Opioid Poisoning Crisis: The Story of Alcohol Prohibition Repeating Itself

In the period between 2016 and 2021, more than 19,000 Canadians have died of overdoses related to the toxic street supply of drugs. Opioid-related deaths have further increased during the COVID-19 pandemic as a result of a variety of factors, such as disruptions in wrap-around support services, reallocation of resources, and challenges to overall mental health and well-being. In this episode of the Public Health Insight Podcast, Dr. Andrea Sereda joins us to talk about:

• The causes of the current drug poisoning crisis and similarities to the alcohol prohibition period in the 1920s;
• Some factors that contribute to the likelihood of people using opioids or substances;
• Distinction between problematic substance use, addiction, and similar concepts; and 
• How the COVID-19 pandemic has impacted opioid poisonings and harm reduction services.

Podcast Guests

• Dr. Andrea Sereda

Podcast Hosts

• Gordon Thane, BMSc, MPH, PMP®
• Ben Umakanthan, HBSc, MPH

References for Our Discussion 

• London InterCommunity Health Centre: Safer Opioid Supply Program
• Opioid Crisis: The Other Pandemic

Subscribe to the Newsletter

What if there was an easy way to receive timely information about public health and global health right to your inbox? Subscribe to the newsletter to stay in the loop about the latest news, live events, jobs, and professional development opportunities. Subscribe to ensure you don’t miss out: https://thepublichealthinsight.com/subscribe/. 

Tell A Friend

If you enjoy our podcasts, it would mean the world if you shared it on social media and tagged us. If you are not the social media type, we would appreciate it if you shared it with a friend or colleague who you think might enjoy the podcast. It helps us to get discovered by other people. 

Transcript

Andrea: 0:00

our current overdoses in Canada, which have chops, you know, 20 1005 years are a completely predictable result of, of Canadian drug policy, which follows American policies on drugs. So when you're asking, how do we get here? We actually need to rewind about a hundred years actually.

Sully: 0:19

this is the public health insight podcast.

Gordon: 0:22

Hello, everyone. My name is Gordon. And I'll be your host for this episode, along with Ben and a very special guest

Ben: 0:30

Before we move on is important to note that the views expressed in this podcast are our own and do not represent any of the organizations we work for or affiliated with.

Gordon: 0:38

Dr. Aandra Serita is a family physician working at the London Intercommunity health center, where she focuses her practice on people who use drugs, people living in homelessness and women involved in the survival sex trade. Dr. Sarita provides care in a traditional office setting, but also through street outreach medicine, going to where people are at in shelters and camp mints or anything in between. She's an avid harm reductionists and is lead physician for the London Intercommunity health center, safe opioid supply program, which is currently the longest running of its kind in Canada. Please join me in welcoming to the podcast Dr. Andrea Serita. Dr. Serita, um, thanks for taking time out of your day to join us, to talk about several important issues, smushed up into one. We'd like to know a little bit more about you Okay and the work that you're passionate about. Uh, so if you could start by telling us, you know, why you decided to pursue a career in emergency medicine and ultimately how you arrived, where you are now.

Andrea: 1:49

Absolutely. And thanks for having me Gordon and Ben. So it it's been a bit of a journey getting to the practice that I hold right now. So as you mentioned, I actually started my career in a combination of working in the emergency room and, you know, some family medicine work as well. My family medicine work has always encompassed marginalized population. So I actually coming out of med school, started a practice when one of our local, uh, homeless shelters at the center of hope here in London, Ontario. And I actually did that because of my little brothers. So, um, my brother, Jason Serita, was working on, on a floor essentially in a social work type of role. Um, and I needed a part-time job in med school. So he told me about a few postings. I was hired and, you know, worked the overnight shift on, on the detox and the withdrawal floor. And it really. Was my first exposure to people who use drugs, people who are you noticing it, using street level substances, people living in homelessness. Um, and the experience was pretty profound. It, it really, I think, you know, altered the trajectory of what I thought I would do with my career. So again, graduating from residency, I had always planned to do emerge. Um, but then actually added that family practice component. Um, did that for quite a few years, you know, I think six or seven years I was in. And then a really amazing opportunity came up at the London inner community health center. Um, so LHC is involved in a really unique program called street level women at risk, um, which is a partnership between housing first organizations, medical and policing. Um, and, and the doctor who was involved in that, Dr. Ann Bodkin was a mentor of mine. And at that point she decided, you know, retirement was what she wanted. Um, and so that opportunity opened up for me and a and I left at it and that's when I became to, uh, you know, doing the full-time work with London, Intercommunity, community health, and, and at the beginning, really working again with women who were involved in street level sex work, and then people living in homelessness and, and the rest of the practice grew. And I'm sure we're going to talk more about.

Ben: 3:52

For sure. Thank you, Dr. Serita. Um, could you share a bit more about the lender into community health center and your role as a day-to-day physician?

Andrea: 4:00

Absolutely. So, um, London inner community health center, where a CHC, which is a community health center, um, CHCs or across the province have a chair and actually across Canada, um, and all CHCs. We have a mandate, um, to care for people, with barriers to care in the traditional health system. So. Our clinic itself. Um, LHC serves about 8,000 patients in, in London, Ontario. Um, my, my corner of it is again, you know, we in the clinic called health outreach and that's where we're, we're working primarily with people who live in homelessness. Um, but there's many other different groups of folks who are served in our clinics. So, so we do have a very large newcomer, um, population in practice that serves at, in your community. Um, we see many undocumented folks. We see many people living in poverty, um, and then many people, um, who for whatever reason, fall through the cracks and in more traditional, a family medicine offices,

Gordon: 4:59

That's awesome. So that brings it full circle to one of the things I was curious about. You identify. As an avid harm reductionists. So first of all, what, what does that mean to you? When you say avid harm reduction?

Andrea: 5:14

Yeah. So, so harm reduction that the term actually did originate in, in substance use and, you know, street level drug use. And it was looking, um, to acknowledge that people who use drugs are able to have the autonomy to continue to do so in a way that, you know, serves their goals and their needs, but with drugs, just like many other things that we choose to do in life, there, there are risks and there are potential. So harm reduction, excepts that individual's choice to use drugs, but ceases to, you know, provide tools and education and medical care that addresses any potential complications of it. The first harm reduction measure that we saw in Canada was actually a immersion to the downtown east side in Vancouver, in the 1980s when they were having the first HIV epidemic here in Canada. And that was a clean needle exchange program. And so that came actually out of the community of people who use drugs, themselves acknowledging, um, that B their drug use, you know, was related to the, uh, acquiring HIV sometimes, and then seeking measures to reduce that potential harm. And then everything else that we're doing within, you know, substance use work follows that narrative as well. And I guess an avid harm reductionist just means that I, you know, I've drank the Kool-Aid and, and I'm all in I'm too.

Gordon: 6:33

Awesome. So John Dewey is an American philosopher and one of the quotes that he said that always stands out for me is, um, a problem well-defined is a problem, half solved. so when we're speaking about the so-called, uh, opioid overdose crisis, or some say it's an epidemic, um, how did we get to this point? And it was there a singular root cause for how this all came to be.

Andrea: 7:02

That is an absolutely enormous question, Gordon that I could write. I could write an essay on, but I mean, I, so this is, this is something that I often try to correct in my media is you're correct. We have to define the problem properly because I really believe like the language that we use to describe a problem really informs the solutions we can think of. So there's, there's kind of a couple of prongs to answer your question. Um, the first is like, what are we really dealing with? You? You mentioned, I think the overdose epidemic, you also call it an opioid epidemic. I shift that a little bit. Um, and, and I refer to it as a drug poisoning epidemic, which we can delve further into, but also a drug policy epidemic. Um, our current overdoses in Canada, which have chops, you know, 20 1005 years are a completely predictable result of, of Canadian drug policy, which follows American policies on drugs. So when you're asking, how do we get here? We actually need to rewind about a hundred years actually. So, um, beginning with, uh, alcohol prohibition and, you know, leading into hearing Anslinger, his actions, uh, in America, around, you know, marijuana and reefer madness and everything else. Um, But what we saw in the 1920s with alcohol prohibition actually completely mirrors what we're seeing with opioids and fentanyl right now. So in the 1920s, when prohibition was brought in the, the, the drink of choice at that time in America was actually beer. So a low concentration, a low potency alcohol drink that you know, was widely abide in America with prohibition. Um, beer became really hard to conceal and smuggle, right? Like you needed a lot of volume to meet people's needs and speakeasies. So people, very predictably switched to a more concentrated product that they could ship smaller volumes of and therefore meet the needs of people in a smaller container. And so. The drink of choice in America really shifted from beer to spirits like whiskey and vodka, uh, and rye and, and that pattern of American alcohol consumption actually, you know, continued in that direction. So prohibition really shaped the type of alcohol that people at the time were trying to consume, because it was outlawed. We see in lots of that, I mean, I run opium and around marijuana and we don't have time to go into all of it. But when we think about what's going on with opioids, it's the exact same issue. So a lot of the media is around, um, doctors over prescribing. And certainly there's a lot of issues, particularly around Oxycontin and other drugs. But what we need to remember is that people have been using opioids OPM since time in Memorial, right? Um, again, in the early part of the, uh, the 1910s people would drink opioid tea and other things, very low potency, um, potency drugs at that time. When we're moving into, you know, the 2010 to 2013 era when people were recognizing the impact of, of Oxycontin on some folks, the reflexive reaction, um, from government and policymakers was to reduce that support. So lots of prescribing guidelines came out to physicians, telling them to, you know, cut people off or significantly cut back their prescriptions. Um, government actually pulled, um, the Ontario government at least pulled, um, Oxycontin from the provincial formulary. And I believe 20 13, 20 14. Um, and, and exactly what happened with alcohol prohibition. People didn't stop using this drug. They're dependent on this drug. They use these drugs from multiple different reasons in their life. Um, but then they no longer had what at that time was their safe supply. Right, right. A known dose prescribed by their physician of a pharmaceutically made drug. That was queen that was pulled away from thousands of people in Canada. They didn't stop using opioids. They then just turn to the street market. So very predictably around 2015. We saw the emergence of fentanyl because you know, the standard opium that that people really think about is heroin. Heroin is, you know, compared to fentanyl shipped in very large volumes, um, hard to conceal. It takes a lot of work to get over borders, whereas fentanyl can, can be shipped in grams. Right. Um, and, and then cut down to two, you know, 10th of gram was, which is what people use. So exactly like the alcohol shift from beer to spirits, we saw people switch from pills to street-based fentanyl, and that was a direct action directly related to government policy about pulling the other medications.

Ben: 11:41

You mentioned a term that really stuck out to me and that was drug poisoning. And from your experience, did you find that the audience was more receptive to this term? Because, you know, historically we had the crack epidemic, the opioid epidemic, um, people, I may not be familiar with these drugs unless they're in the healthcare field and they might say, oh, you know, These are people who use drugs and they're using this drug and that's their problem. It doesn't affect us. But when we take that term drug poisoning, people are like, oh, what's going on here? Why are being poisoned? Did you find that at all?

Andrea: 12:10

Yeah. I think I definitely have to explain the term and where I'm going with it. So again, I'm going to, I'm going to keep bringing it back to alcohol, right? Um, so right now with alcohol being legal, you buy your safe dose known concentration. You know what you're doing? You can go to a safe consumption site for alcohol, which is a bar, um, and, and really imbibe in, in, in your drinking the way you want to, but because opioids are illegal, um, uh, for street-level consumption, um, we're dependent on the black market. And so when you're thinking about fentanyl, it's not actually fentanyl, that is killing people. We use fentanyl in the hospital. Every single day safely, it's used in emergency medicine procedures. It's used in anesthesia, anesthesia. It's used for pain control and it is completely safe because it is a known purity and a known dose prescribed by a doctor. But when you have street-based fentanyl, um, people don't know what they're getting. I often, you know, talk to my patients about it this way. I say. Fentanyl is like a batch of chocolate chip cookies. So if you're not mixing the batch very well, you could end up with a cookie that it has two tacos, chips, and a cookie, a different cookie that has 20 chocolate chips. They're all coming from the same batch. Um, but you don't really know which one you're going to get. And fentanyl is like that. Um, the fentanyl is, uh, unequally distributed through a batch. So, so two people could be smoking, you know, from the same batch of fentanyl, but one person is going to go down from an overdose and the other person isn't again, because of that variability in concentration and, and people not knowing which end of that they're going to get. Right. And then along with that comes all the cutting agents that are in fentanyl. They, the average, um, you know, point of fentanyl sold on the street is only about 8% fentanyl. So it's 92% other crap. Right. Um, and, and that's leading to poisonings and, you know, health complications as well. So, so people, people are poisoned by, by consuming an unknown drug, essentially. Okay.

Gordon: 14:04

Right. So the point you're making here is that, um, there's the opioids. And then there's the unknown quantity and concentrations, which actually causes the severe negative health outcomes that the person doesn't knowingly ingest or into their body. So by saying overdose, it implies this person. Probably wanted to take a lot when the, when the intention was, maybe they use the same amount of what they thought they were getting, but they're just essentially blindsided by, um, other substances as a consequences of needing to get it from, uh, uncontrolled street supply compared to a

Andrea: 14:42

That is a per perfect summary. Perfect summary. And so you're completely right. I think if you think of The origin of the word overdose as well. You're using too much of a dose. That's what an overdose is. You're getting, you're taking, you're ingesting more than you intended to ingest. And I can tell you, my patients don't intend to overdose. These are all unintentional drug poisoning, overdoses. Again, they purchase an amount, they think they know what they're getting and they get something else. That's drug poisoning.

Gordon: 15:11

this is a perfect time to bring up the misconceptions about, um, there's different types of technical terms for a general audience. That might be a bit confusing, like addictions, substance use, problematic substance use. Is there a way you can easily draw a line between those that can help people conceptualize?

Andrea: 15:32

drawing a line. Probably not because it's all a spectrum and it all, you know, depends on the angle that you're looking at it from. Right. Um, and so certainly. When people look at my patients, they say they're addicted, right? They say they're addicted or they say they have chaotic substance use. I just say they use substances. Okay. Some people, again, just like alcohol that's legal will use too much alcohol and we'll have negative health or potential social, you know, uh, consequences of that. That's the definition of addiction ongoing use, despite consequences. The majority of people who use alcohol are not in that group. Um, the same is true of street-level substances. The same as true fentanyl. Yes, we do have a proportion who are addicted. Um, the rest of the folks use substances for various reasons in their life. Okay. Um, for example, my patients, um, at least 60% of people on safe supplier homeless. So I want you to imagine that you've been sleeping on the concrete for three years. Winter, fall, summer, all kinds of weather, rain, sleet, snow, um, you don't have any shelter. You maybe sometimes have a sleeping bag or a tent. And after three years, your back really hurts. And so you can't get a prescription from your doctor because they call you a drug seeking and they judge your intentions for that use. So you'd go to the street supply and you treat your own needs and, and many other things, right? Um, heroin is called a warm hug and it's called that for a reason. Opioids treat not only physical pain, but they treat emotional pain. So again, imagine you're the same person sleeping on the street for three years. You're watching the community step over you, you're watching other people go into houses and have enough to eat and you don't have any of those things. And you're, you're completely isolated from the rest of the community. Would you want to blot that out with drugs? I think I sure would. And, and so sometimes people turn to substances for that reason. Um, and then there's a lot of trauma, right? So, so many people, you know, in the experience of homelessness or living on the street or, you know, experiences that, that predated that there, again, they're trying to block it. We don't have effective therapies. They don't have access to doctors or, or, or, you know, other professionals who could help with those things. They treat their own symptoms. So, so are people addicted? Yes. Um, are, are people who use fentanyl regularly physiologically dependent on that drug? Absolutely, but that's different from addiction. And, and I find in my practice, most people are meeting their own needs, whatever that is. And then we can talk about how we make that better for them. When we get to actually talking about safety,

Gordon: 18:13

So that, that brings up the question. I, one of the things that I constantly hearing you, um, trying to correct is that people have a misconception that, um, the drug use happens before the social exclusion, the social deprivation, uh, the housing deprivation. But what you're saying is, um, that's a means of coping with the emotional, physical trauma associated with maybe not having the same access to those resources as other people, rather than the other around.

Andrea: 18:45

Absolutely. And certainly nothing is black and white in life and humanity. Um, but yes, there's a, there's this general perception in, you know, the lay population, um, that people use lots of drugs or they're mentally ill, or they're doing bad things. And that means say they end up homeless and that's where they're like, you know, to fix homelessness, we need more mental health treatment and you know, more rehab centers when it's really asked backwards. Right. So people are homeless because they don't have enough money to rent or buy. Full-stop homelessness is poverty. And, and you can argue about all the, you know, reasons people get to that level of poverty, but you don't have a home because you don't have enough money to have a home. And so you end up on the street and, and just like I said, you, you undergo new physical and emotional trauma and, and your mental health starts to suffer. Right? I mean, again, if you were sleeping on the street for three years, how depressed would you be? How anxious would you be? Would you start seeing things because you've slept two hours a night for three years, right? Of course you would. Um, and so your mental health deteriorates and, and often people substance use, um, either, you know, starts or gets worse on the street for the exact same reasons that I've described. And, and one of the things that we see with the housing first component of our program is so much mental illness and substance use get so dramatically better when people are housed. Um, Again, it's not black and white, but I think we really need to reflect on, on, on the reasons that people are ill when they're living on the street. And we really stopped me, you know, needing to assume that, um, their personal choices and personal failures that are leading to that, it's a systemic failure. We're all involved.

Gordon: 20:31

And one of the things I wanted to follow up on, I heard you on a, I think it was CBC show, late land. You mentioned. Um, so we have opioids. And then you also mentioned crystal meth, um, is often used for people who are maybe housing deprived, living on the streets a little bit scared to sleep. so we don't think of, um, people, um, using substances as a way to cope necessarily, um, while they're living in housing procarity, but you're, you're you make A great point that actually this brings someone further down the rabbit hole of needing to use, uh, even more to be able to just cope with the daily realities of

Andrea: 21:13

Absolutely. And I, and I know which interview you're referring to and, and I think I missed should it, even in the context of women, right? So if you're a woman who is homeless again, you're living on the street, maybe you're living in a tent, maybe you're living in a group, maybe you're living solo. It can be really dangerous for you to fall asleep in that environment. You're prone to theft, physical, sexual assault. And so you use crystal meth because it keeps you awake for two or three days and keeps you safer from those things. Um, and, and know, obviously there's implications both from the crystal meth use and, you know, from being awake for those long periods. Um, but I think again, yeah, we're reflecting back on what is actually the need that's being met. And then again, you're sleeping terrors a night because the concrete is uncomfortable and it rained. All right. Crystal meth can, is often used like a coffee for my patients. They may have a little talk, a little puff in the morning and it, and it wakes them up just like the espresso I make at home. And, and that can be a mechanism of use. And then again, at the far end of the line, some times people are just so distressed by the way, they have to live that they don't want to be part of it. And so they block it out and they use drugs and then they eat. They seek you for you and being high for that reason. Again, I, I don't think we have a moral leg to stand on by criticizing people for doing that. And until we actually have, you know, a Canadian society to support said basic human rights of everybody who lives here.

Ben: 22:43

Absolutely. And I wanted to follow up with that because we talked a lot about, you know, this existing condition that they have to face every day of their life, 24 7. And now what the elephant in the room of what we've all been dealing with for the past 16 months with COVID-19 in your experience, how has this worsen the situation.

Andrea: 23:02

Um, so it's worse than it, but it's also, it's also exposed the gaps in society, right. Um, so COVID has been hard on everybody, but again, imagine you have nowhere to go home to and all of the services have shut down. So, so in March, 2020, when w when we started to enter that period of lockdown, basic program, shut down for my patients. So hygiene program, Nobody could have a shower for six weeks because everything was closed. There were no bathrooms. People had to, you know, do their business. Number one and number two, and you know, in the forest and the bushes, because there were no bathrooms that were opened and Neil programs reduced because a lot of our meal programs are actually staffed by elderly folks, um, who are told to isolate for the risk of COVID. And so people who are normally able to maybe find two hot meals a day through various, but now we're down to one, if they're lucky and it's a sandwich that you eat on the street, right? So. Again, put yourself in that situation. How would that feel? Again, we've all suffered, but it's so much worse when you're on the street. And again, it exposed a lot of inequities, um, because my folks were the only people who are out and about. So suddenly people are seeing these usually invisible humans, but, but without the other humans around them, they're, they're more obvious. And it, and it also just exposed the, the mass of, um, lack of housing that we have in almost every Canadian community. Um, if you're told to self isolate and you don't have a home, what, like, what would you do? Right. We have no options for these folks.

Ben: 24:39

Right. And moving forward, you know, a lot of people have been laid off due to due to the pandemic. They might have lost their homes as well. So this crisis gets even worse coming out of this. Right. And then if we have services and resources that haven't been established or have been reprioritized to COVID-19 it seems like it's just adding more Kindle to the fire.

Andrea: 24:58

Absolutely. Yes.

Gordon: 24:59

So in theory, um, we would expect that, um, the situation, there's more of a strain on our society because you, you mentioned the gaps have been exposed so that as this translated to an actual increase in, uh, the number of, and, or the rate of drug poisonings or toxicities.

Andrea: 25:19

Yes. So it's hard to know what is causation and correlation, but we certainly know the trends that run together and, and at the beginning, you know, comparing 2019 to the 2020 rates of overdose, we saw a 60% increase and that was consistent across Ontario. The reasons for that are complicated again. Um, there's a lot of despair. There's a lot of people trying to cope. So therefore there's more drug use. There's higher volumes of drug use that can lead to more drug poisonings. But then if we think again about the services that folks need are safe consumption facilities because of, you know, very important distancing rules could see less people. So you might've had a safer consumption site that had five booths for people to use in that could have five patients at the same time now because they have to use six feet apart. They have three. So no longer can, as many people be moved through that service to safely consume their drugs. Also with the advice of self isolation, right? You have a lot of hidden homeless folks who were maybe crashing on somebody's couch, right. And that's called couch surfing. People didn't want to do that anymore. Right. They, they wanted to self isolate if they had a home. And so, so a lot of these folks who were couch surfing were now out on the street and, you know, had their, their use and, and their potential overdose rate impacted by that. And then there was also something that emerged at a COVID, um, in that most, um, many cities across Ontario, at least, um, instituted policies, um, called COVID. And so because shelter space was rationed and socially distance. The federal government did provide money to, to put folks who are living with homelessness in hotel rooms for the purpose of self escalation. And that's wonderful. Say a roof over their head and it's complicated and that's probably a whole nother podcast. Um, but also you take people who were using drugs. In groups and communities in order to stay safe, um, in order to, you know, intervene if their friend has an overdose and now you you're getting city policies that say one person per room and no guests. And so people who would usually use collectively and, and receive Naloxone from their peers are now using in isolation by themselves, in a hotel room with nobody to respond to them if they go down. And certainly I know of many folks like that who had, you know, more or less safely used substances and either a shelter or street street-level capacity who were put singularly into a room and overdose very shortly thereafter and died.

Sully: 27:57

You've just heard part one of Gordon and Ben's conversation with Dr. Andrea Serita about the Genesis of the drug poisoning crisis, its similarity to the alcohol prohibition period. Some reasons people use opioids and other substances and COVID-19 impact on harm reduction services. Join us in the next episode as Dr. Serita shares her experience as the lead physician practicing street outreach medicine for the London, inter community health center, safe opioid supply program, which is currently the longest training of its kind in Canada. Thank you for listening to the public health and say podcast, you would go to space for informative conversations, inspiring community action. If you enjoy our content, I would like to stay up to date, follow us on Instagram, Facebook, Twitter, and LinkedIn, to learn more about our community initiatives and how you can support us. Visit our website@thepublicofinsight.com joined the Phi community and let's make public.