontario hospitals for opioid toxicity, 5.6 per cent initiated OAT in the following seven days. This is better than 2013, when the figure was at 1.7 per cent, but what would we say if only 5.6 per cent of people with a heart attack were started on treatment? We would – and should – be aghast. A number of hospitals now have Rapid Access Addiction Medicine (RAAM) clinics, but asking people to show up at a clinic to start treatment a day or two after almost dying in an emergency department means many don’t get what they need on the day of their crisis, and are lost to follow-up. Treatments such as OAT must be initiated in emergency departments, hospitals should have the capacity to admit people for stabilization when needed, and there needs to be excellent outpatient follow-up. In most hospitals the current best hope for a person to receive in-patient addiction care is to be admitted for something else – an infection from injecting drugs, for instance, or liver failure from alcohol use – at which point they might receive addiction care alongside the main reason for their admission, if there is an addiction consult service at that hospital.
Exceptions show us what is possible. Dr. Louisa Marion-Bellemare, the addictions co-lead at Timmins and District Hospital, explained to me how she achieved change: “I knocked on the mayor’s door. I said: ‘We have the highest death rate in Ontario. I work in the emerg. I have had seven overdose deaths in the past month. We have to do something as a city.’” The mayor at the time, George Pirie, agreed, and the hospital, EMS, the police and the city’s public-health unit became jointly accountable to city council. Now, Timmins has 14 addiction beds, and its overdose death rate dropped by 65.5 per cent from 2021 to 2022; the number of overdose deaths in 2023 represents a 41 per cent reduction compared to 2021.
Stigma and discrimination need to be addressed in many hospitals. My patients often tell me of going to a hospital and receiving welcoming, caring treatment – until it is noticed that one of their medications is OAT, at which point the demeanour of staff becomes cold and suspicious. In Timmins, the hospital required all staff to undertake cultural safety training, as well as buprenorphine training. “We had to change our hospital culture to make people feel safe to come,” Dr. Marion-Bellemare told me. Hospital culture affects not only individual patient experiences, but also the attitudes and priorities of health care professionals throughout the system.
Part of stigma reduction is giving health professionals the education and tools needed to help patients. Dr. Anita Srivastava, medical director of addiction medicine at Unity Health, told me about her experience introducing buprenorphine to the emergency department at St. Joseph’s Health Centre: “The emergency docs told me how much more satisfying they found it to be able to interact with patients who were coming in opioid withdrawal or ‘drug seeking.’ They felt they finally had some knowledge and an instrument which enabled them to treat. It was really powerful for me to watch this transformation in docs who had never heard of buprenorphine but were embracing and open to the idea and ultimately expressed gratitude.”
Some may point out that hospitals are already overloaded, and they are. But patients with substance-related problems are already contributing to that load. Opioid-related visits have increased by 286 per cent between 2016 and 2021. Patients who do not receive proper care for their opioid-use disorder bounce back. They return when their medical complications – infections in soft tissue, in the heart, in the spine, brain damage from overdoses – are more costly in both financial and human terms. Good care can change their trajectory and keep them out of hospital. Provinces fund hospitals, and provinces should set expectations of hospitals around providing addiction care – as they do for many other areas. In some hospitals, this may mean existing departments such as psychiatry or internal medicine taking ownership of addiction issues; in others it will be new addiction departments. Either way, dollars must be tied to clear performance standards around addiction care and no patient should be turned away because a doctor says, “I can’t help them until they are clean.”
Services outside of hospitals still have an important role to play. In recent years some detoxification facilities have begun to employ nurse practitioners who can initiate treatments, but this is inconsistent between sites and often not available 24/7. It should be universal that patients in detox can immediately access prescription treatments for both opioid and alcohol issues, whether through on-site care or provincially run virtual care. We need addiction consultation systems analogous to our existing systems for other health issues, such as the transfer of critically ill patients between hospitals, or for doctors to consult toxicologists on poisoning issues. Rather than limiting supervised-consumption sites, as Doug Ford vowed to do in Ontario, we should ensure their availability in every community and actively leverage them as pathways to treatment. Ambulance services can easily provide much better care. After reversing overdoses with naloxone, ambulance paramedics should immediately offer buprenorphine treatment as a standard of care, in the same way that everyone with difficulty breathing is offered oxygen. When naloxone reverses an overdose, it also puts the person into terrible withdrawal – motivating further drug use and risking another overdose. Buprenorphine safely relieves this withdrawal, and can also be the first dose of a continuing treatment. The Cochrane District Paramedic Service uses this approach, and in doing so has reduced the number of people who refuse to be taken to hospital after overdose by a third.
Beyond starting treatment, outpatient care needs to support patients in the long term. Recovery from opioid addiction is a long journey, and just like diabetes and blood-pressure medications, OAT is often a long-term maintenance treatment. Historically, the combination of intensive legalistic oversight around OAT prescribing and the fee-for-service physician payment system were two forces that drove frequent office visits, and often made OAT care onerous for patients. Until 2018, physicians required a special federal “exemption” to prescribe methadone, a situation with no parallel in Canadian medicine. Strict audits around adherence to guidelines that mandated frequent visits could result in a doctor losing their exemption and their ability to both care for their patients and earn a living. Although the exemption is no more, patients tell me that some clinics remain oriented toward visits that seem more frequent than clinically necessary. If too-frequent visits are required, this becomes an impediment in patients’ lives. Frustrated, they may leave care and stop their medication – putting them at high risk of relapsing.
Provinces pay doctors, and should use this role to ensure citizens receive care that best suits their needs. I am paid on a fee-for-service basis, and it delivers some systemic advantages, such as allowing for innovation and rapid provision of services without much administrative delay. It is also a scattershot approach that does not guarantee access to care and can create misalignments between the interests of patients and physicians. For example, if I provide a monthly injectable buprenorphine treatment for one patient, I earn a third of what I am paid in a month of adjusting another patient’s methadone weekly. Fee schedules need to be devised that are neutral to the choice of treatment, alternate payment models need to be used, and more addiction care should be integrated into primary-care groups. We need to ensure that the growing use of remote care improves access for patients, and doesn’t just provide convenience for doctors. Beyond doctors, we also need to consistently fund wraparound care by non-physicians: counsellors, social workers, housing workers and peer support workers. Their availability is crucial for many patients, and yet uneven across practice types, most of which have no funding for such staff. Trauma and anxiety disorders are so ubiquitous in addictions that I sometimes think our specialty exists primarily to treat their secondary fallout. Yet, publicly funded trauma and mental-health treatment is scarce, and needs to be made available.
Even if a patient is prescribed a lifesaving medication, they must figure out where to get it. At last count, only 37 per cent of Ontario community pharmacies dispensed methadone, and so patients often undertake a scavenger hunt for one that does. In rural communities, there may be no nearby dispensing pharmacy. Stigma can be a barrier. Pharmacy professional colleges, like those of doctors, need to educate their members that OAT is a lifesaving medication, not something that attracts “the wrong kind of customers.” Some hospital formularies have been slow to add OAT. Colleagues at major Toronto hospitals tell me they need to jump through hoops to obtain certain newer medications for their patients, despite hospital visits often being a prime opportunity to initiate treatment. Every retail pharmacy in Canada should be able and willing to dispense lifesaving OAT, and hospitals’ formularies need to stay up-to-date.
Bill C-64, the first phase of national universal pharmacare, should include OAT alongside contraception and diabetes medications. Similar to treating diabetes and preventing unwanted pregnancies, treating opioid-use disorder prevents a host of medical complications and costs, and people often need medication for a long time to fully benefit. Besides, we are often paying for OAT medications already. Many of my patients have medication coverage that is linked to either social assistance or disability support. When these patients are ready to return to work, some can only find entry-level jobs without benefits. They realize they cannot afford to return to work without medication coverage. This is a tragedy, because working is a huge recovery support. (It is also a loss to our society, which is better off if these Canadians are productively employed.) If we include OAT coverage as part of C-64, rather than tying it to provincial income-support programs, we will remove this stumbling block. Federal parliamentarians who proclaim their support for addiction treatment have the power to take this concrete step.
No one sets out to have an addiction, and everyone wants to enjoy a life worth living. Part of the DSM diagnostic criteria for addiction is that it has resulted in a person neglecting other areas of their life, so our approach to recovery must offer support in those areas — including housing, education and employment.
People who are unhoused and addicted to drugs need housing in order to recover. A shelter bed prevents frostbite but doesn’t improve someone’s trajectory unless it leads to stable housing. Housing needs to be dignified, long-term, and for many it should include recovery supports.
People with addictions are overrepresented in correctional institutions, which traditionally manage their health care outside of the purview of ministries of health. Jails and prisons need to ensure smooth continuation of health care and medications when people enter and exit incarceration, and have the ability to manage and adjust people’s medications while in custody. If people’s medications are disrupted during their involvement with the justice system, or they are released from incarceration with no plan for continuing care, they are at high risk for a relapse that may drive further crime, as well as overdose and death. Whenever possible, interactions with the justice system should lead to engagement and treatment, rather than criminalization.
Alberta is deploying an “all-of-government” approach, in which the Ministry of Mental Health and Addiction collaborates directly with other relevant ministries such as housing and labour. Other provinces and the federal government should do the same.
As part of my addiction-medicine practice, I care for physicians and nurses who experience substance-use disorders. Almost universally – with programs run by their professional colleges, and support and oversight by colleagues and employers – they do well, stop using drugs and return to work. They have a respected job to return to, an income, people who regard them as valuable. If someone doesn’t have any of those things, drugs look like a pretty good option, so how can we provide choices that look better than getting high? The construction industry is just one that is hard hit by substance-use disorders; labour unions and employers should be active partners in getting their workers back to work.
Many of the patients whom I have treated for opioid-use disorder over the past years would now be most recognizable to those around them not as a person with an addiction but as a neighbour, a co-worker, a family member. Whether they are open or private about their struggle with substances, they have found a place in the world where they can recognize themselves. It is wonderful to see patients recover, but shameful that many have recovered despite an absence of care or outright discrimination in the health care system that should be helping them. Supporting access to addiction care, integration of addiction care with the health care system, and devoting non-medical resources to reintegrate patients with the community are what it means to support treatment and recovery, although they don’t lend themselves well to political slogans.
We need investment in addiction services. A big part of the work is also to integrate resources such that each step links patients to the next step in care, and ultimately back to their own lives. Right now, too many resources are like joists and beams lying haphazardly around a building site. They need to be properly assembled to support one another, and ultimately a solid house of treatment and recovery. That’s what we must offer people, if we want them to be able to move in, build a home and recognize themselves again.
Editor’s note: A previous version of this article incorrectly stated that the overdose death rate in Timmins has dropped by 50 per cent since the addition of 14 addiction beds. The overdose death rate dropped by 65.5 per cent from 2021 to 2022; the number of overdose deaths in 2023 represents a 41 per cent reduction compared to 2021. This version has been updated.