"I'm looking for a naloxone kit… It's spelled n-a-l-o-x-o-n-e. It's for opiate overdoses."
This is how many of my conversations with pharmacy employees across Ontario started over the past week while I was on a quest to see if the opioid overdose antidote naloxone was actually available over the counter in the province. Though Ontario Health Minister Eric Hoskins announced in May that the life-saving injection would be available at community pharmacies over the counter and free of charge, effective immediately, you wouldn't have known it based on the experiences I had attempting to get a kit.
Targeting cities and areas within Ontario that have been hit especially hard by the opioid crisis, including those with bootleg fentanyl warnings, I contacted 50 pharmacies—a nice round number for my not-totally scientific survey—across the province to ask about their availability of naloxone. When asked in some cases specifically why I was looking for a naloxone kit, I tried the following approaches (both of which are true for me): I have friends who use opioids; and I am someone who has used other recreational drugs I worry could be contaminated with opioids. Out of those 50 pharmacies, which included locations of several major pharmacy chains, I found that only six were able to distribute naloxone on the day I spoke to them. Some other pharmacies had naloxone but didn't have the training to give it out, and a troubling number of pharmacy staff overall seemed to have little idea about the antidote.
According to the most recent statistics in Ontario, there were 663 opioid overdose deaths in 2014. The fact that Ontario hasn't released more up-to-date data on these types of fatalities is troubling given that the opioid crisis has gotten significantly worse in the past couple of years in several other provinces—specifically, BC, where there were 153 fentanyl-detected overdose deaths in 2015; and Alberta, where 270 died due to fentanyl in the same year. As well, there have been bootleg fentanyl warnings issued in Ontario, and other non-opioid recreational drugs—including meth and cocaine—have been found to be tainted with fentanyl. A synthetic opioid that is 40 to 50 times more potent than heroin, fentanyl is now the leading cause of opioid-related deaths in Ontario.
As of June 24, naloxone became available without a prescription and free of charge in Ontario as part of a $2-million program. Though it's unrealistic to think that naloxone would have appeared in all pharmacies in Ontario overnight —the ministry has said some pharmacies still might not have kits and has adopted a staggered rollout—some of my experiences while speaking to pharmacies in the province were unsettling.
Naloxone is a medicine that is usually given as an injection, such as to the thigh, and can reverse an opioid overdose. A person who is overdosing cannot give it to themselves, however, since opioid ODs render the user unconscious—another person must be there to give the life-saving shot. Though it is far from a solution to the opioid crisis, it is a necessary tool that has the potential to save lives.
I experienced confusion and shock from some pharmacy employees when requesting naloxone, and had to explain to some seemingly clueless staff the spelling of the product and what its purpose was over and over again. Throughout the process, I found that a handful of pharmacies were still under the impression that a prescription was needed for the kit. On a couple of occasions visiting pharmacies in person, I was even treated with disdain—one pharmacist said: "We don't carry that kind of thing." However, I did encounter a few of pharmacists who were exceedingly helpful and in-the-know about naloxone, including one in Toronto who, when I told her I didn't have a health card, took down my number and called me back the next day to see if I could get a kit without one.
Often, when a pharmacy did not have naloxone or was unable to distribute it because of a lack of training (there were seven such pharmacies I contacted that had it, but did not have the requisite training to dispense it), I was dismissed without any advice on where I could find it or was pointed to a pharmacy that also did not carry it.
"It's a chronic inability of the Ontario government to collaborate; it doesn't have to roll out this way," Michael Parkinson, coordinator for the Waterloo Region Crime Prevention Council, told VICE. "I started calling pharmacies to try and grab naloxone around Waterloo region—nobody had any idea what I was talking about, not even a clue."
In some pharmacies, it went beyond an ignorance of knowledge about naloxone. When speaking to one pharmacy staff member, I found he didn't know what an "opiate" was, and another asked, "Are you overdosing right now?"
The fact that someone working at a pharmacy thinks a person overdosing on opioids has the ability to not only pick up a phone and dial a number, but communicate effectively that they're looking for a naloxone kit is shocking. Given the current climate of the opioid crisis in Canada, you'd think pharmacy employees would at the very least have read the news. As someone who has a friend who might be dead right now if it were not for naloxone and as a person who has used drugs in this province that could have been tainted with opioids, what I found surveying pharmacies was not only disappointing, but shameful given that human lives are on the line. Yes, there are outreach programs that distribute naloxone at the street level, but that is not the point here—regular pharmacies are supposed to be able to give it out now too, and some are failing to simply educate their staff on just how important this is.
Dr. Meredith MacKenzie, a physician at the Street Health Centre of Kingston Community Health Centre, which distributes naloxone, said she and her team have had to take it upon themselves to educate pharmacies in their area. When I spoke to her, she voiced concerns that pharmacies that had had naloxone auto-shipped to them from the government were confused about what to do since they didn't have the necessary training to distribute the kits. The Ministry of Health hadn't provided "much guidance." She explained that they are now planning on drawing up a one-pager including frequently asked questions about naloxone to distribute to pharmacies in the Kingston area.
But when contacted by VICE, the Ontario Ministry of Health seemed to put the onus on pharmacists to catch up on training:
"As of July 26, 2016, approximately 2,000 [packages containing] naloxone kits were supplied by the ministry to over 1,000 select pharmacies (i.e., pharmacies that previously dispensed methadone and/or suboxone for treatment of opioid dependence) in Ontario… The Ontario Pharmacists Association (OPA) has an online training module available for pharmacists in Ontario… Pharmacists should contact the OPA for more information on training."
But according to Dr. MacKenzie, pharmacies she has been in contact with still have many questions about naloxone when it's been auto-shipped from the government.
"A pharmacist now has to train a person to recognize and respond to an opioid overdose, and I'm doubtful that many of them have the clinical background to support that task," MacKenzie told VICE. "When you get naloxone kits delivered, that may be something that is a barrier for you to then be able to provide that service to your clientele."
VICE contacted the Ontario Pharmacists Association for comment on this story, but they declined to give a statement.
Both MacKenzie and Parkinson are concerned that the current program for naloxone in pharmacies will mean the life-saving injection will not reach all of those who need it. During my survey of pharmacies, I found that you must have a valid Ontario health card, which, for a variety of reasons, someone in need of a kit might not have. As well, the current wording of the program might prevent those who do drugs that could be contaminated with opioids from getting access to naloxone.
"The way we're rolling this out is the ministry is saying [it's for] people who use opioids or are past opioid users who are at risk of overdose, [and] that really should be expanded to anybody who's doing any drugs of any kind because there's a risk of contamination," Dr. MacKenzie said. However, MacKenzie added the additional wording of the new program that makes naloxone available to "a person who is a family member, friend or other person in a position to assist a person at risk of overdose from opioids," has a certain vagueness to it that could be more widely beneficial.
When I spoke to one pharmacy that carried and was able to dispense naloxone about the fact that I had used drugs that might be contaminated with opioids to see if I could get a kit due to that, the staff member told me that naloxone would not be "beneficial" for me.
The health ministry told me the new program's intent "was to ensure the naloxone kits are made available to those (i.e., at-risk individuals and communities) who need them in Ontario." In a province where bootleg fentanyl has been detected in non-opioid recreational drugs, what the ministry is missing is that all drug users can now be considered "at-risk." Not everyone who uses non-opioid drugs would know which pharmacies they could get naloxone from.
For Parkinson, who flagged fentanyl to the provincial government back in 2008, the current state of the program is falling short.
"We are experiencing the worst drug safety crisis in Canadian history… People who are using exactly as prescribed, people who are using illicitly—these are predictable and preventable deaths."
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