We need all hands on deck

Physicians have the ability, knowledge and tools to address the opioid crisis, says Dr. Peter Butt. Now they need enough resources to support their work.

By Girard Hengen

For physicians to play a greater role in tackling the opioid crisis, one of the first things that has to change is to end the stigma around accepting people struggling with opioid use disorder as patients, says addictions consultant Dr. Peter Butt.

“It’s a multi-pronged situation that requires a multi-pronged approach to addressing it,” said Dr. Butt, who works in Saskatoon. That includes more family physicians trained in opioid substitution therapy and willing to do the work.

“From a medical point of view, we need all hands on deck with regards to our treatment of opioid use disorder,” said Dr. Butt, who is also an associate professor with the College of Medicine.

I would like to envision a time when we don’t have the level of stigma that we do – in the medical profession and in the health-care system – with regards to people that are struggling with addiction.

"Because there are many that might be interested when they come out of training in doing this work, but are told when they join a group practice in family medicine, for instance, that they can’t do this work in that clinic, that they don’t want those individuals. In fact they have people that are struggling with addiction already in their practice.”

Dr. Butt recently spoke to the SMA about the emergence of the opioid crisis, including how it has evolved, and the incremental steps that have been taken by physicians and the health-care system to address it.

Emergence of a crisis

A “perfect storm” of factors created the crisis, including marketing of drugs by pharmaceutical companies at a time when aggressive approaches were undertaken to treat conditions such as chronic pain, acute pain in emergency, and pain associated with palliative care, which are each very different pain entities, said Dr. Butt. People who develop a dependence on opioids are at risk of contracting diseases such as HIV and hepatitis C through the sharing of needles and drug paraphernalia. Criminal activity is also associated with opioid dependency, as is the risk of overdose, especially with illicit fentanyl.

Dr. Butt argues there are essentially two crises. One is the use of illicit fentanyl and the high numbers of deaths associated with it, especially in B.C. and Alberta, but less so in Saskatchewan. The other – which accounts for the majority of overdose deaths in Saskatchewan – is the misuse of prescription opioids.

“That aggressive use of opioids in chronic pain syndromes had little to no evidence for it,” Dr. Butt said. “People were going to live with that chronic pain for years, if not decades, and prescribing higher and higher doses of opioids leading to tolerance, leading to side-effects, leading perhaps to substance use disorder and opioid use disorder, created significant problems. And I think that some of the deaths that we’re seeing are iatrogenic. They’re caused by our prescribing, and we need to address this.”

Developing a response

Recognizing there was a problem, the Canadian Medical Association in 2017 developed national opioid prescription guidelines for people with chronic, non-cancer pain. The number of physicians who have been approved by the College of Physicians and Surgeons of Saskatchewan to prescribe methadone, buprenorphine/naloxone, or both under the college’s Opioid Agonist Therapy (OAT) program (formerly the Methadone program) is growing, but very slowly. As of late July, the total was 85 physicians.

More and more emergency response teams, first responders and family members of addicts are being outfitted with take-home naloxone kits to prevent overdose deaths or acquired brain injuries. Harm reduction sites have been established in some centres. However, Dr. Butt says health systems are a long way from developing comprehensive care that envelopes an individual from initial outreach and detoxification to the final stage of recovery, which could take a year or more.

A person diagnosed with opioid use disorder may receive seven to 14 days of detox, followed by 28 days in rehabilitation – a total of five to six weeks. But according to the Diagnostic and Statistical Manual of Mental Disorders (or DSM-5), three months free of symptoms and non-use is considered early remission, while 12 months symptom-free and with non-use is considered sustained remission.

We’re not even meeting criteria to support people into early remission. We wouldn’t do that for cancer, we wouldn’t do that for any other condition. We would get people into sustained remission. We have the ability to do it. We have the knowledge to do it. We have the tools to do it. But we don’t have the system to support it,” Dr. Butt said.

Dr. Morris Markentin, a family physician at the West Side Community Clinic in Saskatoon and clinical manager of the OAT program, agrees more resources are needed to respond to the opioid crisis. More physicians need to be educated in OAT, more multidisciplinary medical teams should be developed and more mental health resources applied to the response.

“Many of our patients are self-medicating,” said Dr. Markentin. “The opiates aren’t just for pain care. They give you a euphoria. They’ll make you feel better. So when your life is full of angst and distress, opioids make you feel better. And if we’re not improving their mental health or improving their lives, they self-medicate with opioids because they do work.”

However, many patients don’t have access to the supports they need, such as mental health, and many come from a culture that has suffered generations of trauma, he said.

“We’re dealing with multi-generational trauma here and we just don’t have the resources to deal with that,” Dr. Markentin said.

Making a difference

Having seen the opioid crisis spring from a “perfect storm” of factors, physicians are making a difference. Going forward, Dr. Butt hopes to see a continuum of care that leaves no gaps in the transitions from outreach and engagement, to harm reduction strategy, through to detox, therapy and treatment, all the way to rehab, support and recovery. Gaps are being filled “incrementally,” he said, adding “we’re not quite there yet and we need to recruit and have the active support of more physicians working with this population.”

Patients with higher needs are probably better off in a specialty clinic, but family medicine is an ideal place for people who are doing well in their recovery.

“Care needs to be targeted so we close the gaps and develop an evidence-based continuum of care so people are able to be supported all the way into sustained remission, just like we do for cancer,” said Dr. Butt. “I don’t think that is an unreasonable thing to advocate for, nor to expect from our health-care system, but we’ve got a ways to go to get there.”

Dr. Markentin calls any progress “at a snail’s pace.” Physicians are being educated on OAT, but the uptake is slow, he says.

We’re making a difference, but we still have waiting lists, we still have people overdosing, and there are still people not getting the help they need.

He agrees family physicians require training and support from the system. “They need access to addictions counsellors, they need access to psychologists, they need access to treatment. It’s not just a quick prescription fix. We are a piece of the puzzle that’s going to fix it, but if we don’t have a concerted effort, it’s not going to be successful.” ◆