For the past five years, Yellowknife family practitioner Dr. Jennifer Harris has been one of a handful of doctors providing addictions medicine management services including the prescription of methadone or suboxone for people struggling with an addiction to an opioid like heroin or oxycodone.
The new kid on the block is so powerful, however, it has prompted Harris and her colleagues to alter their approach.
Synthetic opioid painkiller fentanyl, which is about 100 times as strong and therefore more toxic than its naturally occurring cousin morphine, has altered the way she and other Yellowknife doctors approach treatment.
“The influx of fentanyl sort of changed the nature of opioid addiction in Yellowknife,” she told the Journal. “Prior to that, it was more of a prescription-based type of addiction, and we weren’t treating too many people. I would say a year or two ago with that influx, we also saw an increase in requests to see physicians to provide opioid maintenance therapy.”
Initially, it looked to Harris like those getting hooked on fentanyl were mostly from the 20-something crowd, but use has spread to all age groups.
“Now I would say it’s kind of infiltrated all of the people who are struggling with addictions,” she said. “Most people who are struggling will end up trying lots of different things as they try to manage their demons. I have patients who used to have alcohol as their primary issue, but with the influx of fentanyl that turned into an opioid addiction. I would say people who have longstanding alcoholism end up using lots of substances in their episodes of intoxication, so they end up trying everything.”
Clinically, fentanyl is available as a skin patch, lozenge, pills, shots, a film that dissolves in your mouth, nasal spray, or by IV (intravenous) and is intended for severe pain management, for example for people suffering from chronic pain or undergoing cancer treatment. On the street in Yellowknife it is sold primarily as pills referred to as “greenies” or “fake Oxys.”
“People who are struggling with cocaine addiction would use them as a downer,” Harris explained. “Generally, most people have their drug of choice, but I’ve found with the fentanyl it has created more opioid-specific addiction versus trying it once or twice because of the nature of what it is. It has this fast onset and a short duration, so it’s like the difference between cocaine and (the more addictive) crack. It tends to push people more into the behavioural aspects of addiction, because they’re chasing their next high and going into withdrawal more severely because fentanyl is so strong.”
For the same reason the drug is “incredibly dangerous” to use. Overdoses can occur when just a few grains of fentanyl are contained in a pill.
“There is a variety of different ones on the street depending on the batches that come through,” Harris said. “There is heroin in them, hydromorphone, a variety of opioid and non-opioid substances in them. I think at times, there might be cocaine in them. Certainly for somebody who thinks they are getting an oxycodone, fentanyl is much, much stronger so if their body has no tolerance to that level it’s very dangerous for them to take it.”
For the same reason it is harder to treat with opioid addiction therapies.
“What you’re doing is replacing the opioid but when your tolerance is driven up that much, it’s hard to help people settle out on doses of methadone and suboxone,” she said. “So I’m finding it more difficult to treat people with a fentanyl addiction, but it’s not impossible. We do get new requests for (treatment) regularly, so it has been well-received.”
“What I was able to do before just as part of my practice I found (became) harder in terms of numbers and stabilization,” Harris said. “Certainly, that kind of correlated to fentanyl (arriving in the city), which I think was one of the primary reasons we got this program up and running. In the last two years, most people (say) their primary issue is the street fentanyl.”
Now about two months old, the official opioid maintenance therapy program run through Yellowknife Health and Social Services offers other facets of treatment including counselling and crisis management.
“It’s a more standardized approach that hopefully is more accessible.”