The Decibel - The surge of young people dying from opioids
Episode Date: July 12, 2023The opioid epidemic is taking young lives – the number of 15-24 year olds dying from opioid overdoses tripled between 2014 and 2021 in Ontario. And young people are shown to be less likely to seek t...reatment for their addictions. A deadly mix of those factors and a contaminated drug supply are creating lethal outcomes.The Ontario Drug Policy Research Network’s lead investigator, Dr. Tara Gomes is on the show to take us behind the numbers and how the politics around safer supply programs are impacting the people affected by harm reduction.Questions? Comments? Ideas? Email us at thedecibel@globeandmail.com
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As the opioid crisis continues, deaths among young people have surged.
Opioid-related deaths in Ontario for 15 to 24-year-olds nearly tripled in less than a decade.
These numbers come from a report by the Ontario Drug Policy Research Network,
and their lead investigator is Dr. Tara Gomes. I was certainly concerned when we saw
how quickly these opioid-related deaths have been increasing in recent years against a backdrop of
declining rates of treatment for opioid use disorder in our younger demographic. Today,
Dr. Gomes is here to talk about why this trend is happening and the politics around harm reduction.
I'm Mainika Raman-Wellms, and this is The Decibel from The Globe and Mail.
Dr. Gomes, thank you so much for speaking with me today.
Thanks for having me.
So let's start by breaking this down a bit. Within the younger age range,
who's the age that's most affected? And what drugs are we talking about here? So we look specifically at people aged 15 to 24 years old.
Between 2014 and 2021, there were 752 opioid related deaths in that population. But we do see
that the majority of those deaths are within the 18 to 24-year age group. So it is the older end of that age spectrum where we're seeing the majority of harms.
What's really important to stress is that these are really deaths and overdoses that are happening from fentanyl in the illicit or unregulated drug supply.
It's actually quite rare now to see opioid-related deaths that involve pharmaceutical opioids like OxyContin or Hydromorphone that we were talking about a decade ago when we were talking about the opioid crisis.
These are really deaths and overdoses that are happening from people who are accessing that illicit supply and are being exposed to very potent and unpredictable substances within that supply.
So Tara, the big question, I guess, is what's actually causing
this spike in youth opioid deaths? Unfortunately, I think it's, you know, a combination of a number
of different factors that are coming together at the same time to create this kind of perfect storm
of harm for everybody across Canada, but specifically looking at this younger demographic. So when we looked at what's
been happening during the pandemic, we saw that among the adolescent and young adult age group,
about half of people who were dying from an opioid related cause had an opioid use disorder diagnosis.
So this is essentially the medical term for an addiction to opioids. But only a third of them
had access treatment in the last year.
And that's actually lower than what we see in our older populations. And I think there are a few
factors that are tied into this. So our treatment program is primarily based on providing drugs
like methadone or buprenorphine that people get at a pharmacy. Typically every day they have to
go and have an observed dose
of these medications, especially in the first few months of treatment. And that treatment can last
for years. So there are enormous barriers for everybody trying to access treatment because of
these rigorous criteria that you have to meet. But in particular for younger people, the idea
of having to go to a pharmacy every single morning to get a dose of your methadone, having to navigate that against school and family and perhaps hiding your substance use and
then having to figure out how to do this can be really overwhelming for them, as well as
thinking about the impacts of their quality of life, of having to commit for the next
several years, perhaps, of having to consistently be going and picking up these doses.
So I think that when we consider how we're
providing treatment, it often isn't meeting the needs of many people who are seeking treatment
across Canada. But specifically in this younger age group, we also need to think about how we
can design our treatment programs to better meet their needs and be more accessible to them.
I mentioned methadone and buprenorphine, the brand name product of buprenorphine most
commonly used as a drug called suboxone. Typically, what we're hearing from providers,
especially when thinking about younger populations accessing treatment is that they prefer to
prescribe suboxone as a drug that has buprenorphine and naloxone together. And it's generally seen as
a safer option. It's harder to overdose if you're taking buprenorphine. So providers feel more
comfortable prescribing
that to younger demographics. But what we're hearing from people who are actually accessing
treatment and people who are using drugs is that suboxone isn't always meeting their needs,
especially when they've been exposed to fentanyl in the drug supply, which is very potent.
Buprenorphine or suboxone doesn't always help stave off that withdrawal and give them the
effects that they need. So if we have this competition between what providers are willing to provide to young
people, which is Suboxone, and the treatment option that young people are actually looking
for, which is Methadone, when those don't match, it can be really challenging for people
because they're not actually able to access the kind of treatment that they're looking
for that will meet their needs, that will give them their best chance of being able to stay in treatment for the length of time
that they need to, to get the benefits from that treatment.
What role did the pandemic play in people being able to access treatment?
The pandemic was really interesting because what we saw that was really, I think, incredibly
promising was that clinical practice actually changed very quickly. So clinicians were
given guidance to start allowing people to get more take-home doses. So typically people have to
kind of go to the pharmacy every day for an observed dose until they're stabilized on treatment
and then you start getting one take-home dose every week. So you have you know six observed doses and
one that you can take home and over time as you demonstrate that you're able to stay in treatment and kind of align with these
very strict criteria, you can get more take home doses. Very quickly in the pandemic, they made
this decision to start giving people more rapid take home doses because they just couldn't go to
the pharmacy every day. And they recognized that and said, okay, the benefit risk balance here
needs to shift. And we need to accept that we need to give people more take home doses of methadone
and suboxone. And so we saw these very quick changes in clinical practice. And we actually
did a study published last year that showed that those changes actually helped people stay in
treatment. They didn't increase people's risk of overdose. And I think that that is something positive
that we can say did come from the pandemic,
which is that it showed us
that our historical approach to treatment
that has been incredibly regimented,
that has been forced really strict requirements
on people with an opioid use disorder
to go to the pharmacy every day
and to have all elements of their life
really have to be focused on getting to that pharmacy every day and to have all elements of their life really have to be focused
on getting to that pharmacy on time, that we can change those requirements and they can actually
help better support people staying in treatment and aren't actually increasing people's risk of
overdose. Yeah. I want to ask you about the supply because you mentioned fentanyl is a big factor
behind these deaths. Can you tell me what about the supply that they're
getting is unpredictable? There are a few elements. I would say the main change in our supply that has
been incredibly difficult has been the arrival of benzodiazepines into the fentanyl supply.
This had started just before the pandemic. We started to see benzodiazepines, which are essentially an
anti-anxiety sedative type drug. They were being found in the fentanyl supply. And that has
continued to grow throughout the pandemic. And that's really problematic for a few reasons.
One being that our typical response to an overdose, which is administering naloxone,
which is a reversal agent for opioids, does not reverse the
effects of benzodiazepines. We also know that it's actually led to some changes in the way that
people use drugs because they are anticipating being so highly sedated by the combination of
opioids and benzodiazepines, which essentially work together in your system to increase the
sedating effect of both of those drugs, that people are then using stimulants
like cocaine or methamphetamines to counteract those effects. People want to keep themselves
and their property safe, especially if they're vulnerably housed and they might be using drugs
in public. And so now you're leading to one supply pushing people to be using opioids,
benzodiazepines, and stimulants together, which can be even more risky and dangerous for people.
We do hear a lot about fentanyl contamination.
What is the role of fentanyl in all of this?
Yeah, so fentanyl is a synthetic opioid,
so it means it's not something naturally occurring.
You don't get it from poppy plants, for example.
You can actually synthesize it in a lab.
It is very potent, which means that a small amount of fentanyl can give you an equivalent effect as a larger amount of another opioid. So sometimes people get confused because fentanyl can be prescribed. There are fentanyl that is not coming from a prescription source.
It is coming from this illicit supply
because people can manufacture it in clandestine labs.
They can easily transport small amounts across borders
because it's so potent.
A small amount can be kind of cut
into a large amount of drug that is then sold.
And so that is really the shift that we've seen
beginning in Ontario in around 2015 and 2016,
where instead of seeing heroin as the predominant drug in the illicit opioid supply, it really
shifted towards fentanyl. And so that means that the amount of fentanyl and any amount of drug that
you purchase can vary because usually they cut the fentanyl in with other cutting agents to
increase the volume of the drug that they are selling. So you don't know cut the fentanyl in with other cutting agents to increase the volume
of the drug that they are selling. So you don't know how much fentanyl you're getting. You don't
know if it's being mixed in with other drugs like benzodiazepines. And then because fentanyl is
kind of made in a lab, people often kind of tweak the molecule a little bit to make what are called
fentanyl analogs. So you've probably heard of drugs like carfentanil. That is an analog of fentanyl.
It's a very similar molecule,
but it's actually even more potent.
So people are kind of constantly also tweaking
the fentanyl molecule,
making slightly different fentanyls,
which can have all different degrees of potency
that people may not have encountered before.
And it makes it so hard for people who
use drugs to protect themselves, because if they knew what they were getting the same way when we
go to the alcohol store, you know, the LCBO or what have you, we know in the bottle, what percentage
of alcohol is in there. So we can change our consumption patterns based on that. People don't
know what is in the supply of opioids that they're getting. So they aren't able to actually protect themselves by changing their consumption patterns based on what the potency is,
because they have no idea what that potency is of the drug they're taking.
Yeah. And so you said kind of around 2015, 2016 is when we really saw this influx of fentanyl.
So is this, I mean, if we're looking back at the last seven years, like the time that your research is looking over,
is this kind of a big cause in the spike of opioid-related deaths then?
Is this influx of fentanyl in the supply?
Yeah, it really is.
And this is not anymore a crisis of prescription opioids or combinations of different opioids.
This is predominantly one that is driven by fentanyl.
And in this younger age group, we saw even during the pandemic, that impact of fentanyl
increased.
So 94% of deaths in 15 to 24-year-olds in that first year of the pandemic had fentanyl
involved, compared to 84% in the year before.
So still primarily fentanyl across both of those years.
But you can even see just in that first year of the pandemic, how essentially almost all of the opioid related deaths in this younger age group involve fentanyl.
You were saying a lot of them weren't accessing treatment, but were they seeing other healthcare
providers who maybe could have helped, maybe could have helped step in and improve their situation?
We did see a really high degree of engagement with the healthcare system
before death in this demographic and quite broadly as well in other age groups as well.
But specifically in the 15 to 24 year olds, we found that about one in four had some kind of
healthcare encounter. So visit to a doctor or to an emergency department or being hospitalized for
some reason in the week before death.
Wow.
One in four.
That seems actually pretty high.
It's very high.
Yeah.
And I think that we often, when we have conversations on this topic, I think people gravitate towards
assuming that this is a population of people that are hard to reach, that are really disengaged
from the healthcare system, that, you know, we couldn't have done anything because we
didn't know how to find them. And I think what this shows is that in fact, these are often people that
are actively contacting our healthcare system for a variety of different reasons.
We also saw in this younger age group that about three quarters of the people who died of an opioid
toxicity had some kind of depression or anxiety diagnosis, so had other mental health
diagnoses as well. They're engaging in our healthcare system. And we need to make sure
that when that happens, that these healthcare spaces are inclusive, that they feel safe for
people to come and speak about their substance use, and that they understand the best ways to
connect people to services so that they can ultimately try and prevent this harm that
that is often happening very soon after a health care encounter.
We'll be back in a minute.
So it sounds like a big part of this issue, at least, is around the supply. And I know we talk
a lot now about safe supply and treatment programs. So Tara, what what kind of treatments and safe supply programs are actually available in Ontario right now for people to access?
There are a lot of different options that exist within Ontario, although I would say that they're not all equally accessible in all parts of the province.
So obviously we have treatment options like methadone and suboxone that are prescribed by physicians and that are
typically the first line option for people who have an addiction diagnosis. There's also been
a lot of investment into harm reduction that is available across the province. So we have
safe consumption sites, so spaces where people can go and use drugs, where there are people there who
are trained to help respond if you do have an overdose. We also have naloxone that is freely available at all pharmacies.
You can go into any pharmacy.
You don't even have to show a form of ID,
and you can be provided with a free naloxone kit.
So I would urge everybody to go and do that.
I think it's a simple thing that everybody can have on hand.
And then we also have the evolution of safer opioid supply programs
that have largely been federally funded
and rolled out across the country. And we have several here in Ontario, where people are
prescribed generally hydromorphone tablets that they can use instead of the unregulated fentanyl
supply. And so the idea there is to give people a known amount of a reliable source of opioids so
that they don't have to rely on the illicit supply. And how have other provinces handled this issue of
a contaminated drug supply? What are they doing on this front? So in British Columbia, for example,
they have a similar combination of treatment and harm reduction services, they do have broader access to other
types of safer supply programs. So provision of injectable hydromorphone or injectable drugs,
as opposed to hydromorphone tablets that can better meet people's needs. And that is less
accessible here in Ontario. British Columbia has also moved towards decriminalization of drugs for
personal use, which is another approach that has not been rolled out
elsewhere across the country. Alberta has taken a very different approach more recently, where
they're very focused on abstinence and recovery and residential treatment. They have really
disinvested in harm reduction. And unfortunately, what we've seen there in recent months is some of
the highest levels of overdoses and opioid-related deaths in that province than we've seen before.
Each province is taking a different approach, and often that approach is informed, at least in part, by what political party is in power and where they personally believe the right approach is.
And unfortunately, that isn't always based in best evidence.
Yeah, I'm glad you brought this up because I wanted to talk about this too. Safe supply has
really become a heated political issue. We see this in Alberta. We also see this with
Federal Conservative Party leader Pierre Polyev, right? He's spoken out strongly against safe
supply. Our common sense plan is to take the money away from subsidizing heroin-like drugs and instead put all
of that money into recovery and treatment to sue. He says that government-provided drugs are
actually making the problem worse. Is there any merit to that argument? Certainly it's an argument
we're hearing a lot lately and has been really, I think, challenging for people within community
who have been providing these programs and have been really putting in every effort to try and save lives of people
within their community. It's true that the evidence is developing for safer supply because
it is a newer approach. But some of the statements that are made that safer supply has no evidence
backing are actually just not true. There are more than 20 peer-reviewed publications that have now been
published that have studied the effects of safer supply. We led a study that was published last
year that evaluated the longest-standing safer opioid supply program here in Ontario based out
of London. And that study showed that people who entered into the safer supply program had
immediate reductions in emergency department
visits, in infectious complications from drug use.
They had no increased risk of overdose.
They had no opioid-related deaths while in the program.
So there's definitely a lot of evidence that has been accumulating, primarily over the
last couple of years, that shows that these programs can work and can be really helpful,
particularly for people who have
tried treatment and it hasn't worked for them, people who regularly access the illicit drug
supply and are experiencing enormous amounts of harms from overdoses, from brain injuries,
from infectious complications. We obviously need to continue to grow and adapt these models,
but I'm very concerned at some of the conversation, the direction that conversations are going, just saying that this is just providing people with another source of drug and it's not going to help many people who are part of the safer supply programs, these programs have really helped them get their lives back. They've
helped them stabilize, they've helped them be able to find employment and and keep their families
together. And I think that we need to really think about not just having one approach and thinking
that one approach is going to work here, but having a slate of different options and understanding that we need to meet people where they are and not everybody is going
to benefit from different programs and services in the same way. So if we have options and we
listen to what people are asking for, we can help meet them where they are, help provide them with
what they need in that moment, and then help connect them to healthcare, help connect them
to treatment over time or other supports that they might need. But just forcing people into one route and saying it's all or
nothing, you have to go to residential treatment or we're not going to help you, is really accepting
that you're okay with letting people die. Letting people who can't access or are not finding the
benefit from those options die. Because that's essentially what we're accepting
if we're focusing on only one channel
or one option for people who use drugs.
Tara, thank you so much for taking the time
to speak with me today.
Thank you for having me.
That's it for today.
I'm Mainika Raman-Wellms.
Jay Coburn helped produce this episode.
Our summer producer
is Nagin Nia. Our producers are Madeline White, Cheryl Sutherland, and Rachel Levy-McLaughlin.
David Crosby edits the show. Adrienne Chung is our senior producer, and Angela Pachenza
is our executive editor. Thanks so much for listening, and I'll talk to you tomorrow