June 2021
Summer is upon us and vaccinations proceed across Canada, hopefully leading to reduced COVID-19 infections and the gradual resumption of activities that have been prohibited for many months. Everyone working in addictions is aware of how the pandemic has highlighted the social and economic disparities that lead to inequities in health care.
The biggest topic of discussion in addictions these days is prescription of a “safe supply.”
That is, prescribing opioid medication (usually hydromorphone) for unwitnessed use by persons with Opioid Use Disorder, intended to replace use of the increasingly toxic illicit opioid supply. Illicit opioids that contain fentanyl, carfentanil, benzodiazepines and other substances are one factor contributing to an increase in deaths due to toxic opioid ingestion during the pandemic. Proponents of prescribing a “safe supply” note that consuming a known pharmaceutical substance is safer than street opioids and may save lives.
However, there is minimal data to support that premise, and increasing concern of the hazards of prescribing a “safe supply.” Hazards include medical illnesses including endocarditis and osteomyelitis from injecting hydromorphone intended for oral consumption, and risk of diversion.
Diversion of prescription hydromorphone is leading to reduced prices for hydromorphone purchased on the street, and an increase in available opioids for nonprescribed use. We have heard of organized crime on the Downtown East Side in Vancouver coordinating efforts to obtain prescribed hydromorphone and transporting it to locations where it can be sold for a higher price. Prescriptions of high doses of hydromorphone are being sold to obtain fentanyl, which increases the financial resources of persons with Opioid Use Disorder but also increases the risk of fatal and non-fatal overdoses.
Concerningly, easily available prescriptions of “safe supply” hydromorphone are destabilizing people currently stable on Opioid Agonist Therapy. Supporting and treating persons with Opioid Use Disorder has become more challenging during the pandemic, and the role of “safe supply” needs to be studied, but not at the expense of failing to provide increased funding for evidence-based forms of Opioid Agonist Therapy and ancillary services including housing, medical and psychological care.
Another area of concern in addiction medicine during COVID-19 is the focus on Opioid Use Disorder, with seemingly less attention provided to other addictions.
We know that Nicotine Use Disorder affects over 10% of the Canadian population and a disproportional percent of people with substance use and mental health disorders, yet most smoking cessation programs have been stopped or significantly curtailed during the pandemic, despite the devastating effect of smoking on health, and increased risk for hospitalization in COVID-19 illness in persons who smoke.
Additionally, data suggests alcohol use at home has increased during the pandemic, leading to concerns about increased rates of Alcohol Use Disorder, yet most treatment programs are still operating at reduced capacity, and mutual support groups are, for the most part, only available online.
Many persons with Substance Use Disorders do not have access to the internet to participate in virtual mutual support groups or online treatment programs. Much work is still needed to understand and overcome the impact of COVID-19 on addictions and addiction care. We hope that the government’s plans to significantly increase funding for mental health and addiction care in post-pandemic Canada leads to new and expanded treatment programs for all addictions.
References:
https://www.catie.ca/en/pif/spring-2021/safe-supply-what-it-and-what-happening-canada
https://pubmed.ncbi.nlm.nih.gov/32749705/
Reddy RK, Charles WN, Sklavounos A, Dutt A, Seed PT, Khajuria A. The effect of smoking on COVID-19 severity: A systematic review and meta-analysis. J Med Virol. 2021 Feb;93(2):1045-1056. doi: 10.1002/jmv.26389. Epub 2020 Aug 13. PMID: 32749705; PMCID: PMC7436545.
Lindsey M. Rodrigueza, Dana M. Littb, Sherry H. Stewartc. Drinking to cope with the pandemic: The unique associations of COVID-19-related perceived threat and psychological distress to drinking behaviors in American men and women. Addictive Behaviours, 110 (2020) 106532.
Tanya C., et al., The Changing Landscape of Alcohol Use and Alcohol Use Disorder During the COVID-19 Pandemic – Perspectives of Early Career Professionals in 16 Countries. Addict Med Volume 00, Number 00, Month/Month 2020.
The Canadian Society of Addiction Medicine is a national society of medical professionals and scientists committed to helping Canadians understand, accept, and recover from substance use disorders.
