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Interview with Hakique Virani

If you've managed to get your hands on our latest edition, the Fall/Winter 2016, you've seen our excellent interview with Dr Hakique Virani about the fentanyl epidemic battering western Canada at the moment. Well, we actually spoke to Dr Virani for much longer than we were able to cram into 1,500 words so we've included the full script of our interview below. Dr Virani is a wealth of information and the value of his years of experience cannot be underestimated.

Doctor Virani: I am a public health specialist physician and also an addiction medicine specialist working here in Edmonton. Much of what I've been seeing the last 3.5 to 4 years or so along with my colleagues at our clinic has been a dramatic increase in the number of people who are using fentanyl or fentanyl analogues, bootleg fentanyl analogues and this is something that we haven't seen ever before. Probably this is the scariest I've ever seen the illicit drug market in North America. Mostly as a result of fentanyl and it's analogues being trafficked in the illicit opioid trade.

Marie Engel: When did you first get involved in the drugs and addiction side of healthcare?

DV: Well, in my public health career the population I was most working with early on was First Nations living on reserves and it doesn't take long working with First Nations to develop an affection for those communities and to recognize how much of a role trauma, mental health concerns and addiction plays in their overall health and quality of life. So I felt that I couldn't do a good job as a public health doctor if I didn't learn much more about addiction medicine. So as I retrained in addiction medicine I started to gain an appreciation for the migration of First Nations people who are living on reserves into the inner city of places like Edmonton who became effected by injection drug use and marginalization inside our cities as well and so with my colleagues we opened a clinic in downtown Edmonton to serve that population of people who are struggling with primarily opioid addiction. And more and more over the past several years we are seeing that demographics effected by opioid addiction have become far more broad. We are seeing people from every socio economic status, every geographic location, every age group, every walk of life. So this really is a condition that doesn't discriminate. What we're seeing more and more are young people who have presented having been exposed to fentanyl and fentanyl analogues in recreational use quickly becoming addicted and losing promising futures very quickly before getting treatment. And it's actually quite rewarding to see those of them who do access care and evidence based addiction treatment can find their way back onto a promising path. So that's nice to see.

ME: Was fentanyl on the scene at all when you were first starting out in addiction care?

DV: We would see it used as a prescription opioid in a whole number of conditions. When fentanyl was first starting to be used in the 60's it was almost exclusively used perioperatively for pain control by anesticists in invasive surgical procedures, and then we started to see fentanyl being used for chronic pain associated with terminal cancer. And then in the 90's and 2000's we were seeing fentanyl being used in all sorts of pain conditions. And so we would see early in my career that people would run into trouble with fentanyl that was delivered in patches, becoming addicted to those, using those in ways that they weren't perscribed, or even becoming addicted to them in ways that they were perscribed. But what we're seeing now is illicitly prepared fentanyl, or bootleg fentanyl, and its analogues. Some of it's analogues you might have heard, like threementhylfentanyl, like carfentanil, are particularly concerning because they're even more toxic than the fentanyl we were finding previously from illicit trade and from prescription.

ME: Who do you think were the first people affected by the rise of fentanyl?

That's tough to say. I would say that it's not uncommon who present in their early young adulthood, 18, 19, 20 having become addicted to fentanyl and other opioids but having never smoked marijuana or drank alcohol. So really there's a large focus and concern over young drug users and we started to see that in the rich suburbs of Edmonton and I think in many other cities we were seeing a similar phenomenon. But we also see fentanyl being traded in the inner cities as well among people who are struggling with injection drug use and those tragedies and those fatal overdoses are just as tragic as any other. So I think maybe the first were young people, but we're not sure and one of the reasons that we can't tell you is because the public health surveillance on drug toxicity deaths and drug overdoses that are non fatal is really, really poor. In order to answer some of these questions, which are important questions to answer from a public health point of view so you can direct your resources appropriately, we don't have those answers. Because we don't monitor this health problem the way we should. And the way that they do in the United States for example.

ME: Which group do you feel is the most at risk should the fentanyl emergency continue to go the way that it is right now?

DV: Well I would say that the overarching statement is that everyone who is exposed to opiates is at risk of opiate overdose or any adverse effects of opiates. There are some people who I think require particular attention and particular protection. Incarcertated individuals who were using opioids before being jailed and then are released and relapse to opiate use are at particular risk for fatal overdose. Because the tolerance to opiates while in jail diminishes rapidly and the street opioids that are available are extremely toxic so a relapse to even a small amount of opiates that they were previously experimenting with or using habitually could be fatal. Similarly people who are recently discharged from residential addiction treatment or medical detox are at very high risk of overdose because they too have a diminished tolerance after the intervention they've just received. And the relapse rates are extremely high, and anyone who has gone through an abstainance based treatment. So basically anyone practising recreational drugs or any kind of street drug is at risk of being exposed to fentanyl and we've heard of overdoses from people who thought that they were using cocaine or methamphetamine that were actually cut with opiates or fentanyl and some of it's even more toxic analogues. So really as I said, the street drug trade has never been more scary in North America.

ME: You hear a lot about that, and I also hear a lot of people saying that addiction and drug problems have gotten a lot worse since fentanyl arrived. Do you think that's accurate, or has fentanyl just made addiction harder to hide and ignore?

DV: Again, this is a question that better public health surveillance could help us to answer in terms of what is the overall morbidity and mortality birthed from opiate use or any drug use. But what the perception is, and my sense is, that we're certainly seeing more fatalities from illicit drugs. There's no question about that. And generally speaking the more toxic or poisonous the opioid is the more pronounced the withdrawal symptom is when somebody doesn't have that drug and therefore the more they feel compelled to use in order to function and so it stands to reason that people that have been using fentanyl maybe more likely to become addicted then if they were say recreationally using heroin or another perscription opioid. So I think there's some reasons why we might see that the burden of addictions on our population has increased since the arrival of fentanyl and its analogues.

ME: Do you think that the fentanyl emergency has changed average people's attitudes towards drugs and addicts?

DV: If you read the comments sections underneath news articles online or youtube videos online you might find yourself quite discouraged. There are some people who still feel like addiction is a moral failing or evidence of weakness in individuals who don't belong in society. I don't perscribe to that paradigm. And I think that increasingly Canadians reject that suggestion. The only good thing I can think that's come out of this crisis that we're in is that so many people know someone that has been effected by this emergency. Either as a casualty or as someone who is currently struggling with an addiction, and I think it helps people to recognize that this is just part of the human condition. Some people use substances, and people have used substances for milenia and they'll continue to. And people who run into trouble with substances they use are no less human. They've just run into trouble. And I think it's a particularly Canadian value to help somebody who has run into trouble. So you know it's been encouraging to see people who have not been engaged in this discussion before really jumping up and saying 'hey wait a minute, we can and have to do more to help folks who are struggling with addiction or other mental health conditions.' So that's been good, I've even seen in question periods in our legislature in conservative Alberta, generally conservative Alberta, our most conservative party demanding improvement in access to harm reduction services. So, you know, the typical idealogies that have separated people I think are being replaced by a common concern for folks who have run into trouble with substances.

ME: Speaking of actions being made by government to address this emergency, in Ontario I'm sure you know they just passed some legislation to basically remove high dose opioids from insurance in an effort to make doctors stop prescribing them. As a healthcare provider do you feel that that's going to address this emergency to help or hinder?

DV: Well, as an exclusive measure I don't think anybody that that intervention is going to solve our problem, and I know that several outspoken advocates of this intervention would also agree that in and of itself it can't be a solution to our problem. And most will agree that, if it is, the only thing it'll do is make things worse. Because if there aren't adequate supports for people who have run into addiction trouble from being perscribed opioids for long periods of time or people who have chronic pain that of course remains after they're tapered off of high doses of opioids, if those supports aren't available we may find ourselves seeing additional people resorting to street opioids which is even more concerning. BUT, with that said, there is no question in my mind that my profession has contributed to this opioid epidemic that we have and the demand for opioids that we have in North America. And there's no question in my mind that big pharmecutical companies have been complicit if not leading the charge towards increasing the opioid demand. And that has to be addressed. But it's critical that it's addressed alongside demand reduction and safety measures like naloxone kit distribution, like supervised injection or drug consumption services, like treatment for people who have run into trouble with opioid addiction. Those are all things that have to be a part of an overall, comprehensive solution and I would say are even more important than addressing perscription opioid demand.

ME: With that in mind do you think the BC government's plan, for example, to devote that 10 million dollars to things like increased training in naloxone use for police is a good move and a step in the right direction?

DV: I think so. It's one step in the correct direction from my perspective. Your chief medical officer of health in BC is a smart fellow. To declare a public health emergency in this situation I think was the right call. And for the government to devote significant resources to this problem is also a wise move in my mind. I think that things that must be included in a response though must be extremely rapid expansion in the availability of evidence based treatment for people struggling with addiction, I think that harm reduction services must be increasingly available, and that requires changes in legislation at a federal level to permit safe injection and safe drug consumption services for populations that require them. We have to integrate those services into the way that we deliver healthcare because it's a critical service that must be a part of any public healthcare system. And I think that solutions that we seek out must be informed by the experiences of people who are currently or who have experience using drugs and their families. That voice can't be lost in all of this. And I think that while we all hold ourselves out as experts there is some expertise that comes with lived experience that can't be neglected. And unfortunately as we sit around tables and contemplate what solutions we should entertain many of those solutions are on the tips of the tongues of people who are experiencing this problem first hand and their bereaved families when there have been casualties. So that's a point that I can't overstress, we have to include those people in a meaningful way.

ME: I come from Saskatchewan myself, so another very conservative province by and large, and a lot of the time when that topic of supervised injection sites and needle exchanges and those kinds of really progressive measures are discussed there's a sort of 'moral outrage' from very conservative people. What would you say as a health provider to try and change that narrative and convince them this is a step in the right direction?

DV: Well I was in Saskatchewan earlier this month and I gave an eight hour lecture about 100 physicians that were all interested in learning how they could play a role in addressing this problem for patients of theirs. And the level of interest and commitment I found heartwarming and surprising. For the very reasons that you mentioned, the prairie provinces tend to be quite conservative, in the way that we approach problems like these. But, you know, this is not just a epidemic of overdose death and non fatal overdose this is also an epidemic that will have co-morbid epidemics. HIV and Hepatitis C rates will increase and one of the problems that is right in the face of Saskatchewanites right now is the high level of Hepatitis C and HIV infection occurring in First Nations, and non First Nations, in that province. And it is impossible to transit HIV and Hepatitis C in a supervised injection site. It is also the experience of INSITE in Vancouver that no one has died from an overdose. When they use the services available to them at that supervised injection site. This is not a matter of what is right and wrong, and whether or not you'll go to hell or heaven. This is about saving costs for our healthcare system because the comorbidities associated with addiction are not cheap. And the emergency services required to treat an overdose are not cheap. This is also about saving potential years of life lost that are extremely productive times for Canadians. If you think of the people who have died in this opioid epidemic we're quite certain that the age demographic most effected has been the 20 to 34 year olds. And if you think of what happens between the ages of 20 and 34, this is when people get jobs, they have children, they pay taxes. And those are all things that whether you like someone who has an addiction or not, those are all things that we benefit from. When people take care of their kids, when people get jobs and when people pay taxes. So even those conservatives amongst us must see value in improving the overall health, quality of life and maintaining life expectancy in everyone of our friends and neighbours.

ME: In your opinion what's the best course of action for people who want to make a difference in their local communities in regards to this health emergency?

DV: I think the simple thing to say is, first of all, speak up. People who make decisions often don't know the level of support there is for these types of services that seem like they might get them into trouble politically. But like I said, more and more, the number of voices that are coming forward to demand better treatment for people suffering from addiction, and evidence based treatment for people who are suffering from addiction, are coming from places that one might not expect. From upper middle class families living in the suburbs, from media, and these are influential voices that I think our decision makers need to hear. Speaking up is something that I think is critically important. Next, I mean, everybody knows somebody who is struggling with an addiction I think. Whether you realize it or not, so looking for signs amongst your friend circle and family for people who are struggling. Whether or not you suspect there's addiction or some other mental health issue going on to be understanding and compassionate that sometimes people go through a rough time I think while it sounds cliche or fluffy, is really, really important. I mean, if nobody else thinks that your life is worth anything it's difficult for somebody to see themselves that their life is worth something or that there's any hope. And, it's not uncommon for me to see somebody presenting for treatment for the opioid addiction saying 'this is the first time I've felt any glimmer of hope whatsoever in the past several years' and I think that that really, while you might not be in a lifesaving profession, your interactions with people can be more lifesaving then you know. So to be concious of that is I think is critical for any regular person living in their community hoping to make a difference.

ME: As you said yourself, people have been using substances for millennia and even knowing the dangers lots of people are going to continue to use substances. So what do you think the best advice is for young people to protect themselves from this illicit fentanyl.

DV: To the extent that people can know what they're using is very important. I think more and more we'll start to see, or I'm hoping anyway, that one of the harm reduction services that's offered, is drug testing for people who are recreationally using drugs so that they can have an idea for what the risks are of the things that they're using. I think that the other kind of critical measure the people should take is, don't mix drugs. Particularly if you're using something that you think is heroin or fentanyl, do not be drinking alcohol or using other prescription medications like sedatives or sleeping medications along with them, that increases the risks. Never use alone. Carry a naloxone kit. Make sure that if you happen across someone you think has overdosed on drugs to call 911. I think that increasingly that the threat of police action is a barrier to people calling for help when there's an overdose. I hope that's changing. You see that to the extent possible fire and EMS will respond to overdose calls and police aren't necessary. It's such a great thing to see that folks can be less afraid of repercussion when they call for help and rather feel like it's the normal thing to do. That would go a long way. I think that those are the things. The other thing that's becoming more critical is for people who are using drugs to do a test first, in a very, very small quantity. Particularly recognizing that the opioids on the street now are extremely and wildly unpredictable.

ME: Is there any aid group that you feel is particularly valuable that you'd like people to know about?

DV: While more and more people are becoming involved in the response to this public health crisis it's easy to forget the people who have been doing it for decades. Our inner city organizations that support for injection drug users or for people using substances and become pregnant or even outreach services for community housing in the marginalized population including First Nations and inner city aboriginal folks, we can't forget how strong of a past they've made for us already. They've created an infrastructure that we can leverage in this public health program. So hats off to the INSITE and in Alberta the Street Work and Safe Work and all of these organizations that really have taught us about compassion and using evidence as opposed to using opinion and judgement in providing service for people struggling with substance abuse and addiction.

One of the overarching that has to be made to address this and other problems like this in the future is much stronger drug policy. Nobody who knows anything will try and tell you that the war on drugs has been a success. And you won't even find police officers who say they can arrest and jail their way out of this problem. So smarter drug policy is critical. Decriminalization of drugs for personal use has achieved remarkable things in a country like Portugal, where the fatal overdose rate is an order of magnitude or two lower than what we have here in Canada. And where the approach to substances is not to punish people for using them, but to mitigate the risk of substance for people who use them and to provide compassionate care for people who have run into trouble with them. That sounds to me like much more of a Canadian approach to this then to try and incarcerate your way out of a public health emergency. Not to mention that there's good evidence that shows that the Portugal approach would be much more effective.

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