Meeting People Where They Are At

By: Alex Wong

With the federal government announcing that nearly 4000 Canadians died last year due to opioid overdose, it is clear that more action needs to be taken to address the unprecedented amount of lives being lost. It’s time to ask ourselves the tough questions and examine how our current drug policy climate has both contributed to and exacerbated the ongoing opioid crisis.

Screen Shot 2018-07-05 at 10.20.13 PM.png Source: CIHI (data is from 2016-2017)

As part of my Stretch Experience, I am currently completing a clinical rotation at an addictions clinic in downtown Edmonton. Now that I am in my fourth week, I feel much more comfortable working with the patient population here, and beyond learning the medical concepts surrounding addiction management, I have also been able to witness the impacts of the opioid crisis from the frontlines. I am immensely grateful for the opportunity to see and be part of the recovery journey of the patients who attend the clinic, and being able to listen to their stories have taught me much about resilience, patience and compassion. At the same time, I have learnt about the many ways our health care and justice systems are failing to protect people who use substances. I have heard numerous stories about opioid agonists (the medications we use to treat opioid use disorder) being withheld in correctional facilities, people being turned away from treatment programs because of their medication, and how our system of drug criminalization has contributed to the stigmatization of substance use.

While provincial and federal governments have taken admirable steps in expanding access to take-home naloxone and supervised consumption sites, drug decriminalization is a topic governments have shied away from. Much of the public’s opposition to decriminalization seems to be based on the unfounded belief that the removal of legal penalties will encourage substance use. When Portugal decriminalized drug possession in 2001, while there was a slight rise in overall drug use noted, this increase was similar to other countries in which drug possession was still a criminal offence. Since then, the past-year prevalence of drug use in Portugal has actually decreased compared to 2001.

Screen Shot 2018-07-05 at 9.55.37 PM.png
Source: Transform

Following Portugal’s example of drug decriminalization would be a shift towards recognizing and addressing substance use and addiction as health issues, as opposed to criminal ones.

While there are many who remain skeptical about drug decriminalization, it benefits no one to ignore the vast amount of literature that exists about the harmful effects of drug prohibition. For one thing, prohibition does not stop people from using drugsinstead, it has produced a black market that has allowed drug traffickers to profit billions. This jeopardizes public safety, with evidence associating drug prohibition enforcement with higher rates of gun violence and homicide. Criminalization has also contributed to the current opioid crisis by creating incentives for the development of stronger and more dangerous substances like fentanyl and fentanyl analogues, which were involved in 74% of overdose deaths in 2017. Drug criminalization also disproportionately targets Indigenous communities and contributes to the already high rates of prison sentencings for Indigenous peoples (in 2015-2016, Indigenous peoples accounted for 26% of prison admissions, while comprising just 3% of the Canadian population). The days following release from prison are also associated with a high risk of fatal overdose, due to loss of tolerance while in incarceration. There is much more evidence existing regarding the harms our drug prohibition policies have had, but the bottom-line is that our current system is broken.

Having only recently completed my second year of medical school, I do not yet have much clinical experience, but already I have noticed how differently our society views substance use disorders compared to other chronic illnesses. While I will not go in-depth here regarding the neuroscience and psychology underlying addiction, I do want to convey that addiction is a chronic illness with a waxing and waning course. In this sense, it is not different from any other chronic condition that people take medications for, such as diabetes or hypertension. Yet I frequently encounter clinical situations in which family members or certain residential treatment programs want patients to stop taking their opioid agonist medications. We would never ask or expect people with diabetes to stop taking their medications, so why do we do so with people who have substance use disorders?

Whenever I discuss this issue with family or friends, a common response I hear is that “addiction is a choice” as compared to other medical conditions. This argument however, fails to recognize that addiction is a chronic medical condition that causes structural and functional changes in the brain. As well, there are not many medical conditions that are purely due to genetic causes–in most diseases, there is always some element of “personal choice” or “lifestyle factors” that contributed to the development of the condition, whether it be an unhealthy diet or a sedentary lifestyle. More importantly though, why does it even matter whether it is a choice or not? Since when does making mistakes or unhealthy decisions preclude people from being deserving of compassion, dignity and treatment for their illness? It does not help that many of our politicians are making uninformed comments surrounding substance use and harm reduction, further contributing to the stigmatization of people who use substances.

Screen Shot 2018-07-05 at 10.24.47 PM.png Source: EHN Canada

I am very lucky to be able to work with the physicians and allied health professionals at the clinic I am at, who strive to create a safe and non-judgemental environment for their patients. The biggest lesson I have taken away from my experience can be summed up by the philosophy of harm reduction: meeting people where they are at. At the addictions clinic I am working in, the staff listen without judgement and understand that the path to recovery from addiction looks different for each individual.

Many of the doctors I have worked with go above and beyond their clinical duties by advocating for changes to the health system and drug policy to better protect people who use substances. My experience here has allowed me reflect on and consider the role physicians can play beyond providing clinical care by leading systems-level change to better serve patients. As I wrap up my rotation at this clinic in two weeks, I hope to utilize my experience to better help future medical students understand addiction by revamping the teaching surrounding substance use. Currently, I am working on a project with the MD Program at the UofA looking at different ways to incorporate competencies related to inner city health into medical education. With no current end in sight for the opioid crisis, it is crucial we are training future physicians to have the knowledge and skills necessary to work with people who use substances, as well as challenge preconceived notions surrounding substance use disorders.

After this rotation, I will then be moving onto an Aboriginal Public Health rotation at Health Canada, where I hope to gain a greater understanding of the social determinants affecting Indigenous health. Overall, my Stretch project has allowed me the opportunity to not only explore different areas of medicine, but also to reflect and develop an understanding of how social and historical inequities continue to manifest in health outcomes. I look forward to continuing to learn from the future patients and communities I will be working with.

– Alex Wong
MD/MBA Candidate 2021

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