Those of us in the health care profession are collectively following the news on the latest SARS-CoV-2 updates, bracing for the potential wave of infections that may fill our hospitals and clinics. We’ve seen personally or heard anecdotally the terrifying impact this virus has on people. For many of us, our professional roles in the pandemic response have been to treat those individuals exhibiting or suffering from symptoms of this novel virus. This can be a helpless feeling, to be so response-oriented considering the ongoing uncertainty about the trajectory and overall impact on our communities.
Many people with untreated or undertreated substance use disorder are currently facing dual public health emergencies [2]—the SARS-CoV-2 pandemic and the overdose crisis. They are among the most vulnerable in our communities because of medical comorbidities putting them at higher risk of complications from this virus and potential overdose death from a contaminated street drug supply [3]. Additionally, many face social and structural challenges like precarious housing, homelessness, and food insecurity that compound these vulnerabilities.
Those same factors additionally make it more challenging for many to follow the advice to prevent the spread of infection of SARS-CoV-2. For instance, trying to access substances, often from the street drug supply, means being out sometimes multiple times a day. As prescribers, we now have clinical guidance [4] that gives us the tools to potentially decrease or stop street substance use or at the very least reduce harms associated with drug use and help people self-isolate during this pandemic.
Recent Health Canada exemptions [5] enacted in order to save lives and prevent the spread of infection have led to new clinical guidance, “Risk Mitigation in the Context of Dual Public Health Emergencies [6],” recently developed for prescribers in British Columbia by a provincial writing committee led by the BC Centre on Substance Use. This new guidance was developed specifically to address the compounded risks [7] created by the two provincial health emergencies.
Further compounding these risks is that the drug supply is becoming more unpredictable and contaminated [8] by the day, as the global supply chains are disrupted by the international response to SARS-CoV-2. That means risk of overdose and death is perhaps greater than ever. People who use drugs will have to access this supply to alleviate terrible and potentially fatal withdrawal. We, as prescribers, have a role to play to mitigate and alleviate these risks.
It’s important to note that the prescribed medications listed in these guidelines may not be suitable for everyone who uses substances. There may be contraindications or drug-drug interactions. However, for those with active substance use disorders, who are at risk of withdrawal, overdose, cravings, or other harms related to drug or alcohol use, receiving prescribed medications may help to minimize the harms they experience. Screening and diagnosis is required, including questions about current and past substance use, previous treatments, current harms of drug use, and individual goals. As with any medical decision, a plan should be made in collaboration with the patient and it should take into consideration the individual’s goals, health status, risks, and benefits.
Many of these individuals have a well-earned distrust of the health care system, having faced stigma and discrimination for their substance use. Now is the time we must work to ensure the health and safety of people who use substances and ultimately our communities at large. For those of us who have not treated substance use disorders in our practices, reaching out to addiction medicine colleagues or the RACE line [9] for advice might be helpful. The time to advocate for this population is now.
This guidance is part of an emergency response and, for a patient, it could represent a lifeline.
—Rupinder Brar, MD
—Guy Felicella
Further information
Watch Guy Felicella’s TEDxBearCreek talk, “Is Safe Supply a Viable Option to the Overdose Crisis? [10]”
Dr Rupinder Brar is a clinical assistant professor in the faculty of medicine at the University of BC and a family physician in Vancouver. Mr Guy Felicella is the peer clinical advisor with the BC Overdose Emergency Response Centre. Both were members of the new interim clinical guidance writing committee.
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