At 19 years old, Jordan Miller realized that he had a problem. He went to his mom, Leslie McBain, asking for help.
“We used to say Jordan was over-partying when he was a teenager,” said McBain. “He was drinking with his friends, smoking pot. It seemed to increase over ages 15 to 19, and became a problem specifically with alcohol and cocaine. We got him into rehab. He liked it there. I mean, he did well. He came out and was good for a little while, and then he just started up again.”
Miller had launched his own small business installing wood stoves and chimneys in the Gulf Islands along the southern coast of British Columbia. But he had a back injury on the job and went to his family doctor to get help.
“That doctor gave him oxycodone,” said McBain. “He gave it to him in ever-increasing amounts over about seven months—even after I’d gone to the doctor, who’s also my doctor, saying don’t give this kid opioids, he’s at risk. He thanked me for the information and continued to do that.
“Jordan went to him and said, ‘I’m addicted, I need help.’ The doctor grew angry and basically fired him as a patient. There was no offer of support or treatment or anything like that.”
Left to fend for themselves, McBain helped her son get into detox again for a 12-day stint. She tried unsuccessfully to find a doctor who could prescribe Suboxone—a medication to help treat opioid use disorder by reducing the symptoms of withdrawal and reducing cravings. She also looked for a psychiatrist with experience in helping people like Jordan, but wasn’t able to find anyone.
McBain’s desperate attempts to get help from professionals with the necessary expertise are not unusual. Many of the substance use disorder experts I spoke with highlighted the urgent need for up-to-date training for healthcare professionals to meet the needs of patients during the opioid crisis.
About four or five months after leaving detox, Miller relapsed and started taking drugs again. “What he did was, he doctor shopped. He went to about five different walk-in clinics,” said McBain. “He was very charming and looked like a person legitimately in pain, and was able to get hydromorphone, Xanax, Citalopram, just a little array of drugs. It certainly helped him from going into withdrawal. One day he just took the wrong combination of those prescription drugs and it stopped his heart. He was alone in his apartment in Victoria and his girlfriend found him.”
Miller died on February 4, 2014, at the age of 25.
“It’s the worst tragedy that can befall a parent, certainly, and the family. It ripples outwards in its impacts,” said McBain slowly. “He had a girlfriend, he had an apartment, a dog and a cat, he had his business, he was sort of setting out on his adult life. It can happen to anyone.”
McBain filed a complaint with the BC College of Physicians and Surgeons against her son’s family doctor. Soon after Jordan’s death she spoke to Dr. Evan Wood, who encouraged her, when she was ready, to consider becoming an advocate for families like hers.
“I met two women who are both from Edmonton who had also lost sons to drug harms, and the three of us decided to start Moms Stop the Harm,” said McBain. “I think the first thing we did was create a Facebook page, and we’ve grown in the last three years from three of us to almost 500 people now, families across Canada, sadly. We provide support for families who are grieving; we try to support people who have loved ones in active addiction.”
Moms Stop the Harm also advocates for a more compassionate drug policy. It now has chapters in every province, and is regularly consulted by various levels of government. McBain has also become the family engagement lead at the BC Centre on Substance Use, meaning she helps ensure that the organization’s work is informed by the experiences of families who’ve been affected by the opioid crisis. It was at their office in downtown Vancouver where I met with her.
“The people who have lost a child—we see a person who’s immobilized in grief in the first months,” she told me. “They get numb, they go into deep, deep grief. They’re not able to work, they’re hardly able to often communicate with family. They find that people have a lot of stigmatized thinking around drug deaths. There’s a difference if a kid dies of cancer. There’s a different kind of reaction from family members and people around them to when a child dies of a drug overdose.”
Since her son passed away, McBain has learned a lot more about opioid use disorder and what families can do to help loved ones in active addiction. “We tell them first of all to take care of themselves,” she said. Then, when it comes to those who are addicted: “Love them. You want them to just get the heck out of there, get out of my face, go away, do your thing somewhere else. Most families don’t know very much about addiction. I was the same. Check out what’s in your community for treatment; see what kind of physicians you can find who will treat—because the first line is your family physician, and if your family physician has a clue about addiction and how to proceed, you’re on a good path. Often that hasn’t been the case, so that’s why we really promote doctor training, medical professional training in substance use disorder.
“The people who have loved ones in active addiction, they have their challenges and they sometimes can’t navigate their way into the system because, as Evan Wood always says, we don’t have a system—it’s fractured and we need to build one. We try to help them navigate so that they can get the support they need to stay well and help out their loved one,” McBain told me.
“As I often say, if I only knew then what I know now, I’d like to think I could have saved my son.”
When most people think of substance use treatment, they think of detox—going cold turkey, abstaining altogether. The idea is that if someone is going to stop using a substance, they should just stop using it entirely. Indeed, that’s the dominant model most people have in mind when dealing with substances like alcohol. However, the problem is that applying such an approach to opioid use disorder can have deadly consequences.
“We’ve seen for a number of folks that getting off opioids isn’t the same as getting off alcohol or some other things,” said Jennifer Breakspear. “Going off cold turkey and being abstinent and then relapsing—there are much greater risks of overdose and death.”
Yet many treatment and recovery centres for people addicted to opioids are still based on an abstinence model. That was the case with Brandon Jansen (in Chapter 7) and Jordan Miller (at the start of this chapter), both of whom tragically died from opioid overdose—one while in detox and the other shortly after leaving it. What do leading medical experts have to say about abstinence-based treatment?
“People who go to detox from opiates and then go back into their community lose their tolerance very, very quickly,” said Dr. Bonnie Henry. “So the probability of relapsing and dying the next time you use goes up dramatically. We’ve seen quite a lot and you’ve heard stories in the news about people who have been in recovery, and then they relapse and they die.”
“We know that with leaving an abstinence-based rehab program, the relative risk for a fatal overdose goes up,” Dr. Paul Hasselback told me. “So it’s not something that’s been recommended.” After we spoke he sent me a study published in the British Medical Journal which found that “patients who ‘successfully’ completed inpatient detoxification were more likely than other patients to have died within a year.” I had to read that again. People who’d managed to finish their intensive detox program were more likely to die from a drug overdose than those who failed to complete the 28-day abstinence program. This so-called “treatment” was actually making things worse.
As a result, new medical guidelines on treating opioid use disorder strongly recommend against detoxification alone, since “this approach has been associated with elevated risk of HIV and hepatitis C transmission, elevated rates of overdose deaths in comparison to providing no treatment, and nearly universal relapse when implemented without plans for transition to long-term evidence-based addiction treatment.”
There are also major concerns that residential treatment and recovery facilities can vary widely in quality. “Right now, recovery homes, for example, are unregulated, and they can do anything they want,” said Dr. Henry, speaking about the situation in BC. “There’s no programs. There’s no standards. And they get money from the province—and some of them maybe have good results, some of them maybe not.”
“In fact,” Surrey RCMP Inspector Shawna Baher told me, “there’s several houses that are basically, truth be known, crack houses, but they’re using the term ‘recovery home’ in an effort to try and run a flop house or a boarding house.”
What’s heartbreaking is that families desperate to help their loved ones can end up paying exorbitant fees for so-called treatment and recovery programs that aren’t based on any scientific evidence and aren’t accountable for their outcomes. I was surprised to find that there are no clinical trials or meta-analyses showing residential treatment to be effective. In fact, relapse rates are 60% to 90%. Yet residential detox programs are often the first thing people think of when they learn that a loved one is addicted to illicit drugs. On top of that, these private programs can be incredibly expensive. “I’ve seen them cost $35,000 a month,” said McBain. “How are people affording it? Only the people who can afford it, afford it. And that tells you a lot right there. A lot of these recovery centres that are so expensive do have a certain number of beds for people who don’t have the money. There’s some sliding scale, but I don’t think these really expensive recovery centres have any more success. I’ve heard of people remortgaging their homes, using all their retirement savings, things that they never expected to have to do in their life plans. That’s just such a tragedy given that a lot of the centres don’t have great success rates.”
I’d do anything in my power to save my own child’s life. How could you not? So it’s all the more upsetting to think of those vulnerable families who’ve spent their life savings on detox programs—programs that were not only ineffective but put their loved ones at greater risk of fatal overdose during relapse. And even if abstinence-based treatment does play a role for a limited number of people, organizations that operate in this way without informing patients of the risk raise big ethical and legal issues.
Politicians have often said we need more “detox beds,” and that if people could “just stop” using, we’d reach a solution to the crisis. If only. We know that’s not how it works.
So what’s really needed to help people with opioid use disorder?
Two hours.
According to medical experts, if someone who’s addicted to opioids asks for help, that’s the optimal time you’ve got to get them into treatment—an all-too brief window before the pull of their addiction once more overwhelms their will to escape it.
“If you knew someone who was addicted to illicit opioids and they asked for help in getting into treatment, where would you go?” I asked.
“I wouldn’t have the first idea where to start.”
That’s the answer I got from Bonnie Wilson, co–program lead for mental health and substance use at Vancouver Coastal Health. And if she didn’t know where to go for help—in the very city hit hardest by the opioid crisis and in a country where finding treatment in rural areas is even more challenging—what chance would others have? Later, as I continued my investigation, I would find out.
“We’ve never had a proper addiction care system in North America, maybe worldwide. We don’t have a system of care here like people with other illnesses enjoy and can access,” said Marshall Smith, senior advisor for recovery initiatives for the British Columbia Centre on Substance Use and chair of the British Columbia Recovery Council. “We got here because we didn’t give a shit about people with substance use disorders.”
“A lot of money, a lot of resources initially went to harm reduction initiatives and very little went into treatment,” said Inspector Bill Spearn. “Almost four years into the crisis we’re finally just starting to see some of the treatment options come online, but it’s not proportionate to the problem. People who use drugs and are addicted to drugs have a medical problem and, really, throwing them in jail is not going to solve this problem.”
According to a 2017 Vancouver Police Department report on the opioid crisis, “Research has provided evidence-based options for treatment that reduce overdose deaths, reduce the negative impacts on communities, and reduce costs.” Its chief recommendation was to provide “treatment on demand” for people with opioid use disorder. Interestingly, the police force didn’t recommend stricter laws or more money for enforcement. Instead, they wrote, “we must invest in creating effective addiction treatment and realize the widespread public safety and public health benefits that would result.” Even the police are saying that the answer isn’t more law enforcement, it’s greater compassion.
New national guidelines for treating opioid use disorder were published in the Canadian Medical Association Journal in March 2018. They broke ground, in the midst of the opioid crisis, by strongly recommending “opioid agonist treatment” as a first-line treatment, specifically the use of a prescription medication called Suboxone. Suboxone, which comes in pill form, is a combination of buprenorphine (a partial opioid agonist that prevents opioid withdrawal and cravings) and naloxone (which reverses the effects of opioids, as we saw in Chapter 9). I asked Dr. Mark Tyndall how Suboxone works.
“For the person who says ‘I’m going back to school’ or ‘I’ve got a job’ or ‘I need to be straight,’ Suboxone is a great drug,” he told me. “You won’t get high from it, but it will stop you from withdrawing, and we can stabilize you. And there’s good literature to suggest that for a lot of people that’s very effective. But there’s also good literature to suggest that, if you’re not ready for it, then it won’t work for you. Many people—and I’d actually say most people who are on these programs—are on and off them. It’s just the way addiction goes.”
By preventing withdrawal and reducing the cravings, Suboxone can help regular users stop using contaminated street drugs or misusing prescription opioids. They can get further supports, like individual or group counselling or residential care.
“I’m a huge fan of Suboxone,” said Marshall Smith, who is himself in recovery from addiction. “I think of Suboxone like a scalpel: in the hands of a trained surgeon, it’s a life-saving instrument. We use Suboxone all throughout our treatment centres and in the recovery homes that I directly supervise. I’ve seen phenomenal outcomes.”
Suboxone is now available in BC through prescription from any physician and is covered by pharmacare, which isn’t the case in all jurisdictions. Many doctors are still learning about it, so their training and education is crucial in ensuring that this first-line treatment is made widely available.
Fortunately, Rapid Access Addiction Clinics have begun springing up in cities like Vancouver and Victoria. These clinics, I discovered, are the places to go during that two-hour window after someone with opioid use disorder asks for help. Depending on the clinic, people can either walk in on their own or get referred by doctors, nurses, or social workers. The clinics provide evidence-based treatments like Suboxone or methadone on a short-term basis to help stabilize patients before transferring them to a healthcare provider in the community. Importantly, a health card isn’t needed to access these services, and they’re free.
Compared with more traditional and well-known opioid agonists like methadone, Suboxone is considered a better option overall for most people with opioid use disorder. Those being treated with Suboxone have a significantly lower risk of fatal overdose than those on methadone, both during and after treatment. As well, Suboxone has fewer and less serious side effects; it’s easier to take on an ongoing basis because once the person has stabilized they can get a prescription to take it at home; and there’s no concern about its being diverted to the illicit market since it doesn’t provide the effects people seeking illicit drugs desire.
“The other secret is that a lot of people who are on methadone continue to use illicit drugs,” explained Dr. Tyndall. “A methadone patient can take a day off and say ‘I got some money today. I’d rather use heroin. I’m not going to pick up my methadone.’ And their methadone would have worn off, and they get to use heroin for the day. Suboxone doesn’t work that way. It sticks around more.”
But Suboxone isn’t a magic pill to make everything better. It doesn’t make the underlying reasons for someone’s addiction go away. Instead, they can come back fiercely to the surface.
“They feel very normal on Suboxone. The discussions I’ve had with people, they feel too normal,” said Dr. Tyndall. “Like you have nothing. You’ve blown all your relationships. You live in a shabby SRO [single room occupancy] somewhere with cockroaches on the wall, and now you’re not high anymore and you’re not withdrawing. You’re just bored and irritated and all the trauma that you started drugs for starts coming back again. If the options I give them are Suboxone or nothing, when I know they’re going to buy fentanyl and any one of those times they could die, I think we have to do better than that.”
There are other important limitations of Suboxone. For one, it can be extremely dangerous to use Suboxone with alcohol or other drugs like benzodiazepines (medications such as Ativan, Xanax, or Valium). So someone who has opioid use disorder and other substance use issues may not be able to use it at all. And although Suboxone and methadone can be helpful in stabilizing people, it can be difficult to effectively taper off these medications. Most attempts to taper down are unsuccessful. Still, researchers believe that “there are increased odds of success when doses are reduced gradually with longer periods of stabilization.” As Bonnie Wilson told me, “There are individuals who are wanting to get off opioid agonist therapy. Get off the methadone, get off the Suboxone. We haven’t done enough with the rest of our system to really support that.”
While it was encouraging to hear that Suboxone is effective at helping some people stop using illicit street drugs and reduce their risk of a fatal overdose, Dr. Tyndall had raised serious concerns about its efficacy for many entrenched illicit drug users. These first-line treatments just aren’t effective for approximately 10% of people with opioid use disorder. And more than half of those who start treatment with Suboxone or methadone discontinue it in the first year and relapse. Many are unwilling or unable to stop the self-medicating effects from opioids. That’s where “safe drugs” again come in: they can help reduce the risk of fatal overdose.
Medical experts say that with the right treatment and follow-up, people with opioid use disorder can have sustained long-term remission. Some can benefit from moving between the evidence-based treatments described in this chapter (such as medications like Suboxone and methadone to reduce cravings and withdrawal symptoms so that they can use less drugs or abstain altogether) and those mentioned in the preceding chapter (such as opioid medications like diacetylmorphine and hydromorphone to help them stop or reduce their use of contaminated street drugs). The new guidelines for opioid use disorder say that residential treatment and psychosocial treatment (such as cognitive behavioural therapy and contingency management) may help some people and can be one part of a long-term addiction management approach, although they also note that there isn’t strong evidence in that regard. In short, there’s no one-size-fits-all approach. Treatment has to be patient-centred and responsive to individual needs. After all, every person in long-term recovery has their own unique story.
Controversially, a significant majority of Canadians recently polled want people who use illicit drugs to be forced into treatment against their will. But government- or court-compelled treatment for people with opioid use disorder is a horrible idea. “I don’t think we have any good evidence that court-ordered treatment management, rehab, therapies of that nature have a role to play in long-term sustainability,” said Dr. Paul Hasselback. “We’ve seen that in the past. We know it doesn’t work for alcohol-related dependency. There’s no reason to believe it’s going to work here, and the interventions are not long enough to actually be sustainable.” And as Dr. Ronald Joe told me, “Other jurisdictions have tried involuntary treatment. It doesn’t work very well. In China, for instance, they’ve actually since changed it from an involuntary to a voluntary system now as a result of the fact that it didn’t work. Most jurisdictions in the world would have a paradigm that addictions treatment is voluntary. A person voluntarily takes it on versus being forced to take it.”
And when it’s on a voluntary basis, the long-term benefits of treatment can be significant, not just for the individual, but also for their family and for society as a whole. The U.S. National Institute of Drug Abuse estimates that every $1 spent on addiction treatment saves the healthcare and criminal justice systems up to $12. Try getting that kind of return on the stock market.
Other assistance may be needed for those trying to recover from opioid use disorder, such as housing and employment support. Yet it’s often family members who are left to advocate for their loved ones to get them the help they need. “I know a mom in Victoria whose daughter wanted to die because she was so addicted—she couldn’t get the drugs and she’d get sick and all these terrible things,” said Leslie McBain. “That mom, who’s now one of our leader moms, pushed for about a year and a half to get her daughter the treatment she needed, the housing she needed, the counselling she needed. But the slog—navigating that for her was a full-time job. That would never happen with any other disease. It wouldn’t.”
One critique I’ve heard about the medicalized model of addiction treatment is that it doesn’t address the underlying reasons why someone has opioid use disorder—reasons that we now understand to be a combination of genetic and “environmental factors,” such as trauma.
But one organization that’s championing a greater recognition and role for wellness in helping people with opioid use disorder is the First Nations Health Authority. As Dr. Shannon McDonald, its acting chief medical officer, told me, “Everything we do at the First Nations Health Authority is done with a holistic perspective. We are always looking at people’s physical health but also their mental, spiritual, and emotional health within the context of their particular environment. When we deal with anybody, especially in mental wellness and substance use, we always have to look at it in the context of their whole life. We often talk about not having a drug problem in our community, but as having a pain problem,” said McDonald. “Sometimes it’s physical pain. It could be individual trauma, something in their life that they’re struggling to cope with. It could be family, community, nation, historical trauma. All of those things contribute to an individual’s relationships with opioids or other substances as they move forward.
“[With] people who’ve had severely traumatized lives, to just turn around tomorrow and say ‘Here. Take pill X instead of substance Y’ without dealing with the underlying issues of poverty and racism and trauma, we’re never going to get any closer to a solution.”
I could see Dr. McDonald’s point. I’d heard a related concern expressed by Marshall Smith.
“I think that we’re in the midst of an addiction crisis, and I know that a lot of people like to focus on the actual drug itself,” he said. “No matter what the substance is that people are using out there, this is a people problem. This is a crisis of community. It’s a crisis of connection. It’s occurring in people and in their lives, and so through my viewpoint the solution lies in people, not in drugs, and other processes.”
While first-line opioid agonist treatments like Suboxone or methadone can help stabilize people with opioid use disorder, and providing a “safe supply” of clean drugs like diacetylmorphine or hydromorphone can help keep them alive and reduce criminality and health risks, there’s also a need for a long-term response that helps people in a more holistic way. Although our immediate objective during this crisis must be saving lives, our long-term goal should be helping people deal with the underlying pain, trauma, and other reasons that either caused them to begin using illicit drugs in the first place or are barriers to their sustaining recovery so that they can live full lives, free of the enslavement of substances. And that will take a major societal effort—one that Indigenous communities that have been hardest hit want to see become a reality.
In addition to recommended medical treatments, the holistic approach championed by the First Nations Health Authority for Indigenous people involves making culturally based treatment options available. That includes access to counselling, engagement with Elders, and traditional practices to support those with substance use disorders on their healing journey. “On the land” treatment is an innovative approach being used in Indigenous communities across Canada to help people get respite from often hectic, chaotic lives that can be consumed by substance use. Participants live on the land together and are provided with emotional, mental, and spiritual support. They engage in traditional practices and cultural activities. This helps restore and strengthen connections to their culture and identity that have been horribly damaged by colonization as well as racism and discrimination against Indigenous people. It’s also an opportunity to develop deep, long-standing relationships with fellow participants, Elders, and facilitators.
There’s also a recognized need for a holistic response to the underlying causes of their addiction and the obstacles to their recovery, among them homelessness, unemployment, and mental health issues. Many people I interviewed spoke of the need for “wraparound” services—not only medical care based on the latest research but also support with such related needs as housing, vocational training, and counselling. That would constitute a much better and more cost-effective approach than how we deal with these social issues today, which is to silo them off and ignore the obvious interconnections between them.
“Allowing people the dignity of a home, potential for employment, support services to deal with their trauma as well as medical services to deal with substance use is going to take us a lot further than putting people in jail for short periods of time,” said Dr. McDonald. Unfortunately, instead of addressing the underlying challenges people are facing in their lives, our abiding societal response to illicit substance use has been just that—to punish people who use illicit drugs and brand them as criminals.