Episode 2 – Dr. Alan Brookstone and Rai Read

Fighting the opioid epidemic in Terrace, BC: An interview with two addiction specialists

by Patient Safety Voices | BCPSLS

Overdose deaths are occurring at an alarming rate in BC and across Canada. Here, we speak with two addiction specialists to hear their thoughts on the crisis and how they’re helping the community of Terrace, BC.  Transcript: Full episode 22:20 We apologize for the sound quality in this episode. Thank you for your patience as we learn and improve! [Soundclip] MICHELLE PRESTON: In recent months the extent of drug overdoses, particularly Fentanyl overdoses, has been a growing concern for many in BC and across Canada. Last November the Federal Government held a 2-day summit in Ottawa with provincial officials, doctors and families of victims of drug overdose, to discuss strategies that will help to address this problem nationwide. In BC, Medical Health Officer Dr. Perry Kendall declared the situation a health emergency several months ago and he says supervised consumption sites are a necessary and urgent part of the solution. To speak with us more about that and this issue in general, are Dr. Alan Brookstone, Addiction Specialist with the Alliance Clinic, a doctor-led outreach program for people struggling with addiction, and Rai Read, Integrated Team Lead with Northern Health. I’m Michelle Preston. This is Patient Safety Voices. [Soundclip] MICHELLE PRESTON: Thank you both for being here. DR. BROOKSTONE: Thank you very much. RAI READ: Thank you MICHELLE PRESTON:  What do you think about the recent summit that was just held in Ottawa, I think our audience would be interested in your views in general, is the federal government doing the right thing by looking at this issue on a national scale? [1:16] Dr. BROOKSTONE: As an addiction physician and somebody who has been in family practice for many years before I came to doing work in addictions, I think the government has a role whenever one sees a crisis of the magnitude that we’re seeing right now with regard to the use of and abuse and overuse of opioids in Canada. I’m not certain exactly at what level the federal government should be involved, whether it’s providing guidance, resources and funding, or if it’s actually doing any work that actually impacts the underground delivery of care. The methadone program that we actually run and that is part of our outreach program in Terrace and in other communities is actually a federally funded program that’s administered by the College of Physicians and Surgeons in BC as well as the licensing authorities in the other provinces. So, the federal government already plays some significant role in the management of addictions in the various provinces and certainly in the communities whether they be urban or suburban. So, I do think that the federal government has a role. It’s early days because we’ve just had some initial discussions, but I think we’ll see this evolve much more rapidly over the next six months to a year.   RAI READ: No, I don’t know all of the details of the summit but I think what we’re seeing from a frontline perspective is there’s a lot more focus on tackling this epidemic with the take-home Naloxone program being rolled out earlier on this year. I think that we’re becoming more aware of it. I can’t really speak for the government and whether it’s the right thing, but we’re seeing from a frontline point-of-view that we’re being given more information and more guidelines around how to handle it. MICHELLE PRESTON: So you say there’s more focus. We’re certainly seeing a lot more coverage on this issue now particularly here in BC. We see efforts to raise awareness and fight any stigma that’s associated with addiction. A lot of that is ramping up in schools right now. So, do you have any thoughts on the misconceptions of addiction? What do you think is important for people to know about addiction and the people that need your help? [3:28] DR. BROOKSTONE: Once again, Michelle, I’ll jump in first here and then pass it over to Rai to discuss her thoughts on this. From my perspective addiction is an imminently treatable disease. It’s actually a very satisfying area in medicine as a practicing clinician to find individuals or help individuals who are suffering with disorders that affect their entire lives – their bio-psychosocial involvement with everyone around them – and see them actually get back on track, get jobs again, go back and become productive members of society. But, I think there are a couple of really important things from my perspective that they should be thinking of:
  1. When individuals start using drugs at a young age their brains essentially at that point in time go into hibernation. So, when we see people who are in addiction who are in their early 20s, or late 20s, sometimes into their 30s, and have been using drugs ever since they’ve been in their teens, there are parts of their brain that are still as immature as they were when they were 15 or 16 years old. They’ve got no sense about managing finances, they don’t know how to organize their lives, they don’t know how to cook food, they need a lot of skills in terms of lifestyle training and, in fact, in treating these individuals it can take years before you can actually get somebody to a point at which they can once again take responsibility for their lives, and it’s usually done in small incremental steps.
People don’t get into addiction overnight, they don’t get out of addiction overnight and there’s a part of addiction that’s all about instant gratification and if you are in individual who’s lived your life with instant gratification, the thought is well, I’ll just go and see this particular clinic, go see this doctor, get this medication, in three months’ time I’ll be sorted out, I’ll be back on track and I’ll be living a normal life and of course that never happens. So, I think it’s having a realistic expectation about what one should be able to accomplish in what timeframe if you’re trying to recover from this very long-acting chronic relapsing illness that people suffer from. 2. The other point that I’d like to make with regard to addiction is that the substances that people are dying from these days are often the ones that they don’t expect to contain the very dangerous opioids. So, many of the overdose deaths that we’re seeing are from individuals who are using cocaine, crystal meth, other substances that have been laced with these very strong opioids, particularly Fentanyl, and now the Carfentanyl, which can have literally a grain of Carfentanyl in it and somebody who is opioid naïve – in other words they’ve had no exposure to opioids – can actually die from exposure to those drugs and they don’t get it because they’re using opioids, they get it because they’re using other substances that they normally see as recreational drugs. So, I think the message that I want to impart to people is there’s a significant focus on consumption sites and safe injections…there’s never an injection that’s safe at any point in time…but supervised injection sites and using agents such as Naloxone in order to rescue people from these overdoses. Essentially where I think we need to be focusing more in terms of addiction is encouraging people not to use in the first place. If they were not using the drugs we would not be having a lot of the problems that we’re encountering right now. So, my message is it’s certainly imminently treatable, but I think we need a much stronger focus on prevention and a much stronger focus on not using at all, particularly the substances that people think are benign. RAI READ: Yes, certainly, I think one of the things that we quite often see from the mental health point-of-view as well is individuals who are trying to medicate-away trauma. And, it’s one of the things we particularly see in this region is there’s a significant amount of trauma that people experience. And, really having staff who are skilled with supporting individuals who have gone through significant trauma in their lives and how to manage that and how to recover from that and look at healthier ways of processing. And, educating Emergency staff to not compound that, not to trigger individuals who have previously been triggered in other areas and just a consistent approach, I think, on all healthcare professionals. [Soundclip] MICHELLE PRESTON: Let’s talk about the clinic in Terrace. It sounds like you’re doing some wonderful work with your patients. You’ve been up and running now for about two months and it’s the first opioid substitution clinic in the area. I believe it’s modelled after another clinic in Prince Rupert, which has also been very successful for helping people to return to living normal healthy lives. What did it take to open your clinic and what are some of the early results that you’re seeing? [9:00] RAI READ: Well, the clinic in Terrace came about because the physician who previously held the license to prescribe methadone retired, and so there was a gap in services. There wasn’t a great deal of interest at that time for a local physician to step in and take over that practice, so we really wanted to offer something a little bit more comprehensive. There’s a lot more that goes with it than just writing a prescription – there really is an opportunity to support an individual with life skills, with looking at that ongoing counselling, with getting immunizations up-to-date. A really much more comprehensive approach and that’s something that we have been able to do with Dr. Brookstone. Being able to guide us with that expertise and being able to really provide a wrap-around service locally for people. DR. ALAN BROOKSTONE: As someone who works in a clinic with a large group of addiction physicians, the opportunity to expand the services out to communities such as Terrace and, as Rai had mentioned, based on some work we had initially done in Prince Rupert, I think has been a tremendous value to the community. Some of the early successes that we’re seeing are…it’s incredibly important for individuals to have consistency. They need to be seeing the same care providers, the same physicians, psychiatric nurses, counsellors, basically you need a team to work with individuals so that they can develop a level of trust and comfort. And, what we’re starting to see, which is very similar to what we saw in Prince Rupert, is individuals who have been indigent, living on the street, or who have been chronic users of IV drugs are now getting to the point, even within this very short timeframe, that their usage is down significantly, they’re starting to present and look more healthy when we’re seeing them. We’re certainly getting information from them that they’re using significantly less substances – some of them have stopped using completely. Some we’ve taken off other substances in addition to the fact that we have optimized the amount of treatment that they require, and we use both methadone and suboxone where it’s appropriate for management of these individuals. But, I think the other point which is very critical is that you need to have more than one physician who can actually support a community, primarily because that individual is often the only one who is able to write the prescription for the suboxone or for the methadone if these individuals are on treatment. And unless you’ve got a team-based approach where you’ve got at least two and maybe even three physicians who are able to cover for one another and consistently ensure that the missed prescriptions and missed doses – the little crises that happen on a day-to-day basis – are able to be taken care of, it’s very difficult to maintain consistency with our patients. Our patients live completely chaotic lives – they miss the bus, they don’t have transportation, they don’t have funding sometimes to get into the clinic to see the physician or see the other providers, and we try as best we can to accommodate them and to support them through these early stages of recovery. So, my belief is that we will see more and greater success over a period of time, greater stability in the community and we’ll see individuals starting to return to a more productive lifestyle. But, it really takes a whole town of people to make this happen…it’s not just two individuals working together it’s a whole team approach. MICHELLE PRESTON: Certainly, lots of people and services, several moving parts, a complex issue. I’m curious about patient safety. Of course we’re here at the BC Patient Safety & Learning System (BCPSLS), so are you folks able to use that tool to capture any kind of safety concerns that come up with your clients, and if so, how is it helping you and what are you learning at this early stage about the safety issues that people might not know about? [13:26] RAI READ: I think one of the main focuses for patient safety is about reducing the amount of travel for individuals, making sure that the care is provided locally so that they’re in the community and that they have a support network around them. In terms of actually using the PSLS system, at the moment we haven’t utilized that and maybe that’s something we can certainly review and see if that’s a tool that we can incorporate. But, I think really it’s just about serving up the population locally with having a spectrum of staff with different training who can really meet their needs, work with the clients where they’re at and making sure every aspect of healthcare is addressed. DR. BROOKSTONE: I’d like to add something to that and I didn’t mention that earlier when we talked about the clinic, and a key component of the clinic is that we’ve structured it so that we are onsite, and this speaks to the patient safety that Rai had mentioned about travel. Physicians fly up once a month in order to do a clinic with our patients and we’ll do new intakes on those particular days as well as follow-up visits with our existing patients. But in the interim, in the time in-between, we do all of this via telehealth, so we actually come in to the clinic using a secure software application that we can use for video conferencing. But, it’s not simply just video conferencing with the patient – the patient actually sits with a nurse, with a care worker who’s working with them at that particular point in time, and we do the telehealth visit together so that if we need urine drug screen testing, or they need to have their immunizations, or they need referral for STI (Sexually Transmitted Infections) counselling, whatever else needs to happen, it can actually be done at that time. I think one of the great successes that we’ll see come out of this from both a benefit and from a patient safety point-of-view is that we are capturing them back into the community of care whereas previously they might have existed in a very isolated environment where all that they did was they went in and got a prescription. Now, they’re actually coming in and they’re being re-introduced to the counselling resources that are available to them and the other support services that are there to reduce the risks that they might be facing within the community as well. [Soundclip] MICHELLE PRESTON: So going back to the Ottawa summit just for a moment, Minister Jane Philpott says there will be new opioid prescribing guidelines coming out for Canadian doctors, is that something that you think will impact your work in Terrace at all? [16:35] DR. BROOKSTONE: I think it’s always interesting to see how the provinces in particular across the country, how the different authorities are viewing the prescribing patterns, but we’ve been doing this for a very long time now. I’ve certainly not been treating addictions as long as some of the colleagues in my practice, however we have been using methadone and we’ve been using suboxone very successfully in treating our patients now for many years. And, although the guidelines have evolved and developed and we will see national guidelines, we really do need to see something that is applicable not just to individuals of the downtown eastside, which is a highly polarized but also a very specific population of individuals. We need to see guidelines that are flexible enough to meet the needs of individuals who are in the urban centres as well as those that are in suburban and in rural centres. My only concern, not my only concern, but one of my concerns around the guidelines is that they’ve been developed – if we’re talking about the BC guidelines that are now being looked at as a potential model for both provincial and also for federal guidelines – one of the concerns is that these have been developed primarily in the downtown eastside with a different population of patients to those that we see in a community for example such as Terrace. So, we’re not going to be able to make a comment on that until we see where the federal government is going to go, however I think we have a pretty good understanding of what the requirements are for our patients. We’ve used methadone for many years and in the right hands it’s an extremely safe drug, although according to the new guidelines they are placing it as a second-tier drug behind suboxone. I think both can be used very effectively if you’ve got skillful people, if you’ve got knowledge of the drugs and can actually prescribe them properly in the community. We can speak about the guidelines for a long time and there’s certainly a lot of meat in the guidelines that should be dissected apart, but right now I don’t see that the guidelines are going to significantly impact the way that we’re managing our clinic and managing the services that we provide in the community. MICHELLE PRESTON: You’re doing tremendous work in Terrace, it’s exciting to hear, do you think other clinics like yours will begin to pop up in other areas of BC? [19:31] DR. BOOKSTONE: I hope so. I think there’s a significant demand for these types of services because of the difficulty of retaining trained providers and having a team-based approach within the communities, and I believe that over time the effectiveness and also the cost-effectiveness of these types of services will become apparent. People don’t have to travel anymore and it’s not even a matter of travelling within the province of BC, it’s just travelling to another city that’s even within 80km to 100km distance of the location in which they live and, as you know, the roads in the north in the wintertime can sometimes be quite dangerous. So, the more that we can provide these types of services in communities that are in rural settings that are less accessible, I think the better, however it needs to be calculated, it needs to be done properly, we need to have a team of trained people that are highly committed. And if you’ve got all of those elements together and you get the support of the pharmacists in town because there’s a lot of back and forth in terms of work that gets done via telephone and via video communication – as long as you can put those services in place and work with individuals who are well trained and well organized in the community I think it can be done very effectively. The risk is having individuals who feel it’s simple to just write a prescription and to have a telehealth visit and not put the other measures in place around issues such as random urine drug screen testing for people who have now got carriers of their medication to ensure that they’re actually compliant with their program, or ensuring that there are backups in place when individuals are not available so there’s no loss of continuity for patients who are actually getting treatment. I think things can go sideways very quickly. It doesn’t take long for somebody to slip if the right supports are not there for them. We have to be there 24/7 and totally committed to a program such as this. MICHELLE PRESTON Dr. Brookstone, Rai, thank you it’s been a pleasure. [22:01] DR. BROOKSTONE / RAI READ: Thank you. [Soundclip] Additional resources:

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