The duality of two health crises in North America
Dr. Austin Mardon & Imran Ahmed
The COVID-19 pandemic has had profound and far-reaching consequences for almost every individual around the world. It is due to this pandemic that public health measures such as physical distancing has played an integral role in saving lives and slowing the spread of the virus (Jayasinha et al, 2020). However, measures like these have had quite the negative mental health impact in various individuals. Furthermore, those that suffer from opioid usage disorders suffered most heavily due to these measures as there was limited access to a safe supply, supervised injection sites and outpatient treatments, which resulted in increased risk for these individuals to relapse and overdose (Jayasinha et al, 2020). The notion of “safe supply” has always been a point of contention when addressing the opioid crisis. Many point to the criminalization of possession of these controlled substances as an accelerant, that leads to users developing solitary and dangerous consumption patterns that prevent access to life saving supports (Diab et al, 2022). The criminalization aspect has led to users looking towards untrustworthy street suppliers where the risk of substances being laced with fentanyl has increased, leading to increased mortality rate (Diab et al, 2022). Fentanyl is a synthetic opioid that acts on the same brain receptors as other substances like oxycodone, morphine and heroin. However, it is around 50-100 times more powerful than morphine, thus, making it much more lethal even in small doses (Wakeman, 2016). Before delving into specific examples which go into the mechanisms as to why the pandemic has exacerbated the effects of the opioid crisis, it is paramount to highlight the opioid crisis in a Canadian context, timeline,statistics that connect the two issues at hand. Opioid use has been referred to as a public health crisis in Canada due to the 16,364 opioid-related deaths that have occurred between January 2016 and March 2020 (Morin et al, 2021). Ontario, British Columbia and Alberta have been the hardest hit regions in Canada in terms of the opioid crisis (Morin et al, 2021). It is also important to highlight the different groups that are being affected by this epidemic within this pandemic. First, the number of opioid related deaths had more than doubled among the homeless with 1 in 6 opioid related deaths during the pandemic having occurred in this population (Public Health Ontario, 2021). Furthermore, opioid related deaths amongst men and women increased from 93% and 44% respectively from February to December 2020 (Public Health Ontario, 2021). Evaluation of wastewater in the community is an extremely helpful and non-invasive way to study opioid exposure at the community level as it bypasses the barriers associated with the healthcare system (Perlman, 2021). In the past, researchers seeking to directly measure opioid exposure in a community were limited by the fact that they only had access to people that had passed through the healthcare system, through overdoses or treatments. The use of wastewater evaluation includes people who use opioids but have had no interaction with the healthcare system in the dataset (Perlman, 2021). Furthermore, fentanyl consumption appeared to increase in the early months of the COVID-19 pandemic according to wastewater fentanyl loads per capita. Loads were nearly twice as high in May 2020 and close to three times higher in June and July 2020 (Hatt, 2021).
British Columbia and other provinces have been attempting to resolve this issue in two ways: providing the safe supply of narcotics and the decriminalization of simple possession (Diab et al, 2022). Conversely, there have been various steps taken to address the first issue during the COVID-19 pandemic. One of them being opioid agonist therapy (OAT). In response to the state of emergency declared by the Ontario government in March 2020, new guidance was released for the therapy to increase the expansion of eligible take-home doses (Kitchen et al, 2022). Treatment with OAT involves regular interaction with a clinician and daily supervised dosing in community pharmacies until the individual is deemed eligible for take-home doses (Kitchen et al, 2022). A take-home dose is beneficial under certain circumstances as having face-to-face contact with the provider of OAT can be a barrier to those seeking treatment (Kitchen et al, 2022). The associated changes to healthcare delivery to accommodate physical distancing included aspects such as reduced hours of pharmacy operation, shifts to virtual care and requirements to quarantine. These changes disrupted the regular access to OAT (Kitchen et al, 2022). Some guideline changes that were implemented into the program once the state of emergency was declared was included recommending prescribers to use their best clinical judgement to increase the number of take home doses to those already receiving them, and limiting the number of doses for those that aren’t eligible under the current guidelines (Kitchen et al, 2022). The study by Kitchen et al investigated the impact of COVID-19 public health restrictions on OAT and the patterns that were associated with take-home doses of methadone and buprenorphine/naloxone. They hypothesized that declaring the state of emergency in Ontario would lead to an immediate increase in the provision of take-home doses of OAT. To add more context, buprenorphine and methadone are both synthetic opioids that are used to treat pain and opioid addictions. In addition, naloxone is often paired with buprenorphine when treating opioid addiction to prevent people from misusing the drug (CAMH). Since methadone is a full agonist, and thus no ceiling for respiratory depression, an overdose can be fatal. Methadone is not usually paired with naloxone because there is already a long timeline before an individual is able to use take-home doses. Daily supervised doses are recommended for 2-3 months for methadone, compared to 7-10 days for those receiving buprenorphine and naloxone (Kitchen et al, 2022). The more rigid treatment timeline for treatment with methadone doesn’t necessitate the need for the opioid to be paired with naloxone. Some of the differences between buprenorphine and methadone include easier access, lower risk of overdose and less pronounced side effects for the former (CAMH). Moreover, a population-based time-series analysis of Ontario residents receiving methadone or buprenorphine/naloxone treatment for OAT was conducted from June 25, 2019 and November 30 2020 (Kitchen et al, 2022). Results showed increases in the duration of take-home doses following the placement of COVID-19 restrictions and updated OAT guidelines (Kitchen et al, 2022). The study concluded that a small, but statistically significant increase in the dispensing of longer take-home doses of OAT immediately following the declaration of the state of emergency. However, approximately only ⅓ of methadone recipients and ⅕ of buprenorphine/naloxone recipients continued to receive daily supervised treatments during the pandemic (Kitchen et al, 2022). It is due to these findings that the best course of action is to develop strategies to improve retention in OAT and ensure equitable access to take-home dosing is required (Kitchen et al, 2022). Findings suggested that despite the increased access to take-home doses, there was a lack of standardization across and many had not adapted their services to allow for an ease of accessibility (Kitchen et al, 2022). To clarify, the implementation of COVID-19 health restrictions required the prescription renewals to be done virtually or over the phone. While 30% of OAT users viewed this change positively as it was a more convenient method, 41% of OAT users felt that this change had a negative impact (Russel et al, 2021). Many individuals felt that the virtual appointments resulted in a reduction in the frequency of communication and overall quality of service (Russel et al, 2021). These lapses in communication made it difficult for those whose OAT physician were their primary doctor and relied on them to address any and all health concerns (Russel et al, 2021). Additionally, some participants found it damaging that random urinalysis tests were halted as they were deemed to provide necessary accountability (Russel et al, 2021). Therefore, resulting in an increase in substance abuse.
In conclusion, it is important to understand all the circumstances of the opioid crisis in Canada and how the pandemic has shaped the way this issue has been approached. Given the exacerbated effects of the opioid crisis during the COVID-19 pandemic across Canada, all the findings suggest strategies to improve OAT and intervention policies for supporting those that may not have access to the necessary resources to receive help. COVID-19 has disproportionately affected those afflicted with this addiction; there hasn’t been the necessary infrastructure to support them while enforcing public health measures. It is the hope that as the world emerges from this pandemic that reassessment of the most effective treatment programs is done.
Imran Ahmed is a student in the Faculty of Science at McMaster University. Austin Mardon, PhD, CM, FRSC, is an Adjunct Professor in the Faculty of Medicine and Dentistry at the University of Alberta.