Street drugs in Canada are becoming more toxic — and tools to treat them less effective. Why?

From Global News

A rise in the circulation of highly potent fentanyl that is increasingly being mixed with other drugs is making Canada’s street drug supply so toxic and unpredictable, tools to prevent overdoses such as naloxone are not always fully effective, experts say.

The situation has become so volatile, front-line doctors and workers say they are left to guess at what mixture of substances a person in crisis may have been exposed to, which is why they say Canada needs to move faster on measures like safe supply and drug regulation to stop the sharp rise in opioid-related deaths in Canada.

Tara Gomes, a scientist at Unity Health Toronto and director of the Ontario Drug Policy Research Network, says the increasing unpredictability in the drug supply in Canada poses challenges for community-based programs that help people who use drugs, as they are not set up to handle the longer-term care that may be required to aid someone overdosing from opioids mixed with benzos.

“They’re able to administer naloxone, and the person might be OK … but they are not able to be roused and people within those programs have to help monitor that person might have to stay open later or make sure there are people around because this person might need a couple of hours before they’re fully aroused and can leave the program,” Gomes said.

Patients who use virtual walk-in clinics more likely to go to ER later: study

From the Toronto Star

People who used a virtual-only medical service — a kind of virtual walk-in clinic — during the pandemic were more likely to later go to an emergency room than patients who did appointments with their own family doctor online, a study by Toronto researchers has shown.

The study published Thursday in the Journal of Medical Internet Research explores the different outcomes between two kinds of virtual medical care during the pandemic — that given by walk-in-style clinics and that given by family doctors.

Conducted by the University Health Network, ICES, Women’s College Hospital and Unity Health Toronto, the study found that the patients who saw a physician who was not their family doctor through a virtual-only medical service were twice as likely to visit an emergency department within 30 days.

The visits “can add to an already overwhelming strain” on emergency departments caused by staff shortages and the prevalence of viruses, says lead author Dr. Lauren Lapointe-Shaw, a general internist at Toronto General Hospital and an assistant professor at U of T.

“To add any potential demand related to these virtual appointments is suboptimal.”

Emergency departments in Ontario have been experiencing record-high wait times and some rural emergency departments have closed temporarily because of a lack of staff.

The study showed that patients who had a virtual-only walk-in appointment often had a virtual follow up and then ended up in emergency, in contrast to patients who had a virtual appointment with their family doctor and then could have an in-person follow up, possibly avoiding a hospital visit because they were able to have a physical exam.

Changing nature of Canada’s overdose crisis calls for more aggressive response, experts say

From the CBC News article

An evolving mix of opioid cocktails and changing consumption habits mean governments must now respond more aggressively to the overdose crisis, experts say.

More than 32,000 Canadians have died of toxic drug overdoses since 2016, according to data released by Health Canada last month.

Over 3,500 people died of overdoses in the first half of 2022 (data is available only up to June). That’s almost 20 people per day, and more than half the number of people who died of overdoses during the first year of the pandemic.

The federal government has spent hundreds of millions of dollars to combat the crisis by funding community-led projects such as safe consumption sites and safe supply programs and improving access to naloxone, medication that can reverse the effects of an opioid overdose.

Fentanyl remains a driving factor in overdose deaths; Health Canada says that 76 per cent of all overdose deaths involve that opioid. But an increasing number of overdose deaths involve more than one substance.

Health Canada said just under half of the 3,556 overdose deaths that occurred in the first half of last year involved a stimulant such as cocaine or methamphetamine. At the same time, health services are increasingly warning of illicit opioids being contaminated with depressants such as benzodiazepine or “benzos.”

Tara Gomes of the Ontario Drug Policy Research Network said the two trends are likely linked.

“What we’re seeing more and more is benzodiazepines in the opioid supply. So they’re actually mixed in with the fentanyl,” she said.

That means the people who use these drugs aren’t necessarily aware that they’re taking benzo along with the opioid, she said.

But Gomes said some are intentionally using stimulants in an effort to counteract the sedative effects of an opioid and benzo cocktail.

“Oftentimes what they’re looking to do is counteract those effects, try and moderate the effects of the opioid so that they don’t get too sedated,” she said.

Benzodiazepines are dangerous when paired with an opioid like fentanyl because the added sedation increases the risk of an overdose, says Health Canada.

And the lifesaving medication naloxone does not work on benzos.

“It makes it more challenging for already burdened overdose prevention services,” Cheyenne Johnson, executive director of the British Columbia Centre on Substance Use, told CBC News.

Johnson also said a mix of opioids and benzos can also complicate substance use treatment by intensifying withdrawal symptoms. Such symptoms can include extreme anxiety, sweats and dangerous seizures.

“It makes it very complicated in terms of managing their cravings and withdrawals when there’s multiple types of potentially unknown substances like benzodiazepines” she said.

Fentanyl and benzodiazepines on their own can be used in clinical settings, but Johnson said substances never meant for human consumption are appearing in the illicit drug supply.

Xylazines, an animal sedative, and nitazenes — a synthetic opioid that is estimated to be several times more potent than fentanyl — are two such drugs, Johnson said.

“The sky is the limit on what is coming next,” she said.

Karen McDonald, head of Toronto’s Drug Checking Service, echoed Johnson’s point, saying that the illicit drug supply “is increasingly more contaminated, more toxic and less predictable.”

“[It’s a] recipe for disaster,” she said.

McDonald’s organization tests samples from the illicit drug supply to warn people who use drugs about what is being mixed in. But while the technology her organization uses is quite sophisticated, she said the illicit supply changes so fast that it feels like they’re “constantly playing catch-up.”

Opinion: We can’t view health as an exclusively personal matter – it’s a collective endeavour

From The Globe and Mail article

Perhaps this year you’ve resolved to improve your health. You’re eating better. You’re exercising regularly. You’re staying hydrated, and prioritizing sleep. But have you also thought about what you can do to ensure your friends are healthy too? Your neighbours? Your surrounding environment and wildlife?

No doubt the measures you’re taking are good for you. But regardless of what any one of us does to keep fit and stay well, our risk of COVID-19 and other viruses depends heavily on how many people around us are infected and how close they are, and how much virus circulates in the air we breathe. Likewise, even assuming we have the ability and resources to do so, practising self-care can only protect us so much from countless other health threats, from environmental carcinogens to deadly heat waves to toxic work cultures that induce chronic stress and burnout.

There’s nothing like a global pandemic occurring amid a climate crisis to drive home the reality that our individual health depends not just on our own efforts, but on the health of our communities and ecosystem.

Yet the pandemic has demonstrated how difficult it is to shake the stubborn myth that we are masters of our own health. The phrase “we’re all in this together” quickly gave way to advice from public-health officers and politicians to “assess your own risk,” and consider using “individual public-health measures” as “a personal choice.”

The every-person-for-themselves approach to COVID-19 has driven deep social divides among people trying to protect themselves, either from infection or from a sense of threat to their freedoms. Behind all the debates about face masks, vaccines and the necessity for lockdowns and mandates lies a deeper, more fundamental question: Why should we protect or even care about the health and well-being of others (including those who don’t share our views)?

The reasons aren’t always obvious. But some doctors, researchers and academics say failing to do so could come back to bite us. If we continue to view health as an exclusively personal matter, one that does not require us to also act as stewards of our community and environmental health, it could be to our own detriment, leading to more illnesses, increased burden on our health care system, and greater social costs in the long run.

“It’s kind of a sad state of affairs that we would even ask that question,” said Lindsay McLaren, a professor in the department of community health sciences at the University of Calgary. “We are a collective and there’s no two ways about that.”

Toronto epidemiologist Dan Werb says thinking about vaccines as personal protection is a mistake.

“People regularly get vaccinated under the assumption that doing so will directly help them,” he wrote in his award-winning book, The Invisible Siege: The Rise of Coronaviruses and the Search for a Cure. “But vaccines aren’t meant to protect a person from disease – what they are meant to do is protect populations from epidemics.”

Certainly, individuals have died of COVID-19, even after being fully vaccinated. But at a population level, vaccines have prevented as many as 19.8 million deaths from COVID-19 worldwide, according to the estimates of a mathematical modelling study published in The Lancet Infectious Diseases journal in June. Even though vaccines have not reduced infections to the extent many had initially hoped, they have drastically slashed the proportion of people who require hospitalization and lowered the risk of long-COVID.

The difference between personal and population-level protection isn’t just semantics. Consider this, Dr. Werb suggested: Would you rather be the only vaccinated person in the world? Or would you rather have your entire social network, your co-workers, and everyone you encounter vaccinated, except you? (The same concept can be applied to masks, too. The benefit of wearing them is greatest when everyone wears them.)

Filling the gaps: How Unity Health’s programs support Toronto’s homeless population

By Jennifer Stranges, Unity Health Toronto

When Dr. Stephen Hwang joined Unity Health Toronto, he was drawn to the organization’s longstanding commitment to helping those most in need. All three of the network’s hospital sites were founded by the Sisters of St. Joseph, who were called to serve people who are disadvantaged.

“Unity Health has always been dedicated to serving people experiencing homelessness, and it’s always been an area we’ve sought to find innovative ways to provide better care,” he says.

Yet, as Hwang devoted his clinical care and research to caring for people living without permanent shelter, he noticed something else. Not only was the homeless population in Toronto growing in size, the needs of the population were growing as well. Living without shelter puts people at risk of many health challenges, but people who are homeless are also more likely to experience mental health problems and age-related decline. 

Today, caring for people who are unhoused remains a core part of the mission at Unity Health – a value that informs the basis of research, education, outreach and clinical care. The network has also continued to expand its services to meet patients and clients where they are, particularly in the areas of mental health and geriatric care. 

“Our services fill an important need for patients who often fall through the cracks,” says Hwang.

It’s ‘damning on us as a society:’ Toronto falls behind in offering warming centres for homelessness

From the Toronto Star article

One of the most “morally upsetting” nights of Maggie Helwig’s life was earlier this winter.

There was a man at Toronto’s Church of Saint Stephen-in-the-Fields, near Bathurst and College Street where she’s the priest and runs a drop-in program, who was “obviously unwell” and “couldn’t even get his socks on properly.”

The shelters were full. The only thing she could do was walk him out to the encampment near the church, wake up some people there, and ask them to take him into their tent for the night.

“It was a very very cold night but the warming centre wasn’t open,” Helwig recalls.

That man this past November was welcomed into someone’s tent. But Helwig said another individual died in a tent over Christmas, when there was a cold alert and warming centres were open, but very busy. The person was not in an encampment community at the time. Their friends are trying to honour their wishes for privacy.

As Hamilton expands access to warming centres, following a public outcry over a Christmas gap in services, advocates are calling for Toronto to do the same, and highlighting that temperatures don’t need to be super cold for people to die on the streets.

As it stands now, warming centres are “generally activated” when an Extreme Cold Weather Alert (ECWA) is issued by Toronto Public Health — when the temperature is forecasted to be -15 C or colder, or -20 with the wind chill — said a city spokesperson in an email.

“There may also be instances when the city decides to open warming centres independent of ECWA “out of an abundance of caution due to colder nighttime temperatures and forecasted wind chill values. For example, warming centres were open and accessible from December 23 at 7 p.m. until noon on December 28,” the spokesperson added.

The city is “aware of unconfirmed reports of the death of a person experiencing homelessness on or about Christmas Eve,” they said.

“The cause of death of people experiencing homelessness, and discovered outside at any time of year, is determined by the Office of the Chief Coroner of Ontario and only communicated to the next of kin.”

“Toronto used to do a lot more,” said Helwig of warming centres.

“Before the pandemic there actually was a whole network of warming centres all over the city.”

Now there are just three, all walk-ins, and they were “very crowded” over Christmas when they were open during the extreme cold temperatures.

Some of them closed because of the pandemic, some have become part of the 24 hour respite system, but what’s needed is a “low barrier flexible winter space,” she said.

“The need is just growing, and growing in every area all the time.”

The city of Hamilton announced on Wednesday expanded warming centre hours until the end of March, following public pressure.

Dr. Stephen Hwang, director of MAP Centre for Urban Health Solutions, said his team conducted a study in 2019 that showed about 70 per cent of injuries due to cold happen when the weather is warmer than -15 C.

“I don’t believe there’s evidence to support -15 as being the correct threshold. I suspect that it’s driven more by resource constraints than by anything else,” he said in an interview with the Star. There’s a need for shelter beds. But “on nights where it’s cold, there should be enough warming centres available that people can at least get out of the cold,” he added.

What the rest of the country can learn from Ontario’s family doctor payment model

From The Globe and Mail article

Allan Carpenter shuffles into the doctor’s office and gets down to business.

The 65-year-old patient and his long-time physician, Gordon Arbess, have plenty to talk about, even though they see each other for a check-up every second week.

Mr. Carpenter’s back and hip are so sore he worries he’ll end up in a wheelchair. He is anxious about getting to all his medical appointments, including a coming visit with an orthopedic specialist. He’s had HIV since the late 1980s, and he recently beat throat cancer.

“We do have a team of people that are trying to help you,” Dr. Arbess says, soothing his patient’s nerves, “and I know how much you’ve gotten out of it. But I know some days it’s difficult for you to get to these appointments. I get it. I hear you.”

For Canadians without a family doctor, the thought of having a physician guide – a “captain of my ship,” as Mr. Carpenter calls Dr. Arbess – is appealing in itself. But Mr. Carpenter is fortunate to have more than a captain. He has a whole crew.

His clinic east of downtown Toronto is part of the St. Michael’s Hospital Academic Family Health Team, a five-site organization with more than 200 staff, including nurses, dietitians, pharmacists and social workers, as well as clerical staff to support about 80 doctors and 36 medical residents.

This model, which Ontario calls the Family Health Team, is widely considered by health-system experts to be the best way to deliver primary care, especially for patients like Mr. Carpenter with multiple complex medical conditions. Family doctors also favour the team approach because it helps them stave off burnout by sharing the workload. The Canadian Medical Association has named “expanding team-based care” as one of its top recommendations for solving the country’s health care crisis.

Despite that, Ontario hasn’t opened a new Family Health Team in a decade, in part because of the cost.

Ontario began overhauling its primary-care system in the early 2000s. The new models paid family doctors working in groups mostly for the number of patients they enrolled in their practice, a departure from the traditional fee-for-service approach where doctors are paid for every discrete episode of care they deliver.

The alternative models blended capitation payments – which are annual payments to doctors for every patient on their roster – and fee-for-service to different degrees. The approach was supposed to encourage long-term relationships with patients and give physicians time to deliver comprehensive care to older, sicker patients who might have four or five health concerns to discuss at a single visit.

Doctors had to join one of the new payment models, the most popular of which is called a Family Health Organization, or FHO, if they wanted to be a part of a Family Health Team, or FHT. What set the FHTs apart was that the provincial government paid the salaries of the dietitians, pharmacists, social workers and other health professionals who rounded out the team.

There are currently 181 Family Health Teams in Ontario, the last of which opened in 2012.

In many ways, the reforms succeeded. Doctors flocked to the new patient enrolment models, leading to a 43-per-cent increase between 2006-07 and 2015-16 in the number of Ontarians who said they had a family doctor.

Patient care improved, too, said Tara Kiran, a University of Toronto primary-care researcher and physician at the Family Health Team where Allan Carpenter is a patient. She and her research colleagues found that FHT patients received better diabetes monitoring and visited the emergency department less often than patients at non-team practices, although emergency-department use increased for both groups over time.