Thread by @Thrombocytosis

I lost another patient to overdose recently. I suppose that’s not that surprising – about once a week I have a patient die from an opioid OD, these days – but this one hits harder than most. A 🧵. #abpoli #ableg #opioidcrisis (1/24)

We’d had discussions about which DLC for Witcher 3 was better (he said Blood and Wine, I liked Hearts of Stone) in between discussing how best to treat the giant monkey on his back. However, recently we’d lost touch – he’d stopped going in for his methadone, and sometimes (2/24)

that just means that someone’s had a relapse, but sometimes it means that they’ve overdosed and I’ll find out later. Usually I get a call from the medical examiner or, in this case, when his partner told us a couple of months later that’d he’d died in his dad’s basement.(3/24)

This has happened so much in the past two years, frequently with patients I’ve known for over a decade. When I get a chance to sit with this, when my pandemic hours revert back to ‘normal’, I’m sure I’m going to have to deal with all this death and grief. (4/24)

But for now I’m just left with a profound sense of hopelessness. Unlike with a lot of additions, I essentially had a magic bullet in my toolkit when it comes to opioids in the form of buprenorphine. (5/24)

But the problem is that the fentanyl and, latterly, carfentanil coming in during the pandemic is so powerful that bupe isn’t strong enough to treat everyone. (6/24)

Like most mental illnesses, most people don’t seek treatment for their issues for addictions – part of that is stigma, part of that is lack of availability, and part of it is simply denial that it constitutes a problem. (7/24)

Moreover, in my experience most addiction is deeply rooted in trauma, and serves as a coping mechanism to deal with the consequences of cruelty I can’t even comprehend. When you stop using, you have to deal with all of that horror flooding up. (8/24)

So what can we do to stem this epidemic that’s killing as many Albertans as COVID? Access to bupe would help – not every doc offers it as part of their practice, even though it doesn’t require a triplicate. Teaching it well in med school and residency would be a start. (9/24)

For patients who fail traditional OAT, injectable opioid agonist therapy is an option – that’s where docs or NPs prescribe an opioid that’s much safer to inject than street drugs, and the outcomes I’ve seen from that are better than continuing to inject street. (10/24)

Unfortunately, our present government in Alberta is opposed to this on principle, and has tried to close our iOAT programs. After winning a court battle, iOAT is allowed to continue to treat its present clients, but they can’t take on any new patients. (11/24)

If patients can’t get into iOAT or can’t manage the scheduling required for that, what else can they do to keep themselves safe? Well, they can use in a safer consumption site (SCS)… or at least, they could, if this government wasn’t also trying to close all of those. (12/24)

The availability of this has dropped substantially, and now there’s essentially none in any smaller centres. It also doesn’t solve the issue that the substances they are injecting are so powerful that there’s still a high risk of overdose. (13/24)

There’s been some talk and movement towards the concept of ‘safe supply’, wherein the patient gets pharmaceutical grade opioids with the intent that they will be injecting them; it’s substantially safer than injecting whatever the hell is in the fentanyl that’s out there. (14/24)

I don’t know how I feel about this as a provider – it’s certainly not the safest option, compared to the previously listed treatments, and the amount of opioid you’d have to prescribe to compensate for the weapons-grade street stuff they’ve been taking is… substantial. (15/24)

But the point of harm reduction is meeting patients where they are to a) keep them alive, and b) move them towards safer options. It’s a moot point, because our government is hosting a sham committee that’s going to tell us how bad safe supply is and that we can't use it. (16/24)

What IS the Alberta government trying to do? Well, they’ve been focussed on providing ‘treatment’ beds for patients. For some people, having a bed in a residential treatment facility can help give them time away from their addictions and give them some coping skills. (17/24)

However, it doesn’t do enough to treat the underlying causes of continued use - untreated trauma and dire housing situations. Getting completely off of opioids is hard; “detox” and tx, if not combined with opioid agonist therapy, is no better than no treatment at all. (18/24)

Finally, I have not seen an increase in the availability of treatment beds for my patients – maybe if they had enough money to go to private facilities (coincidentally run by donors and friends of the present government) they’d have access, but alas, they are poor. (19/24)

It certainly doesn’t help that housing is more of a crisis than it’s ever been. Rent is going up, but funds for people who can’t work aren’t. I used to be able to get ‘housing allowances’ from Alberta Works for my patients, but those are nearly impossible to get now. (20/24)

People on ‘medical welfare’ get $330 in rental funds per month. This will not get you a place literally anywhere in Alberta. Also, if you’re homeless you don’t get even that because your housing needs are being met by homeless shelters! Nothing wrong with that whatsoever! (21/24)

I have never seen anyone who’s not housed get their addictions under control. I can’t argue with that; if I were on the street, or jammed cheek by jowl into the shelters here, I’d want to be as messed up as possible. (22/24)

There are solutions for the drug poisoning epidemic, but they require foresight and investment, neither of which are in copious supply in Alberta in 2022. Until that situation improves, I’m going to continue seeing my patients die, one by one. (23/24)

And I’m going to get around to writing the medical examiner for information on the deaths of dozens of people I’ve known for years.

When it doesn’t hurt quite so much. (24/24)

cc: @momsstoptheharm @ehyshka @EZMSA2 @DShepYEG @shoffmanAB @JanisIrwin @RachelNotley @edmonton_anne