How do you handle an epidemic that doctors before you had a hand in creating?
Canada's future physicians are beginning their careers during an opioid crisis that has killed hundreds of people across the country, particularly in BC.
Opioids are synthetic painkillers similar chemically to derivatives of the poppy plant. They've been around for centuries. But prescription painkiller prescriptions increased when a new drug called OxyContin was introduced in 1996. The only catch was that the pharmaceutical company's literature underplayed OxyContin's addictive effects.
Many patients who took opioids for chronic pain found their doctors no longer willing to renew their prescriptions. The clamp down on drugs like OxyContin pushed users to street drugs like heroin and fentanyl.
Fentanyl and its deadlier cousin carfentanil are synthetic opiates more toxic than heroin. They've made their way into all kinds of street drugs, killing numerous recreational drug users who didn't realize what they were taking.
British Columbia declared a public health of emergency over overdose deaths in April 2016. Last year, 914 people in B.C. died of illicit drug overdoses.
Now new physicians are grappling with the impact of the actions of their predecessors and front-line aid workers say they are burning out during the current crisis. We asked Canada's physicians-in-training what's going through their heads during this crisis and how they think they will handle it.
Fourth year medicine at the University of British Columbia
VICE: What's your impression of the opioid crisis?
Vancouver, and specifically the Downtown Eastside, has been one of the hardest hit communities within all of Canada in terms of number of overdose deaths and individuals who are affected by the incoming fentanyl.
It's just been a longstanding epidemic. Right now, we're seeing the peak.
During the four years you've been doing your MD in Vancouver, how have you come in contact with the opioid crisis?
We've had public health physicians and guest lecturers who are opioid users themselves come in.
Within a hospital setting, I've personally worked with two patients who came in with a possible overdose.
I've also been active with the medical students at UBC who are advocating for more upstream preventative strategies for tackling the opioid epidemic.
What does it feel like to be starting your career at a time like this?
There's always that apprehension of dealing with patients who are overdosing because they are presenting so acutely with a potentially life-threatening issue. But because of the opioid crisis there's been more and more training to recognize overdose and how to quickly respond.
As someone who's entering residency, I think there's a lot of hope. I see a lot of momentum behind the discussion surrounding prevention and harm reduction.
You're going to be inheriting the healthcare system in a few years. Any systemic changes you think could help fight the opioid crisis?
I think the biggest systemic change would be focusing on primary care.
When I was working in my fourth year of medical school, we were investigating where overdose patients had their last contact with the healthcare system and seeing what could have been done better at that point to possibly prevent their overdose.
A whole team of health workers can help them before they get to the stage where they need to have Naloxone injected into them on the street.
We learn in medical school there are many different ways to treat pain. And prescribing opioids for anything but cancer pain is not the best thing.
You often see people with non-cancer pain treated almost exclusively with opioids. It's the most efficient thing for a physician because they are so overworked.
I'd just like to see more resources put into all these other forms of pain treatment that we learn about. Like physiotherapy, occupational therapy, even cognitive behavioural therapy.
Third year medicine at the University of Western Ontario
VICE: What's your impression of the opioid crisis?
The interesting thing about the opioid crisis is that it's entirely physician-driven. Because you can't make it. It's not like marijuana where you can grow it. You have to get it through a prescription.
Every single pill on the market is tied back to some physician.
(Editor's note: Counterfeit fentanyl pills, often ordered from China, are also a serious problem in Canada.)
As a physician in training, what implications does that have?
There are some physicians who have a policy of never ever prescribing opioids for anything at all. And that's really quite unfair.
For one thing, every single lecture that we have gotten on pain is divided into two categories: pain and cancer pain.
And really, to deny cancer patients their needed pain medication is pretty horrible. I'd almost rather have the risk of diversion there.
Especially from my perspective where my dad just died of cancer. He was taking percocets and things like that all the time. And why not? I mean, you're dying. You should be entitled to that, I think.
How have you come into contact with the opioid crisis?
I think it comes into everything. There's pain in most of medicine.
I like learning about it because there's a huge patient population within [obstetrics] that has opiate addiction and that's a big problem because it's actually dangerous to withdraw in pregnancy. But it's also dangerous to continue in pregnancy because then your baby will withdraw when they're born
Any systemic changes you want to see?
I don't know… More often than not, it's a source of incredible hassle.
It sucks that this happened. Because now, for example, you can't have a crash terminal inside a hospital lying around that has fentanyl or morphine on it.
If somebody is suffering so much they're crashing—a code blue kind of thing—they need to be intubated. There's a sequence of drugs you're supposed to use to intubate someone and one of them is fentanyl.
And so, essentially, you're going to intubate them without that. And that's pretty cruel, I think.
Anything else on your experience with the opioid crisis?
I feel like we can really easily get on the high horse of talking about addicts like they're a different species. But really, you would have the exact same physiological response within three weeks if someone just gave you that prescription.
Third year medicine at the University of Toronto
Where have you come into contact with the opioid crisis?
Just last week I admitted someone who overdosed on 100 tablets of Percocet per day for the past three days.
Her family physician didn't want to give her any more. She ended up going to a methadone clinic to try to wean off.
She met some connections there that supplied her with illegal opioids. We don't know what's in those. It could be tainted. Fentanyl is often a substitute because it's cheaper.
How does it feel to start your career in the midst of this ongoing crisis?
It's definitely tough. The first two years we're in a classroom setting. We tend to think, like, oh the world is perfect. We have all this medication and things are simple.
But during clerkship we become exposed to the reality where the medication that was originally intended to do good actually does harm.
What have you learned about when to prescribe opioids?
You have to look at other issues that the patient has. If you have a patient who has a longstanding history of addiction or psychiatric issues like depression, try not to prescribe opioids.
For people who are on other medications, especially benzodiazepine, try to avoid opioids. Because benzodiazepine depresses your respiratory drive.
A substitute [for opioids] could be ketamine. They use that for anesthesia. It's also been proven to be very useful for pain. It's off label, for sure. But we used it on one of our patients and it did wonders.
Megan Devlin is a journalist based in Vancouver. Follow her on Twitter