Ricky Bélanger, originally from Gatineau, Quebec, spent ten years living on Ottawa’s streets, through the brutal winters and broiling summers. She has been using heroin and morphine for more than fifteen years. Like many other people who struggle with opioid addiction, she has tried treatment after treatment, without lasting results. For people with severe opioid-use disorder, relapse is common. In fact, detox programs and abstinence can make relapse more dangerous for people like her. Bélanger has overdosed on multiple occasions. Sometimes, she was revived by doctors; other times, her life was saved by other drug users armed with naloxone, which occupies the brain’s opioid receptors, making them temporarily unavailable.
But Bélanger may have finally found an addiction treatment that works—at Ottawa Inner City Health’s managed opioid program (MOP), which has been working to make a dent in the opioid-overdose crisis with a highly individualized, flexible approach. It is a surprisingly rare strategy of meeting clients’ needs—including the need for a safe, steady source of opioids. Relationships, not doses, define this program. “It’s changed my life,” Bélanger says. “I don’t buy from the street now.”
The twenty-one current clients of Inner City’s MOP have all been dependent on opioids for years: heroin or, more recently, synthetic opioids. Less than a year ago, many were chronically homeless, with some staying at one of the Shepherds of Good Hope shelters in downtown Ottawa, an Inner City partner where two MOP participants currently live. They’ve all been using opioids for more than two years. And they have all not yet found treatment that worked. Every one of them has tried either methadone or Suboxone, opioid-replacement medications with lower abuse potential that are administered to manage withdrawal symptoms in those with opioid dependence. Some have been through abstinence-based treatment. Many of the participants at the MOP have Hepatitis C, a virus that can lead to chronic infection and which can be acquired through injecting drugs, and a few are HIV positive.
Before joining this program, many participants were already clients of Inner City, which plants health care services in the facilities of partner organizations that provide services for the homeless in Ottawa. While many other programs across the country seem focused on addressing the immediacy of the opioid crisis, the MOP is steady and slow. In fact, set beside a detox program or a dose of naloxone, it’s practically artisanal: considered, expensive, and painstakingly focused on responding to each individual’s ever-changing needs. That’s a kind of care the participants in this program have rarely, or never, seen.
Ottawa is not the epicentre of Canada’s opioid crisis. Vancouver is—especially its Downtown Eastside, where heroin and, later, crack cocaine contributed to a crisis that has recently been made worse by the increased presence of illicit fentanyl in the drug supply The city has also been home to pioneering efforts to address addiction and contain overdoses. Still, the number of overdoses in Ottawa is frightening: they’re happening daily. Between January and July 2018 alone, Ottawa saw 182 cases of suspected opioid-related overdoses in its emergency rooms.
The constant stress of life on the street, in addition to withdrawal symptoms, can amplify the revolving-door nature of classic treatment options. The MOP, first and foremost, is about stabilizing lives that have rarely been stable.
The building where Inner City MOP operates sits on a quiet Ottawa street. It houses a common area for residents, a dining room, and bachelor apartments upstairs that clients rent. They drift down at different times, according to their individual schedules, and consume their controlled-release hydromorphone (Dilaudid) a strong opioid painkiller, or in some cases, Kadian, an extended-release morphine, under a nurse’s supervision.
The nurses at the MOP also dispense short-acting hydromorphone for some clients to inject. Up to seven times a day, depending on the participant, a nurse will watch carefully as the client injects their measured dose. A heroin user doesn’t usually inject this frequently, but MOP staff are trying to approximate heroin’s effects with the injectable hydromorphone. They need to do so well enough that these users will be able to mostly stay off street drugs, which can’t be safely dosed and can’t be verified as the drug the user thinks they are.
Dosing occurs day and night. “The idea is not to prevent them getting high,” says Stephanie Muron, nurse coordinator for the MOP. “We want them to feel a rush of some sort.” But they don’t want clients to “nod out”—to drift into unconsciousness—or to overdose and stop breathing. The MOP is focused on health rather than abstinence: it’s not concerned with “getting clean” or even about replacing street opioids with opioid agonists or partial agonists (drugs including methadone or buprenorphine that, like morphine or heroin, bind to the brain’s opioid receptors), which prevent withdrawal without giving users a high. For participants with severe opioid-use disorder, traditional alternatives just don’t cut it, and sometimes, their side effects are too unpleasant as well. Like Belanger, other MOP participants have tried abstinence or opioid replacements and returned to the street, some more than once. The hydromorphone ensures they do not have to seek illicit drugs. The participants are able to focus on rebuilding lives that have been devastated by a self-perpetuating combination of factors, including poverty, criminalization, and addiction.
The MOP, then, guarantees participants a source of safe opioids, comprehensive medical care, and a place to live. The supportive-housing apartment is a room of their own—which they pay for—in the same building as their legal drugs. If severe addiction, refractory to other treatment, is the result of multiple needs going unmet, untangling these factors must be a slow process of addressing each one. Inner City aims to build on groundbreaking international work on serious addiction as well as on a unique managed alcohol program it started sixteen years ago.
In 2002, alcohol was responsible for more than 4,000 deaths in Canada. Jeffrey Turnbull, a doctor with the Ottawa Hospital at the time, co-founded Inner City and its managed alcohol program (MAP), in which people with severe alcohol-use disorder are given a measured dose of wine every hour. The program reduces binge drinking and allows participants to rebuild their lives. The program has been successful, with results that include overall improved health, re-established relationships, clients re-engaging with activities and friends, and fewer clients relying on costly emergency health services.
The Inuk artist Normee Ekoomiak, one of the first full-time MAP participants and a chronically homeless residential-school survivor, had a safe, supportive space to start peeling back the layers of physical, mental, and emotional trauma fuelling his persistent alcoholism. With the MAP, his chronic illness was treated and he received physical rehabilitation and mental-health treatment—as well as acrylic paints, allowing him to get back to a career that had long been stalled. Ekoomiak died in 2009, but one of the artist’s tapestries hangs in the Canadian Museum of History in Gatineau and some of his other works hangs in Inner City’s office, acting as a reminder of the impact a slow approach to addiction can make.
“There has always been replacement therapy for opioids,” Turnbull explains. But these programs require strict attendance. Their stringent criteria, he says, are “not easily within reach of the homeless person who lives in complete chaos.…The traditional approach is failing this community.” Seeing the same reality in his patients who use opioids, Turnbull decided that perhaps what worked for alcohol could also work for opioids. He hoped his network could stabilize the lives of patients by providing safe, legal access to drugs and then by addressing their spectrum of needs. Turnbull, a recipient of the Order of Canada and the Order of Ontario, made headlines in 2017 when he stepped down as chief of staff at the Ottawa Hospital to devote more time to his work with Inner City. A registered charity, Inner City is funded by the city, the province (through the Champlain Local Health Integration Network), and donations.
As with the managed alcohol program, the goal of the MOP, Turnbull says, is not just to substitute one drug for another—although safe and managed opioids are an essential component. Drugs can act as a form of self-medication, providing vital escape from both present reality and past trauma. “It’s unravelling that whole history, going back to first circumstances,” he says—circumstances that can be truly daunting. Muron describes abuse, neglect, unstable childhood environments, parents, including pregnant mothers, who were themselves users of illicit drugs. New layers of trauma are added through the years, with poverty, homelessness, and then the constant struggle to acquire the drugs that provide an escape—which leads to a circular dilemma. By providing housing, community, medical care, and safe opioids, the program attempts to break this cycle of despair.
It’s an exceptionally dangerous time to be a drug user, as criminalization has led to the rise of ever more potent drugs. Meanwhile, a crackdown on the diversion and overprescription of pharmaceutical opioids has driven users from the medicine cabinet to the street. In 2017, opioids are suspected to have played a role in nearly 4,000 deaths across the country, with illicitly produced fentanyl and its analogues—which are also commonly added as an adulterant in other drugs—playing a role in many inadvertent overdoses. Ontario-wide stats reflect what seems to be the case across the country: deaths are rising at a ferocious pace (fastest in BC). For every death, there are numerous opioid-related emergency visits and resuscitations. Unable to be sure what they’re injecting, even experienced, careful users who have survived decades of injection drug use are now succumbing to overdoses—from illicit fentanyl or the elephant tranquilizer carfentanil—at a devastating rate.
“I’m an opioid addict. That goes without saying if you’re in this program,” says R, a thirty-three-year-old MOP participant who asked to remain anonymous. Like Bélanger, R has overdosed many times. “Struggling with addiction while being homeless creates a unique set of challenges,” he explains by phone from the MOP building, where he has lived since the spring. He became homeless after moving to Ottawa from London, Ontario, as a young man and encountering a series of misfortunes: sudden unemployment, difficulty navigating employment insurance, loss of housing, nowhere to land. “[The MOP provides] not only freedom from drug addiction on the street but freedom from homelessness,” he says.
While Turnbull stresses the value of being away from addiction-perpetuating street culture and Bélanger says she doesn’t like to go back downtown—“bad memories”—R says that the stability of the program allows toxic relationships to fall away. “People who I considered my friends, including on the street, they’re still my friends,” R says. “We’re just in different places.” The stressful search for money, drugs, and a place to use without being arrested or assaulted no longer dominates. As a result, R now has time for other things. “When you have time to spend on things that matter to you, you can become more yourself,” he says. Since joining the MOP, he has reconnected with his family. The only drugs he takes now, he says, are those that are given to him. “Opiates,” he says, “make me not want to kill myself.” For him, they “are not just a drug, they’re a tool.”
In Canada, there are a few similar programs, but none quite like the MOP, which started working with clients late in 2017. Vancouver’s famous Providence Crosstown Clinic, or Crosstown, is the only program in North America to provide pharmaceutical-grade diacetylmorphine (heroin) to users who, like the chronic alcoholics who found stability with the MAP, have been unable to manage their drug use any other way. Crosstown has carefully documented its success on a range of measures, from reducing criminal activity to lowering nonmedical drug use to improving general physical and mental health. The PHS Community Services Society, also in BC, is probably the most similar program to the MOP in Canada. The PHSCSS offers housing with clinical support for users, rather than serving as a residential facility for ongoing treatment. Like the MOP, though, the PHSCSS uses prescription hydromorphone as a convenient alternative to diacetylmorphine to stabilize and keep people from using street drugs.
Despite having been successfully used at Crosstown, prescription heroin is punishingly bureaucratic to access in Canada, which has discouraged expansion of a model proven to work. And so a clinical trial was started in 2011 to see if injectable hydromorphone could work equally well for people for whom other heroin alternatives just didn’t work. It does. As a result, Vancouver agencies are moving quickly to expand access to pharmaceutical hydromorphone as an overdose-preventing alternative to fentanyl-laced street drugs, with Mark Tyndall, the executive medical director of the BC Centre for Disease Control, calling for low-barrier access to oral hydromorphone in order to make it easy for users to avoid the dangerous street supply of opioids.
The MOP represents perhaps the next step in broad-spectrum harm-reduction addiction treatment. In a sense, it expands on Crosstown’s precedent-setting (in Canada, anyway) prescription-heroin program by incorporating managed-opioid treatment into a residential, multifaceted program focused on meeting the multiple needs of people with severe opioid-use disorder, significant life trauma, and chronic homelessness. The move from heroin to hydromorphone is not easy. “You still struggle with cravings and the desire for sure,” says R. “This program’s a lifesaver. I would probably be dead if I were on the street.…I hope to god that nothing changes.”
There has been conflict. Although they still perform their own injections, the preparation, administration, and storage of the drug is no longer within users’ control. Nurses help locate a vein and sometimes insert the needle. They offer advice to participants on taking care of their veins and improving their injection technique to prevent vein damage, abscesses, and infections. Some clients complained that the nurse was too slow administering doses. The loss of control was hard for these clients. It took a while for participants to develop trust in this new way of doing things and for staff to figure out their needs. “They needed to learn that we will have their meds for them when they want it,” Muron says.
The decision of how much participants need is a collaboration between the client, nurse coordinator Muron, and the registered nurses who administer and watch the effects on their clients, multiple times a day. Discussions around dose are not about quitting: they’re about what dose will enable participants to stay off other sources of opioids and maintain their well-being. “We want to work with them and find a high enough dose that they feel a good enough high,” Muron says.
Although Muron feels that her clients would benefit from access to prescription heroin, in this program they have had to accept the different Dilaudid high. The trade-off requires careful management to prevent a return to street drugs and overdoses. “The clients are using drugs whether we’re giving it to them or not,” says Muron. “We’re just giving them a safe way of doing what they’re going to do.”
Rather than trying to push people into giving up the drugs that they’re physically and emotionally dependent on, harm reductionists target harms not intrinsic to the drugs themselves, such as criminalization and poverty, both of which can result in dramatically more dangerous use. From this perspective, there are measures of success far more significant to users’ lives than the number of days since someone’s last injection. The other measures include simple things like acquiring hobbies and friends and enjoying each day, by sleeping in, reading the paper, or going for a walk in the park.
Portugal has become the poster child for wraparound, public-health-focused treatment for addiction. In the seventeen years since the country decriminalized possession of small amounts of all drugs for personal use, in tandem with a slate of programs intended to stabilize the lives of users, the results have been impressive. New HIV cases plummeted from more than 1,000 in 2002 to fifty-six in 2012. Deaths attributable directly to drug use dropped from approximately eighty in 2001 to sixteen in 2012. (By contrast, there were 272 drug-overdose deaths in British Columbia in 2001 and 528 in 2016).
Inner City’s MOP already offers evidence of the public and individual health benefits that Portugal has seen, on a smaller scale. As part of the program, participants underwent a blood test for communicable-diseases, a physical assessment, and checks of their kidney and liver function. New HIV cases were diagnosed and are now being treated, preventing further transmission. All of the current clients are smokers; now some are on nicotine replacement. Clients including Bélanger have gained desperately needed weight.
Life has changed dramatically for the MOP participants since they have had stable housing and a safe, consistent source of opioids. Some of the clients ride bikes to get around. At least five now volunteer at a supervised-injection site downtown, helping their peers use drugs more safely. There have been challenges along the way. A few participants left the program because they were not able to reduce their illicit drug use—continuing to take street drugs as well as prescribed opioids. “We’re still really early in the program. We are still trying to maintain people where they are and maintain their mental health,” Muron says. “They’re still struggling with what’s in their brain.”
Finding the right long-term, affordable mental-health counselling has been a struggle for Inner City. All MOP participants have anxiety disorders and some also have depression or bipolar disorder. Unhealthy coping skills are standard, and many have been diagnosed with PTSD. They often have difficulty sticking with structured programs. They will need trauma-informed counselling, Muron thinks, as their increasingly stable lives allow them to gradually peel back the layers of trauma that have made opioids a form of self-medication. Despite a nascent alliance with the Canadian Mental Health Association, which provides an outreach psychiatrist who stops in every couple of weeks at Inner City, and access to a psychiatrist with Royal Ottawa Hospital, MOP staff continue to search for the ongoing counselling their clients will need. Meanwhile, some of their clients have to relearn or, in other cases, learn for the first time the basics of self-care. Buying groceries and cooking, doing laundry: these are skills the program supports them to acquire. “I don’t want them to be totally dependent on us,” Turnbull says. “That’s not a road to recovery.”
Despite high demand, there’s no funding to expand this promising program. Inner City originally planned to enrol forty participants before the high costs of running the MOP became clear—nurses are there 24/7, preparing and dispensing medications on an all-day, all-night schedule—and the organization ultimately settled on allowing about twenty participants. There is not yet a plan for the long-term future of the current cohort of twenty-one in-residence participants. And, despite the long-term economic benefits of reduced crime, reduced emergency-room use, and fewer communicable diseases, this slow, multifaceted treatment is a tough sell. “If we had a wait-list for cardiac surgery where people were dying on the wait-list, we’d see funding to reduce the wait-list,” Turnbull says. “These people are dying on the wait-list.” Turnbull and his staff are carefully documenting the emerging results of the MOP in hopes of publishing them and conclusively demonstrating that the program deserves funding and expansion, given the results. They hope the government will recognize that, during a deadly crisis, this program both prevents deaths and sets out a vision for long-term recovery.
For Ricky Bélanger, living what feels like a safe, stable life is enough. She is babysitting a puppy and has reconnected with her parents and children. After a decade on the street, Bélanger has found a home and a program that works for her, restoring relationships, safety, health, and self-esteem where nothing else could. When asked her hopes for the future, she says, “Just to be here right now, for it to continue. We have our life.”