Three profiles of opioid users

The fish-bowl lives of drug users on the streets of downtown East Vancouver provides an easy, but distorted, window to drug use. That picture is as distorted now as it was 139 years ago when B.C.’s second premier, Amor De Cosmos, headed a commission to investigate opium use.

The window to most drug overdose deaths is closed. Typical victims are single men, in the prime of their life, who die alone from opioids containing fentanyl according to a report from the BC Coroners Service released last Thursday.

Michael Strange. image: Globe and Mail

Even reports of typical deaths are somewhat distorted. For some opioid users, the drug is a godsend. Take the case of Michael Strange. He injured his back while working as a cameraman and found opioids to be the only treatment that provided relief.

“I’ve tried so many different things for my pain,” said Strange. “People say, ‘Have you tried acupuncture?’ Yeah. I’ve had two different kinds of laser therapy. I had doctors and friends say I had to try marijuana. I got the vaporizer and it did nothing for my pain (Globe and Mail, September 7, 2018).”

It wasn’t easy but Michael Strange finally found a doctor who would treat him. Many doctors were “running scared” because they didn’t want to be seen to be contributing to addiction. Now his pain specialist gives him a two-month prescription and before renewing, asks: “Michael, how are you? Are you OK with the drugs? Do you need more? Do you need less?”

Self-medication turned deadly for Chris Willie, a university lecturer with a PhD in environmental physiology from UBC Okanagan. He wrote memoirs about his recovery from fentanyl addiction but he died from an overdose before they were published. With the approval of his family, his memoirs were published in the September, 2018, edition of the Walrus. He describes his mental pain as a child and the calm he found in taking dangerous risks:

“I have never excelled at coping. I was that infant child who hammered his head on the ground when frustrated by anything at all. It must have been embarrassing to parent the son with the ever-present forehead scabs. Perhaps I found it soothing, because, thirty years later, I still find serenity in chaos and derive calm from risk. By fighting to live through near-death situations, I could find the high I needed to briefly escape the pain.”

Like Michael Strange, Emily Wharton lived a productive life with opiates. The twenty-year old opium smoker from Victoria, told a House of Commons Select Committee on Chinese Immigration of her use. The federal committee was initiated by John A. Macdonald in 1879 and headed by B.C.’s second premier, Amor De Cosmos (a.k.a. William Alexander Smith).

Back then, the stereotypical opium user was Chinese. They lured good white women into lives of depravity in opium dens. The real agenda of the committee was to rid Canada of Chinese immigrants.

Wharton’s testimony 139 years ago is recorded in Dan Malleck’s book, When Good Drugs Go Bad. She told the committee that she had been using opium for four years and suffered no ill effects. Wharton testified that opium’s “somnolence and complete rest” left her productive. Chinese men in opium dens treated her well and she objected to the characterization of the dens as depraved. She suggested that if the government legalized opium, “one need not have to come into such holes as this to smoke (p. 102).”

Medical-grade opioids are not the problem. The social stigma of drug use that drives users to overdose, and the lack of pain-treatment specialists, leads mostly young single men to self-medicate, and to die, alone.

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Doctors beware: this opioid is not listed

Doctors rely on Canada’s Controlled Drugs and Substances Act as a guide in prescribing drugs. Tramadol is not listed there but that could change soon.

image: Tramadol dropshipper

Tramadol is a sneaky drug, as Dr. David Juurlink discovered when a patient with a shoulder injury was prescribed tramadol. On the positive side, tramadol relieved the shoulder pain. Then problems starting showing up says Dr. Juurlink:

“The first sign of trouble arose three months later. His shoulder pain gone, the patient assumed he no longer needed tramadol. He was wrong. Shortly after stopping it, he developed debilitating insomnia, shakes and back pain – something he’d never experienced before. Irritable, exhausted and functioning poorly at work, he soon found the solution: All he needed to do was keep taking tramadol, and these problems went away (Globe and Mail, November 27, 2017).”

There are two outcomes of being hooked on drugs. One is a physically dependence, such as exhibited by the above patient. The other is addiction in which a patient’s health deteriorates and their behaviour is transformed –what we usually think of as addiction. This patient needed the drug for no other reason than to avoid the debilitating effects of not taking the drug.

The reasons why tramadol is not listed are complex. First, the way that it affects patients depends on their genetics. Tramadol acts as if it were two drugs. It relieves pain using the same mechanism as aspirin does but for some with a particular enzyme, it converts to an opioid. Only 6 per cent of Caucasians have the enzyme, whereas 30 per cent of those of East African or Middle Eastern decent will experience opioid conversion.

Tailor-made drugs, specific to a patient’s genetics, hold future promise. That would allow doctors would know in advance whether a patient has the enzyme or not. For now doctors roll the dice in prescribing tramadol.

Second, when Health Canada last reviewed tramadol in 2007, during the era of the Harper government, a libertarian regime affected policy. Manufacturers of tramadol lobbied Health Canada directly and indirectly to keep the drug off the list. Manufacturers peddled the “dual mechanism of action” of tramadol without disclosing just what that meant. Indirect lobbying came in form of financial support to at least one patient advocacy group who wanted to keep the drug freely available.

The Holy Grail of pain-killers would be one as effective as opioids without the side effect of addiction. Researchers have been looking or more than a century. The German drug company, Bayer, marketed a cough suppressant derived from morphine under the trademark Heroin in 1895. It was marketed as being non-addictive.

More recently, OxyContin was marketed as a pain-relief drug “without unacceptable side effects.” Doctors believed that they were prescribing a safe drug but OxyContin proved otherwise. Patients who took it for pain relief got hooked and when prescriptions ran out, they went to the streets in search of substitutes.

Under the Trudeau government, Health Canada is considering placement of tramadol under the Controlled Drugs and Substances Act –where it belongs. Whether it is listed or not will be a test of a government’s resolve to put the health of Canadians above commercial interests.

Bring drug overdose plan to B.C. interior

To reduce drug overdose deaths, Vancouver Coastal Health authority plans to track patients to make sure they are taking their prescribed opioids.

image: IFL Science

I may seem odd that lives can be saved by making sure that patients take one opioid (Methadone) so that they don’t die from another (fentanyl). But that’s what statistics show. If patients stay on Methadone they’re more likely to be alive a year later.

It’s the first program of its kind in Canada and the latest effort to turn the tide on the opioid crisis that is projected to kill 1,500 British Columbians (Globe and Mail, Sept. 15, 2017). That’s up from 914 in 2016.

The problem is that patients have hectic lifestyles that make daily prescriptions difficult to take. As a result, only one-third are still on Methadone after a year. Laura Shaver, board member of the B.C. Association for People on Methadone, supports the plan:

“I would think it would be a great idea for many people that are, you know, a little bit unstable, for them to have a bit of a push behind them. With a bit of support, things could be a lot different.”

Rolando Barrios, assistant director at the Vancouver Coastal Health, sets his goal at 95 per cent Methadone compliance:

“We may not achieve that, but think about doubling the 30 per cent to 60 per cent . . . and the impact that would have.”

Tracking Methadone patients is labour intensive. The unregimented lifestyles of drug addicts make it difficult for them to make daily appointments. Starting this month, 20 teams, each comprising of three health professionals, will check on 3,000 patients to make sure they are taking their drugs.

Pharmacists will alert the teams if patients have not taken their daily dose. The team will then phone or visit the patient to check up. Participation in the program is voluntary: the teams are not policing patients.

The plan is modeled on the highly successful program to stop HIV/AIDS launched in 2010. It actively sought untreated HIV-positive people and followed up with an antiretroviral therapy. As a result, the transmission of AIDS was reduced by 96 per cent.

“With HIV,” says Dr. Barrios, “we used to wait until people had low immune systems before they started treatment . . . and then science came in and said we need to treat them earlier and faster. We learned that we needed to be aggressive.”

If the plan is so good for Vancouver, why isn’t it being applied throughout the province? Vancouver’s drug deaths may make news but the problem is worse in B.C.’s interior on a per capita basis.

Kamloops is bad -40 people died of drug overdoses in 2016- but Kelowna is worse. Kelowna led all Canada in per capita opioid poisoning hospitalizations. Vancouver was 16th. Kamloops didn’t make the top twenty but the program is needed here.

The Interior Health Authority needs to match the efforts of Vancouver Coastal Health. Users of prescription opioids need to be monitored. Only by reaching out will the death rate be brought down.

Opioid use rises despite crisis

Am I the only one not surprised that the opioid crisis has worsened? Despite the widespread distribution of naloxone kits to save lives from fentanyl overdose. Despite increased prescriptions of methadone to treat addiction.

       opium den

It’s all so predictable. The fuse to the opioid bomb was lit long ago.

I just finished reading Dan Malleck’s thoroughly researched book When Good Drugs Go Bad: Opium, Medicine, and the Origins of Canada’s Drug Laws. He traces the opioid crisis that gripped young Canada at the turn of the twentieth century and led to the Opium Act of 1908.

As now, the problem wasn’t the “recreational” use of opium, but rather the prescribed and drug store concoctions of opium. Laudanum, a tincture of opium, was commonly found in medicine chests to treat toothaches and diarrhea, and as a cough suppressant.

Opium was, and still is, a powerful drug in a doctor’s medicine bag. It was especially useful to treat the illnesses of urbanization before the advent of antibiotics; diseases such as dysentery, cholera, and tuberculosis. Even today, nothing surpasses it as a pain killer.

As now, the crisis then was triggered by drugs other than opium. Cocaine had been introduced as a pain killer. The effect on users was startling different than that of opium and its sister morphine. The concept of “drug fiends” didn’t exist until cocaine came on the scene. Now the term easily applies to crystal meth addicts. Charles Heebner, Dean of the Ontario College of Pharmacy commented in 1906 that the public alarm over drug users was non-existent until “the Cocaine Monster came upon the arena . . . Cocaine proved to be a far more enslaving drug than opium or morphine (p.199 of Malleck’s book).”

The politics of the opium scare were quite different than the reality of the problem. Whereas the medical problem was opium addiction and the crazed effect of cocaine, the politics dwelt on the anti-Asian sentiment, especially in B.C.

Nineteen hundred and eight was a federal election year and Prime Minister Laurier was looking for his fourth majority in a row. In response to “race riots” in Vancouver, Laurier sent his minister of labour, William Lyon Mackenzie King, to Vancouver to investigate.

King found that Chinese workers had been brought to British Columbia to build the railway and there now 16,000 Chinese immigrants and their decedents which amounted to eight per cent of the population of B.C. White Canadians claimed they were taking jobs away. Chinese Canadians were demonized for leading good, white, Canadian women astray in “opium dens.” The Chinese were perfect scapegoats: too many, too shady. Laurier played the race card and was returned to power in 1908.

One hundred and eight years later, nothing much has changed. The opioid problem is characterized by sensational news coverage of ordinary Canadians, many of them in the prime of their lives, being killed in alarming numbers by overdosing on fentanyl.

However, the root of the problem is not the recreational use of opioids but the prescription of opioids by doctors. “Prescriptions for hydromorphone have soared 57 per cent over the past five years (Globe and Mail, March 27, 2017).”

And predictably, the more opioids that are prescribed, the more Canadians get hooked. The problem is compounded as users get habituated and require increased dosages for them to work. So they turn to multiple doctors to get them. Failing that, they turn to the streets and the deadly fentanyl.

The problem is not recent -it’s been going on for generations according to the Globe and Mail. “The problem is particularly challenging for new doctors who have inherited patients on high-dose opioids from a colleague who has retired.”

It feels like 1908 all over again.