Last year, I was invited to speak at the Catholic Health Association of BC annual conference about a novel and, for some, controversial pilot project we’re undertaking at our long term care facility in Vancouver.
We’ve invited patients taking methadone and other opioid treatments to come live with us because of convergence of factors we noticed:
- increased rates of addiction in the aging Baby Boomer population
- the current and ongoing opioid crisis and tainted street opioid supply
- new, effective treatments for opioid use disorder
a provincial policy concerning placement in long term care that used to be called the “First Available Bed” renamed as “Interim Bed”
Our team saw this confluence of issues and recognized it was a matter of when and not if patients on methadone would eventually come to live at our facility and we wanted to be ready to provide the same exceptional care we give all of the patients who live at our facility.
Watch the re-recording and/or read the transcript from my presentation to this inspiring group of faith-based health leaders.
My name is Marcus Greatheart, and I use he/him pronouns.
Thank you for welcoming me. This is my first time at the CHABC conference, and I’ll admit I was a little nervous and barely touched my lunch. But someone left a bottle of wine and some bread in the greenroom so I’m good to go.
I want to acknowledge that this event takes place on the traditional, ancestral, unceded, and occupied territory of the Musqueam, Squamish, and Tsleil-Waututh nations.
I’m here today to speak with you about opioid addiction among elders and a pilot project we started at St. Vincent’s Langara (pictured here) our long-term care facility, to invite patients taking methadone and other opioid treatments to come live with us. The reason we’re doing this is the result of the convergence of factors: the aging Baby Boomer population, the current, ongoing opioid crisis and the effective treatments for opioid use disorder, and a policy that used to be called the first available bed. Our team at St. Vincent’s Langara saw this confluence of issues and realized it was a matter of when and not if patients on methadone would eventually come to live at our facility and we wanted to be prepared to provide the same excellent care we give all of the patients who live at our facility.
I have no financial disclosures.
Before we do that let me tell you a bit about me. I’m a family doctor and a social worker. three days a week I work at Three Bridges Community Health Center providing primary care, addictions and mental health care as well as transgender health to the 5% most complex patients in the city of Vancouver. One day a week I work at St Vincent’s Langara a long-term care facility affiliated with Providence Health Care. There I have a panel of about 35 residents and I’m also the medical coordinator.
I love working within a Catholic organization. After completing my Master of Social Work degree in 2010, I took my first job as a social worker at Mount St. Joseph Hospital. I worried that my own non-Catholic spirituality and those of the organization might clash. Until I met the wife of a patient who was dying on our ward. At the end of a busy day, we found a quiet place to sit down and I counselled her. She spoke with such clarity about how the love of Christ gave her solace that I was deeply moved, and her beliefs resonated deeply with my own understanding of God. From that perspective, I found it easier to counsel her when I realized the names did not really matter. In that moment Christ, Creator and the Divine were all the same, and I found myself supporting her in ways I never thought I could. The freedom to talk openly about God is unique to a religious organization, and I realize it’s in the secular realm where I feel more inhibited.
I worked with a wonderful team at Mount St. Joseph, including a Geriatrician named Joy Liao whom some of you may know. She told me that after training to be a physiotherapist, she attended medical school at McMaster University because they looked for the kinds of people who make good doctors, not just people with good grades in science, and she encouraged me to consider it. I applied on a whim to one medical school, one time, at the age of 40, with an Art History degree and a Masters in Social Work, and I got in.
I believe that God illuminated a path for me, one that went deeper and could have a deeper impact on me and the patients I work with. Nervous and excited and not really knowing what I was getting myself into, I packed up my life in Vancouver and moved to St. Catharines, ON, to start medical school.
While I was there, I met this guy, my husband Bradford, a beekeeper from Portland, OR. And that’s our rescue dog, Vince.
I want to acknowledge the privilege with which I move through the world as an older White male physician. As a queer person I have a touchstone to oppression and marginalization. And I appreciate that this experience does not offset or diminish the significant privilege I experience in other realms. From an intersectional perspective the scale is pretty heavily weighted toward privilege. As a white man who practices anti-racist practice it’s important for me to amplify the voices of women and people of colour, particularly as they inform the work that I do.
So let me honour three women who have particularly Informed this work I’m sharing with you today.
Dr. Amanda Bell is associate dean of the Niagara Regional Campus of McMaster University undergraduate medical program. She is a mentor and friend, and I would not have survived medical school without her encouragement and support and clarity in terms of the role of family physician. On Monday she defended her Masters thesis which explored the effects of harassment on medical students.
Dr. Rita McCracken trained me in the care of the elderly as a faculty member St Paul’s Hospital Family Medicine site. She is a medical doctor and recently completed her PhD in evidence-based medicine focussed particularly on treating chronic illness like high blood pressure in frail elders .
Lastly my understanding of addiction and its treatment is significantly informed by the work of Dr. Rupi Brar, member of the St. Paul’s Hospital Addictions Consult team and staff at the Portland Hotel Society Medical Clinic. She was one of a number of physicians who encouraged me to start this pilot project. She would be here if she weren’t at home with her 2 week old baby girl Kaavya.
So now that we have all those preliminaries out of the way, let’s talk.
According to the Government of Canada’s Action for Seniors report, seniors are one of the most rapidly growing segments of the Canadian population. It is estimated that by the year 2030, people aged 65 years and older will constitute up to 23% of the Canadian population, that’s over 9.5 million people. Back in 2014, just 5 years ago, seniors were only 6 million and 15.6% of the population.
Life expectancy of Canadians is also expected to increase in the coming years according to the same report. This is due in part to advances in medical management and the reduction of disease. But this also means that we are seeing greater levels of Frailty in our aging population and greater demand for long-term care facilities.
We also have to recognize that this growing population, the Baby Boomer generation, the folks born between 1946 as World War 2 was ending, and 1964 the year Dr. Martin Luther King, Jr received the Nobel Peace Prize.
The Baby Boomers came of age at a very unique period in time. the late 1960s and early 1970s side University campus riots and Woodstock concert when conservative values were relaxing and more permissive of sexuality and recreational drug use. These relaxed values are among the many factors that help us understand substance use disorders among older adults.
Such changes in culture resulted in increased prevalence of substance use disorders (SUDs) among older adults (La Roux 2016). There are several factors that further contribute to substance use in older adults, including history acute or chronic pain, experiencing complex trauma, depression and anxiety, and psycho-social factors such as isolation, being home-bound, or institutionalized. Due to the physiology of aging and decreased physical reserves, older adults are more vulnerable to the effects of opioids, alcohol, and sedatives.
I would like us to consider that there are a number of Pathways which lead an individual to develop an opioid use disorder.
Our understanding about how opioids work as medications to treat pain has changed over time. As physicians we have reflected on older guidelines and recognized that at times we may have over-treated individuals. The research was limited and often influenced by Pharmaceutical companies.
We may recall hearing about the recent court case against one such company that required a payout in the hundreds of millions of dollars for predatory marketing to influence Physicians who we’re doing the best they could to provide care for their patients. so for some patients we may have over-prescribed and it may have been care providers who set some patients up 4 dependence. Other patients may have been predisposed for an opioid use disorder and it was merely the exposure that brought them down a difficult path. Remember that opioids are a good medication used appropriately particularly in the treatment of cancer pain and acute pain after injury or surgery. It is with chronic use where the evidence gets really murky.
Then there’s another pathway to opioid use disorder.
Use of illicit opioids outside of the Healthcare System is an old issue. People have been using opium for centuries for pain and pleasure. It is when their use becomes problematic impacting the life of the individual that they often connect with the healthcare system.
There are a few basic concepts about how the brain and opioids interact that are important for us to understand.
Opioids act on pain receptors in the brain. This is why they are good at managing acute pain, like when you have an injury or have surgery. They dull the experience of pain in the brain. Choosing the right dose is a skill, and sometimes we don’t get it right. Take too little and you still feel pain. Take a little too much and you feel stoned. They are most effective used for short period of time.
Opioids used chronically can hijack the reward centre of the brain so that the everyday highs and lows of life, the successes and experiences no longer meet the threshold that make life tolerable and so the substance becomes a substitute for joy and happiness. People end up needing more and more to feel that joy, and at some point they use opioids just to feel normal.
Opioids also act on the breathing centre in the brain. They relax it. This is very usefulin palliative care, for example, because when people are dying, it’s common for them to experience laboured breathing. So we use small amount of opioid in a controlled setting to relax their breathing in their final hours so they can have a comfortable natural death.
However, take too high a dose all at once, and the breathing centre can stop completely. So when we talk about opioid deaths, we’re talking about people who take enough opioid to stop their breathing. Without oxygen, organs like the heart and brain are damaged, often irreparably. Which is why we need to help people who overdose by giving CPR and naloxone, a medication that counters the effects of opioids.
So how do we know when someone’s opioid use is problematic?
The Diagnostic Statistics Manual is a Resource used by Psychiatry to describe and diagnose mental illness. It has evolved over many decades, been revised multiple times, and remains a source of disagreement and non-consensus. At the same time it is the common vocabulary used across Psychiatry and Medicine to share our understanding of patients’ Mental Health and illness. Included in the DSM-5 are diagnostic criteria for substance use disorders, which include opioid use disorder.
I think it is useful to look at these criteria together so that we can have a shared understanding. Before we do that I’d like you to think about someone you know with an opioid or other substance use disorder. They may be a patient or client, family member or friend. Please take a moment to consider the context of their problematic substance use, your encounters with that person and how their substance use had an impact on their life.
Now I don’t want to open up a can of worms and if this exercise hits a nerve that you might find difficult, I invite you to think about someone else or just listen along. My goal is not to trigger anyone with this exercise.
These are the criteria for substance opioid use disorder. As part of this exercise invite you to keep track with hash marks on a piece of paper or count on your fingers how many of these criteria are met by the person you’re thinking about.
- Opioids are taken and larger amounts are over a longer of time than was intended
- There is a persistent desire or unsuccessful efforts to cut down or control opioid use
- A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects
- Craving or a strong desire to use opioids
- Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school or home
- Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids
- Important social, occupational, or recreational activities are given up or reduced because of opioid use
- Recurrent opioid use in situations in which it is physically hazardous
- Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have being caused or exacerbated by opioids
- Tolerance as defined by either of the following need for markedly increased amount of opioids to achieve intoxication or desired effect markedly diminished effect with continued use of the same amount of opioid
- Withdrawal as manifested by either of the following
- Characteristic opioid withdrawal syndrome
- Same or closely related substance is taken to relieve or avoid withdrawal symptoms
To clarify, with regard to tolerance and withdrawal, patients who are prescribed opioid medications for pain relief may exhibit withdrawal and tolerance but would not necessarily be considered to have a substance use disorder.
The presence of at least two of these symptoms indicate an opioid use disorder.
Two or three symptoms are considered mild. 4-5 symptoms are moderate. And six or more symptoms are severe.
For those of you who were keeping track, how did that exercise go for you.? You may have found some of those categories difficult because of their subjectivity. I like to remember that we use these criteria to help patients who are presenting with a problem. This process can be relatively straightforward when it helps us recognize who clearly does or does not meet these criteria. On some occasions we see that these criteria are met for patients who are reluctant or in denial. As we discussed before, there are many pathways to opioid use disorder. For patients who experience a lot of privilege, who have greater and easier access to healthcare, those who have been prescribed opioids by healthcare providers, it may be difficult for these folks to recognize they have a problem. Further their acceptance may be hindered by anger and blame toward health providers who’s prescribing practices, based on the best available evidence at the time, may have contributed.
Many people have a conception of opiate use disorder as the heroin addict they’ve seen on television or in the movies. Maybe you remember the movie Trainspotting and the characters desperate search for substances as well as the scene where the fellow locks himself into his room to forcibly withdraw.
I think the movie accurately depicts how horrible the withdrawal process is but it also sets people up for being good enough or strong enough to withdraw alone and that’s really problematic. Because we know that people use substances to cover physical pain as well as emotional pain, expecting them to suddenly be able to tolerate not only the withdrawal but a re-presentation of all of their deepest trauma just doesn’t make sense.
In fact we know from research that people who quickly withdraw off of opioids fare much worse.
Withdrawal management alone is not an effective treatment for opioid use disorder, and offering this as a standalone option to patients is neither sufficient nor appropriate. Rates of dropout and relapse to opioid use are high, regardless of treatment used. Furthermore, the risks of serious harms, including fatal and non-fatal overdose and HIV and hepatitis C transmission, are higher for individuals who have recently completed withdrawal management compared to individuals who receive no treatment
We also know that people who are incarcerated and have no access to opioids have some of the highest risk of death after they are released. Their body is less dependent but their pain and trauma is the same, if not worse, than it was before they were incarcerated. So they take amounts of opioids that they think they can handle but their tolerance is lower so they stop breathing.
In 2015 we saw an increase in the number of deaths related to opioid use, and we are now in a public state of emergency. These results from British Columbia are now trending across the country.
The reason is that the street supply of opioids is now contaminated with fentanyl and other synthetic opioids which was found in over 80% of drug-related deaths last year.
Because it’s cheaper to produce and easier to import into Canada. Heroin is grown in fields at significant cost, then in large volumes transported to Canada at risk of seizure. Fentanyl is produced in labs, is 10 x stronger and can be shipped in through the postal service in packages like inkjet cartridges that often don’t attract scrutiny from customs officials.
So when we say that our current supply of illicit opioids is poisoned with fentanyl and other agents, we mean that people think they are buying heroin, but really they are getting fentanyl mixed with other drugs and substances which makes it really hard to gauge from use to use how much you are taking. So people overdose, some of my patients overdose many times and survive. And many are dying. And those who are dying are leaving behind friends and family.
I’m not being dramatic. This is the lived experience of many of my patients. Perhaps even patients you’ve cared for or members of your family or your congregation.
This quote from the African-American author Ta-Nehisi Coates is about the deaths of Black men related to police and gang violence, but it resonates with the devastating losses in the opioid crisis as well.
“Think of all the love poured into him…Think of the surprise birthday parties, the daycare, the reference checks on babysitters…Think of family photos. Think of credit cards charged for vacations. Think of soccer balls, science kits, chemistry sets, racetracks and model trains. Think of all the embraces, all the private jokes, customs, greetings, names, dreams, all the shared knowledge and capacity of a black family injected into that vessel of flesh and bone. And think how that vessel was taken, shattered on the concrete, and all its holy contents, all that had gone into him, sent flowing back to the earth.” -Ta-Nehisi Coates, Between the World and Me
Opioid agonist therapy (OAT) is an effective treatment for addiction to opioid drugs such as heroin, oxycodone, hydromorphone (Dilaudid), fentanyl and Percocet. The therapy involves taking the opioid agonists methadone (Methadose) or buprenorphine-naloxone (Suboxone) to prevent withdrawal and reduce cravings for opioid drugs in the context of a safe, non-adulterated supply. People with OUD can take OAT to help stabilize their lives and to reduce the harms related to their drug use (Centre for Addiction and Mental Health, 2016).
Here in British Columbia, Canada, our provincial government regulates and organizes placements in long term care facilities. Elders who are deemed appropriate for placement, whether from home or hospital, can choose three facilities where they’d like to live. Family members can help in those choiced. If there is no bed available at the time of transfer, a patient may be placed in an Interim Bed at any available facility until such time as a bed at one of their preferred facilities is available.
Which brings us to the rationale equation for our pilot Quality Improvement project:
Aging population +
Ongoing opioid crisis +
Effective treatment w/ opioid agonist therapy (OAT) +
Interim Bed Policy (formerly First Available Bed)
Only a matter of time before people on opioid replacement therapies will arrive at long term care
It was important for us to be in alignment with the mission, vision, and values of PHC.
Providence Health Care lists six populations of emphasis, who are the most vulnerable populations of our society, on whom it focuses its care, research, and teaching. Older British Columbians, and people with urban health issues (including substance use) are two of those six populations. The target population of this proposed project, older adults with substance use disorder is where these two populations of emphasis overlap. This further underscores their vulnerability, highlights that caring for them fits well within the vision of Providence Health Care.
We aim to admit older adults who are on OAT at St. Vincent’s: Langara and monitor their stay in order to build capacity at our facility and share our lessons learned with other long term care facilities at Providence Health Care and beyond.
We started this project with the leadership team at Saint Vincent’s Langara just over a year ago. We collaborated with Addictions and Eldercare specialists within Providence and Vancouver Coastal Health. We learned that the baseline level of knowledge around addictions varied greatly across the team. And I expect even in this room.
Raise your hand if…
- Your primary training or education was prior to 2010, before Y2K, before the internet
- Your primary training was outside Vancouver, BC, Canada, North America
- Raise your hand if you received no formal addictions training
We also learned that among the positions as well as among the staff there was a lot of variation in how much and what people had learned about addictions. That our team had been trained received their primary training and healthcare domains in different decades in different places in the world.
Some received absolutely no training in addictions and it had only experiential knowledge that they’ve gathered along the way. Which meant that for some there were old understandings of addiction as personal failure and a lot of stigma.
But we were also pleasantly surprised at the great questions we heard. They wanted to know about basics like where to find the lNarcan on the ward and how to give it. And how to tell the difference between opioid overdose and the underdosed patient.
We heard stories from team members who had worked with patients with addictions in the past that had gone very badly and where they had received very limited support. These team members were understandably wary and asked lots of great questions about where the support would come from this time around.
And in terms of stigma the image most commonly conveyed was around a worry that someone would be actively self injecting themselves with heroin in the bed next to someone’s 90-year-old grandmother.
- “Admitting such patients will fundamentally change long term care”
- “We will lose the purity of long term care”
- “Once we open the door, there’s gonna be an avalanche of people.”
I get it. On the news all we see are pictures of people injecting drugs in alleyways, images that make it very hard to muster compassion. Even this picture conjures up thoughts about substance use and poverty. Would it surprise you to know it’s called Man in Front of Bed Praying.
When I spoke with the physician group became clear but for the most part the kinds of physicians who work in long-term care tended to be a bit older and also generalists, meaning they are providing full spectrum care. And historically addictions has been a specialist role and it hasn’t been until the last few years that by necessity more family doctors were managing and treating addictions out of their clinics. In Vancouver in particular Family doctors carry a good portion of the addictions burden.
Prior to formally admitting any patients, we provided training to our staff. We did two education sessions on substance use, including case discussions on stigma and vulnerable populations. Majority of regular staff members attended the education sessions.We did Naloxone training.
My colleague Rupi Brar provided an in-service on substance use disorder and treatment in older adults for the physician group. And we created a resource website that contains the slides from Rupi’s presentation and other materials such as BC Centre for Substance Use’s opioid treatment guidelines.
The first patient we admitted on OAT to Langara actually came three years ago. A younger person in their 40s who had a history of a few decades of opioid use disorder and street entrenchment. After an opioid overdose they were left without oxygen for enough time as it takes to deprive the brain and cause brain damage, but not enough to die. So now the patient requires full care. They can’t communicate with words. We do our best to interpret their needs. The medical team who first cared for this patient after the brain injury recognized a baseline level of agitation which they postulated was related to her chronic opioid use. They wisely did a trial of a Buprenorphine Butrans patch and the patient settled right down. They recognized that the opiate receptors in the brain had been so conditioned that the irritability was a demonstration of withdrawal or craving.
Our first official patient was in their 80s and had a 6 decade history of opioid use. They told me at the time that about 10 years prior they got sick and tired of being sick and tired and were done dealing with all of the sketchy people and drug dealers and had been robbed twice. And perhaps because of wisdom comes with age decided to stop. The family doctor offered methadone which the patient took at a stable dose for almost 10 years. Then in the spring they developed an acute illness and were hospitalized for a month. They became deconditioned and an overlying dementia made participating in physiotherapy difficult. And so they sat in the hospital, a patient on methadone until we announced our pilot project.
For the next few years we’ll be observing and learning about new issues, behaviours related to Opioid use disorder.
We want to learn from our care plans and share what we’ve learned.
We plan to expanding to other wards and facilities when the time is right.
And we will continue with our QI project.
So these are our take home messages:
- Canadians are aging and the prevalence of SUD among elders is on the rise
- Stigma is the primary barrier for elders on OAT needing LTC placement
- We hope this pilot brings new knowledge that reduces stigma and increases access for elders with OUD
Thank you for your attention.