Hamilton clinic is prescribing safe, but strong opioids to counter the toxic supply of fentanyl
The man with a duffel bag slung over his shoulder stood in the park across the street from the Wesley Day Centre downtown.
He had just returned from a visit to the doctor where he received a prescription for morphine and hydromorphone, a powerful painkilling opioid.
Two months ago, the 37-year-old was hospitalized after suffering a stroke. Up until that point, he had been regularly using potentially lethal street fentanyl.
But then Matt - who asked that his name not be published for privacy reasons - met a Hamilton doctor overseeing his postsurgery recovery. The doctor had an unconventional approach to avoiding opioid overdose from toxic street drugs.
Dr. Tim O'Shea, an internal medicine physician, prescribes a safer supply" of opioids to those with addiction issues.
For Matt, that means receiving daily doses of Kadian (morphine) and Dilaudid (hydromorphone) prescribed by O'Shea.
Kadian and Dilaudid are strong prescription-only opioids and are often used recreationally as illegal substances.
Matt, who speaks softly and with difficulty due to the stroke, said the stable doses" are keeping me away from needles."
O'Shea and his team at the Support and Safer Supply (SASS) program at the AIDS Network on King Street East are prescribing opioids to some Hamilton patients with addiction disorders to replace street fentanyl - essentially to keep them alive.
Officially running since January of this year, the safer supply pilot program currently has nearly 40 patients, who visit weekly or biweekly to get opioid prescriptions from O'Shea, Dr. Claire Bodkin, a family physician at the AIDS Network, or Dr. Lauren Cook-Chaimowitz, an emergency medicine physician.
This safer supply" concept - a part of harm-reduction philosophy - means replacing potentially fatal street opioids with more reliable prescription opioids.
Fentanyl, laced with toxic chemicals, has become the leading cause of overdose deaths in Ontario.
People don't know the strength of fentanyl" they're buying, which can vary day to day, O'Shea told The Spectator. The street supply of fentanyl is also often cut" with other substances - including benzodiazepine - which may increase the risk of overdose, he said.
The goal is not to get users off opioids, O'Shea said, but to try to prevent the exposure to toxic supplies on the street and potential incarceration for possession of illicit substances.
Patients don't have to think about where they'll get their next fix." They just have to take their prescriptions to a pharmacy and get a daily take-home dose for Dilaudid, or in the case of oral morphine, take it in front of the pharmacist.
Matt said he has been digging the prescription drugs every day," and will continue with it as long as I'm staying away from the street drugs" - eventually tapering down" the amount.
The cost of prescription medicine for Matt is being paid under the active Ontario Disability Support Program (ODSP), which also covers his chronic heart condition. Matt said that he suffered endocarditis in the early 2000s, leaving him weak and frail for months and pushing him toward addiction.
For other patients, the cost of the eight-milligram Dilaudid tablets and slow-release oral morphine is covered under the Ontario Drug Benefit program.
A spokesperson with the City of Hamilton said the downtown safer supply clinic is not overseen or operated by Hamilton Public Health Services.
SASS received Health Canada funding of $875,000 in April of this year to run the 18-month pilot program in Hamilton.
While the program is clearly helping patients like Matt, it remains a controversial concept - to replace a highly addictive street drug with another highly addictive prescribed opioid.
Prescribing opioids could increase the chances of people either selling or sharing their medications with others who aren't prescribed to take the medication in the addiction community.
Many doctors think that this is really dangerous and irresponsible and not the right thing to do," said Bodkin. But this is an important approach and it works and it is useful to people."
The notion of prescribing safer supply in Hamilton, however, began at least three years ago.
O'Shea first prescribed Dilaudid to a patient at the AIDS Network in 2019 - unofficially.
Back then, he was treating a patient with addiction via methadone - a common treatment modality for addiction relief.
However, methadone is not considered a safer supply" because it doesn't alter the state of mind or body like Dilaudid.
The patient, at risk of overdosing, kept on asking for Dilaudid tablets for safer supply prescription and I kept saying I can't do that,'" said O'Shea.
Opioids like methadone and suboxone have been established as a treatment for substance-use disorder by the scientific community, while prescribing heavier opioids for substance-use disorder is fairly new.
But then O'Shea spoke to his colleagues in London, Ont., and British Columbia who were already prescribing safer supply opioids and stimulants like clinical meth and cocaine.
He said they told him: write a prescription that might stop him from dying." And so he did - saving a life from an overdose.
This has now expanded into a bigger cohort of patients visiting Tuesday and Thursday afternoons from 1 to 4 p.m. at the AIDS Network and Monday mornings from 9 to 11 a.m. at YWCA Hamilton.
London InterCommunity Health Centre was among the first in Ontario to begin a safer supply pilot in 2016. Three years later, a study published in the Canadian Medical Association Journal (CMAJ) on Sept. 19 shows the program led to important declines in (emergency department) visits (and) inpatient hospital admissions for incident infections" for participants, while reducing health-care costs.
No opioid-related overdose deaths occurred during the three-year pilot program, the study showed, hinting at the important role" the safer supply program played as a part of harm reduction.
O'Shea told The Spectator that many harms" people suffer from substance-use disorder come from the lack of access to a pharmaceutical-grade, safe supply of drugs ... rather than having to buy unregulated drugs off the street."
The clinic, however, is small. It can't meet the demand for the program in Hamilton. Already at its full capacity for prescribing opioids to people, SASS had to close its wait list for more patients within two weeks of opening spots in February. Those on the wait list are still waiting.
For those already in the program, Dilaudid is the most potent drug currently available to them under the provincial coverage plans.
But it is so much less potent than fentanyl that people are using off the street," Bodkin said - making it harder to match the tolerance needed for replacing fentanyl.
The Hamilton doctors are relying on a combination of Dilaudid and morphine which helps cut down fentanyl use, but in some cases, not fully replace it" because the prescriptions are not strong enough, she added.
The medications Bodkin wished they could prescribe are expensive" and not covered under the Ontario drugs plan, like injectable opioid agonist treatment, pharmaceutical-grade heroin or high-dose concentration liquid hydromorphone - some of which are already being used in British Columbia.
Despite that, Hamilton's clinic manages to stand out by bringing a warm and welcoming environment" with an additional peer support program, said Bodkin.
We focus more on changes in a person's life and function than on specifically (tracking) what drugs they're using or how they're using it," she said.
Instead of trying to fix people with substance addiction, we're saying, You deserve to be able to make choices about your life, and be healthy and safe. How can we support you in that?'"
The support comes in multiple ways - doctors' appointments for routine visits, training programs, peer support groups, assistance in finding housing or jobs, or providing a destigmatized space.
What helps the patients at the clinic more is the peer support. They know that this program is led by people with lived experiences or are living it, and feel a sense of connection," Bodkin said.
Marcie McIlveen, SASS program manager, is at the heart of it - ensuring patients get more than just a clinical experience with their doctors.
She knows how it is to be on the other side of the addiction disorder. She has lived it for the most part of her life - facing incarcerations, failed rehabs and missed appointments with doctors for chronic illnesses.
Everybody wanted to fix me. Nobody wanted to know me," she said.
McIlveen was working at the clinic when O'Shea was prescribing a safer supply of opioids. But it was a step. The medical model is not always great," she said.
She suggested the team to take the professionalism out of the services" and add the peer support element to it, something nonclinical and more welcoming to people.
We don't do goal-setting. We don't do worksheets. We just spend time with people," McIlveen said.
It has been working well for the team since.
As for Matt, he is taking one day at a time," continuing with the SASS program and hoping to one day come off the drug addiction.
He desperately wishes to go back to his job in the construction industry and build a better life again - not just for himself but for his pregnant wife and a child on its way.
Ritika Dubey is a reporter at The Spectator. rdubey@thespec.com