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Aug 06, 2019
“No one ever thinks when they first use an opioid that they’ll become dependent on it,” says Dr. Andy Blackadar, a family physician in Liverpool, N.S.
“But it’s easy for people to see it as a personal failure. It’s not about right or wrong – it’s about finding the best way to manage this clinical solution.”
People of all ages and all socio-economic backgrounds can become dependent on opioids. In Nova Scotia, the number of fatal overdoses from opioids has held steady since 2016, with about 60 Nova Scotians dying each year.
Dr. Blackadar is part of a small but growing number of physicians in the province taking a harm-reduction approach to help people with opioid use disorder (OUD). “We want to help our patients achieve better health outcomes and regain their lives, regardless of where they’re starting from,” he said.
Evidence-based treatment like opioid agonist therapy, which uses methadone or buprenorphine (more commonly known by its trade name, Suboxone) to replace opioids and prevent withdrawal, has surpassed the rigid abstinence-only approach of the past.
Taking methadone or buprenorphine gives people a steady dose of long-acting opioid medication throughout the day, so they can avoid withdrawal and suppress cravings, access services and support, and start rebuilding their lives.
Lack of patient access to this treatment in his own community inspired Dr. Blackadar to get trained eight years ago. “I had patients who had to go to the Valley for this care. When training became available, I jumped on it.”
Now, he offers a weekly opiate replacement clinic from his collaborative family practice clinic at the Queen’s General Hospital in Liverpool, working with addictions and mental health care providers.
Halifax family physician Dr. John Fraser has been treating people living with OUD for more than 25 of his 40 years in practice. He works at the North End Community Health Centre, at the pain management clinic at the QEII and at Direction 180, an opioid treatment program he helped found in 2001.
For Dr. Fraser, helping people in their current situation is what harm reduction is all about. “It’s accepting the decisions people make about their health care and finding strategies to minimize harm and maximize health.”
That can mean giving people clean needles and take-home naloxone kits, and helping them get the right treatment.
Dr. Tommy Brothers is exploring what harm reduction means for hospital patients. A third-year resident in internal medicine at the QEII, he’s been passionate about harm reduction since he was a med student.
He has learned a lot from physicians like Dr. Fraser and community-based groups like Mobile Outreach Street Health (MOSH), a mobile clinic that provides health care to marginalized people in Halifax, and Mainline needle exchange. “They build relationships with people in the community and work with them to help them meet their goals, whatever they might be at the moment” Dr. Brothers said.
Physicians are taught to treat the illnesses that addiction brings on (such as cirrhosis, endocarditis and hepatitis C) but steer clear of treating the addiction itself, said Dr. Brothers. This creates a vicious cycle.
He says having physicians in the hospital trained to prescribe methadone or buprenorphine can save lives. “It reduces by half a person’s risk of dying. It’s an enormous opportunity to help people get treatment.”
To that end, Dr. Brothers has trained as an opioid agonist therapy prescriber, and helped develop a protocol for emergency department physicians to start people on methadone or suboxone right away.
He’s also educating physicians, nurses, and other providers about treatment options and tools. “Some people still think that abstinence is the only way to recover and be safe,” he said.
“For a lot of people, that’s not realistic. Their goals might be reducing the amount they take, or using more safely. That could be smoking or snorting their substances, instead of injecting them, or even injecting more safely.”
Ultimately, Dr. Brothers would like to see the hospital provide a formal service that offers evidence-based addiction treatment alongside expertise from people who have experienced addiction.
Physicians across the profession are keen for more training in harm reduction, says Dr. Fraser. He trains family practice residents, lectures residents and medical students, and gives talks to colleagues across the Maritimes.
For Dr. Blackadar, helping people manage their substance use is some of the most gratifying work that he does. “There aren’t many aspects to my practice where I get to see people turn back into people,” he said. “Even folks who struggle to stop using other things completely, they stop going to jail, they’re able to return to work and to their families. Their lives are so much better.”
