Opioids and COVID-19: A Crisis Within a Crisis — Josée Joliat and Dr. Mark Lysyshyn

Alex Maheux:

As the COVID-19 pandemic is rapidly evolving, the circumstances may have changed from the time this podcast was recorded, and may not reflect the current environment.

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Alex Maheux:

Hi, and welcome to the CHIP, the Canadian Health Information Podcast. I’m your host, Alex Maheux. This show from the Canadian Institute for Health Information will give you an in-depth look at Canada’s health systems and talk to experts you can trust. If you’re interested in health policy, our health care systems and the work being done to keep Canadians healthy, this podcast is for you.

Today we’re discussing the overlapping crises of opioids and COVID-19 with 2 experts who will give us a deeper look at what’s happening in their parts of our country. We’re talking with Dr. Mark Lysyshyn, the Medical Health Officer for Vancouver and North Shore in British Columbia. He’s been co-leading the public health response to the COVID-19 and overdose emergencies. He specializes in public health and preventative medicine. He’s also a clinical assistant professor at UBC’s School of Population and Public Health.

We also have Josée Joliat, a public health nurse from Public Health Sudbury and Districts in Ontario. Josée works on the Mental Health and Substance Use Team and is the coordinator of the Community Drug Strategy for the City of Greater Sudbury. She works to address the issue of opioids and other substances through an all-encompassing approach.

Please remember the views and comments of our guests may not necessarily reflect those of the Canadian Institute for Health Information. Let’s get to it.

Hi, Josée and Mark. Welcome to the CHIP. Thanks for joining us today.

Josée Joliat:

Hi, thank you.

Dr. Mark Lysyshyn:

Yeah, thanks. No problem.

Alex Maheux:

So the spread of COVID-19 across Canada and around the world over the past 18 months has obviously had some significant ramifications for the health of all Canadians, but we do know that it has affected different populations disproportionately, especially those living with substance use. Mark, in your role as medical health officer, I imagine you’re working on a number of health portfolios, including the pandemic. But knowing what you know about the opioid crisis, how do you balance the opioid crisis, a raging pandemic among all the other health needs in your jurisdiction?

Dr. Mark Lysyshyn:

Yeah, well, it’s been a real challenge, I would say. You know, the overdose crisis is really a severe problem, but the pandemic is such an all-encompassing problem that’s really taken all of the attention of government and society that it’s been difficult to focus on other health issues, even including overdose. And part of that is because the pandemic and the response to the pandemic is affecting overdose so much that we can’t just look at overdose and hope to fix that while the pandemic is happening, you know, we also do have to control the pandemic, otherwise people won’t feel safe accessing services they really need to prevent overdose death.

Alex Maheux:

Josée, in your role as public health nurse, how do you and your team balance the challenges of COVID and pandemic priorities?

Josée Joliat:

It’s difficult to try and balance the two, obviously, because COVID has taken up so much of the capacity of public health as an agency, but we’ve been lucky where we, you know, through the Community Drug Strategy, which is our local kind of collaboration with various agencies, we’ve been able to continue the work and being able to adapt as best as possible to the current situations. And so, I think it’s really through those external collaborations that really have allowed us to maintain the work that we’ve been doing so far. And then I think just definitely making sure that we have a specific, you know, keeping that lens of practice in our minds, although COVID is so encompassing and kind of wants to take over everything. We know how much COVID-19 has heightened certain disparities in our community and has affected people differently, so the work that we’ve done, you know, making sure that we have that lens of practice of making sure that we’re keeping certain communities as a priority and keeping them to the front of mind so that whatever interventions we’re doing, we’re making sure that certain folks aren’t being left behind.

Alex Maheux:

Mm-hmm, absolutely. CIHI recently released a report on the unintended consequences of COVID-19, including substance use, and it showed that emergency departments and hospitalizations related to poisonings for fentanyl derivatives, opioids, increased by 20% and 49%, respectively, in the last year. Josée, we’re talking about numbers and we hear the data about the impact of opioids — what are we seeing on the ground? What’s it truly like and what do you wish we could see and hear?

Josée Joliat:

Well, there’s lots going on, right? And I think we’re seeing the numbers, but we’re definitely also hearing a lot of stories coming out from community members. We’re seeing grassroots organizations even starting up in the community just seeing the need and feeling like something needs to be done. For example, in Greater Sudbury, since the pandemic has started, we’ve seen this kind of movement, Cross for Change, where folks have taken it upon themselves, you know, feeling that they need to commemorate and remember people that have been lost in our community from the opioid crisis, but also just substance use in general. And so, we now have this memorial that just keeps growing and growing and growing in our community and so, yes, there’s the numbers, but we’re also hearing those stories and it’s absolutely heartbreaking as folks imagined that it would have had an impact, but I don’t think we knew to what extent this would have impacted people who were using substances in our community, mental health even as well. We know that isolation and stress and everything else has so much impact on our mental health. We’re definitely seeing it in the statistics, and unfortunately, Sudbury has been hit very hard as well. I mean, as we’ve seen across the country, but Sudbury has been hit hard as well with those same statistics.

Alex Maheux:

Mm-hmm. Mark, obviously in Vancouver, opioid use was already well-documented prior to the pandemic, but you kind of touched on this. What were some of the challenges that have made the pandemic, and resulting restrictions, increasingly difficult to support people living with substance use?

Dr. Mark Lysyshyn:

Yeah, I mean, I think the first impact was really on the drug supply. You know, the pandemic has affected the entire world and has affected so many sectors of society, including the way people move across the world and the way goods are transported and things like that. And so I think the first impact we saw is that drugs became more toxic. And speaking to our police and border officials, I think there’s really a belief that the supply trains were disrupted and the locations where people were making drugs changed and shifted actually to more local production, even though they might be using materials from other places. And so basically, the people who had figured out how to mix fentanyl into fake heroin were no longer making the drugs; other people were making drugs and they had to become familiar with that again. And so just like we saw at the beginning of the overdose crisis, the drugs became way more toxic. We saw higher concentrations of fentanyl, variable concentrations of fentanyl, we saw carfentanyl back in the system again and we’ve seen these illicitly manufactured benzodiazepines in the system as well.

So the drugs got more toxic and then people became less willing to use the harm reduction services that were really preventing overdose deaths. Things like supervised consumption sites, overdose prevention sites, drug-checking services, you know, these services are in community settings that were not designed to have physical distancing between participants. They’re often very small spaces and they’re trying to provide the service to as many people as possible because they’re not well-funded and they need to be there and they need to be close to the participants so that they can respond during overdoses and things like that. So when we started telling everybody stay physically distanced, the sites had to change and then the participants didn’t feel as comfortable going to the sites. We saw visit volumes just plummet at the beginning of the pandemic because, of course, people were afraid that they might get COVID there. And we did all we could to make sure all of the infection prevention and control measures were put in place at these sites, but I think people still felt uncomfortable going to sites that could be somewhat crowded, because they felt they were at risk of COVID. And so, when people use drugs outside of those supervised environments, they’re much more likely to overdose and die than they are in those environments.

Alex Maheux:

And so, is that what you’ve seen, an increase in opioid deaths during the pandemic?

Dr. Mark Lysyshyn:

Yeah. I mean, it’s always difficult to know exactly what the cause of the deaths are, you know, how much of it is due to the drug supply, how much of it is due to not using the available services. But, you know, the deaths that we see are not occurring at our service locations, they are occurring in people’s private residences, in alleyways, in all these places where using drugs is very dangerous because nobody sees you overdose.

We’ve also wondered, you know, because overdose deaths have gone up outside as well, so we also wonder if people are less willing to help other people who might be having an overdose because they don’t want to approach a stranger and intervene because that stranger might have COVID. And then also there’s less eyes on the street these days. People are told to stay inside and not go outside, so it’s less likely that a bystander is going to walk by an alley and see somebody passed out and then call for help and things like that. So, you know, the pandemic, I think, affects overdose risk in a number of different ways.

Alex Maheux:

Mm-hmm. Josée, can you tell us a bit more specifically what are some of the challenges that have made the pandemic and resulting restrictions increasingly difficult to support people living with substance use in your community in Sudbury?

Josée Joliat:

Well, some of the COVID guidelines and public health measures that are put into place — you know, isolating and staying 6 feet away and not seeing many people — are very contrary to some of the messaging that we promote with harm reduction, right? Like, isolation when it comes to using substances is often the thing that can become fatal for someone who’s using substances, and so we’ve seen overdose lines coming up as well to try and support folks in that isolation with the shutdowns that happen as well, and organizations having to scramble and kind of readjust their services. We saw a reduction in service offering in hours and group support as well, which, you know, that sense of community that a lot of people were getting through these services, we saw a lot of those disappear.

Alex Maheux:

How about you, Mark?

Dr. Mark Lysyshyn:

Yeah. The first strategy was really to try to control the pandemic, and specifically in the neighbourhoods where we see a lot of people who are vulnerable to overdose, and so it’s a complicated neighbourhood to manage COVID in, but we had to take special measures there like creating isolation hotels, creating isolation shelters where people could be moved from some of the high-risk housing environments that they were in into these lower-risk environments so that transmission wouldn’t continue. We had to have a mobile testing van that would go and find the cases and then move them to these isolation locations. And we had to have a specific campaign to get that population immunized very early on in our immunization campaign for COVID. And so it was a real focus for us to really look at that community to try to make it as safe as possible for COVID. And now that we’ve actually done that immunization, we’ve seen the rates of COVID come down dramatically in that neighbourhood. And so now we’re trying to make sure people know that, because if they know that COVID has been controlled in that community, they’re more likely to access our services.

And then from the point of the services, we’ve tried to make sure that people understand that it’s more important for them to attend these services than it is to stay at home and try to avoid other people. But then we’ve also tried to make these services as safe as possible with Plexiglas and with the kind of measures that can ensure that people can be in the space and not get COVID from the other participants.

Alex Maheux:

Do you think that the culture in Vancouver specifically had any impact on how quickly you were able to mobilize these strategies because you already had some of that infrastructure in place?

Dr. Mark Lysyshyn:

You mean like the overdose prevention strategies?

Alex Maheux:

Yeah.

Dr. Mark Lysyshyn:

Yeah, I mean, we had a lot of sites that were operating, but I think each one of the sites faced a lot of challenges as, you know, back a year ago when the COVID lockdown measures went in, because they realized that it was difficult for them to operate the same way that they were used to operating. Their staff were also afraid of getting COVID from the participants, and so they all really had to learn how to wear PPE and how to use it properly and what circumstances you need different types of PPE in. This was training that they all didn’t really have before and, you know, in order to operate the site safely, they needed to quickly become comfortable with those types of procedures.

Alex Maheux:

Mm-hmm. Josée, how about you? What kind of new policies or strategies have been implemented in your community to help mitigate these challenges?

Josée Joliat:

Well, so I mentioned the overdose line, it’s not necessarily something that’s specific for Greater Sudbury, but definitely something that we can have in the meantime that we can promote to folks: you know, don’t use alone. So at least if you have access to a phone, you can call, so there’s the North Line, which is actually created and led by people who are using the substances, which is awesome. We always know that the intervention centre, kind of led by people who used substances or have lived the experience of substance use, those tend to be the best practices that come out. So we have that line that, of course, we’re promoting. But then also that community collaboration. So we’ve seen agencies kind of mesh together and try to bridge the gap in offering services and sharing staff and going to certain locations and whatever else so that we can continue either our withdrawal management services or just isolation shelters have been very important for people who use substances, or even people who are experiencing homelessness, you know, don’t necessarily have a place to go. So our community has really come together to try and really figure out how best to adapt as COVID keeps developing.

Alex Maheux:

It’s great to hear that there’s some cross-collaboration happening.

Josée Joliat:

Mm-hmm, it’s been great.

Alex Maheux:

I can imagine being in the health care sector specifically working with opioid use is already a very stressful job. How do you cope with something so heavy and how are you doing right now?

Josée Joliat:

It’s rough. Some days it hits us really hard and, like, I feel like I can speak to the whole group to this because it depends on the day. Some days it feels really overwhelming, it feels really difficult. But then we’ve got to remember why we’re here and what we’re doing this for, and that without folks that are doing this work, it’s not really going to happen. So we just have to continue sticking together and remembering what that bottom line is: we’re there to save lives, we’re there to support folks that are in dire need. And so, any work that we’re doing, you’ve got to consider that as good work. And so, I do think that it is good work that we’re doing in trying to just advance those projects forward for Greater Sudbury.

We’ve been working on trying to implement our first supervised consumption service and that’s been a project that had been happening even before COVID, and now that the pandemic is here, you know, it’s even bringing up that need even more. So just trying to keep moving forward and just remembering why we’re here, I think that’s kind of what you’ve got to hold onto.

Alex Maheux:

Mm-hmm. It’s incredible work. Mark, how about you? How are you doing?

Dr. Mark Lysyshyn:

It’s definitely been a hard year for those of us in public health, that demands on our time have been very extreme. And especially as cases go up and there’s exposures all over the community that need to be managed and, you know, we’re not a big work force, so it’s been tough. But, you know, there has been at least good government support to the pandemic response, and so we have been able to build up our contact tracing teams and we’ve been able to do that. And so, you know, now we’re in a pretty good place. But at various times during the pandemic, it was hard to stay above water, and it’s definitely hard to look at other health issues, even like overdose, just because of the sheer number of cases, outbreaks and exposures that were occurring as a result of COVID.

Alex Maheux:

Mm-hmm. So on the flip side of that, what gives you both hope? What inspires you to come to work every day?

Dr. Mark Lysyshyn:

Well, I mean, we are going to get through this and I think the successes we have seen around the vaccine in the populations where we’ve been able to deploy it really gives us a lot of hope. The downtown east side of Vancouver, for instance, has a very complex population with a lot of risk factors for COVID transmission, like the kind of dense housing environments where people live, you know, a shared bathroom for the entire floor of a building. You know, like, these are conditions where COVID can really circulate, but we’ve deployed the vaccine in that setting and it’s really worked. Cases have come down, we’re just not seeing it there, whereas we are seeing it in all the other neighbourhoods in Vancouver that are actually much lower risk in terms of COVID transmission because people live in houses or condos or whatever. So, the vaccine works where we deploy it and so now it’s a matter of getting enough doses of the vaccine and getting it into the arms. And so, we’re doing that now and so I think that does give all of us a bit of hope.

Now, of course, that’s not going to solve the overdose crisis, but we need to at least remove the pandemic’s influence on that and then get back to the progress we — you know, we were making progress on the overdose crisis, I would say. You know, over 2019, we were seeing overdose deaths come down and it looked like the toxicity of the drug supply was improving as well. But then that, of course, all got disrupted, so.

Josée Joliat:

Mm-hmm. One thing that I mentioned a little bit is the community collaborations or even, like, the grassroots groups that have come up. I think it’s showing, you know, we’re seeing that folks in the community are seeing the need or seeing that things need to get done and so I’m hopeful that these are kind of, these grassroots initiatives are going to help amplify the message that we’ve been attempting to try to convey and, you know, to try and continue to bring that message up forward. So there is quite a bit of media coverage regardless, even with the pandemic that, you know, the opioid crisis is still very much a topic that folks are talking about. But I’m hoping that by seeing these grassroots initiatives really coming from a place of compassion, you know, the memorial that I mentioned as well is definitely a place of compassion, of love, of folks just kind of feeling like, okay, enough is enough and we want to get this, we want to get things moving, is definitely something that is encouraging.

The other thing for me is seeing different communities being able to move forward some of their interventions and their projects, right. So we’re seeing folks putting up supervised consumption services really quickly through announcements that the federal government has done. That the urgent public health need site is kind of the aim of them, to be able to implement these life-saving services without necessarily the long timeline that’s usually required in implementing them, and also seeing some of these safe supply initiatives. So there’s folks down south in southern Ontario like London and Ottawa, Toronto. In the Kingston area, we’re offering folks pharmaceutical-grade alternatives to the illicit drug supply which, you know, because it’s so unpredictable, it’s so scary. At least this, you know, we can support folks, we can make sure that they’re being as safe as they can be. And they’re seeing really great results coming from these programs as well. So seeing those success stories is definitely super encouraging.

Alex Maheux:

Well, thank you, Josée and Mark, both for your passion and your compassion, and thank you for being here to help us shed some light on what’s happening in your communities.

Dr. Mark Lysyshyn:

No problem. Nice talking to you.

Josée Joliat:

Thanks so much for having me.

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Alex Maheux:

Thanks for listening. We hope you enjoyed this episode. Check in next time when we bring you more valuable health perspectives and continue to chip away at health care topics that matter to you.

If you want to learn more about CIHI, visit our website: cihi.ca. That’s C-I-H-I-dot-C-A. If you like what you heard, subscribe where you find your podcasts and leave us a review and give us a follow on social media.

This episode was produced by Jonathan Kuehlein with research from Amie Chant, Marissa Duncan, Shraddha Sankhe and Ramon Syyap. I’m Alex Maheux, thanks for tuning in to the Canada’s Health Information Podcast. Talk to you next time.

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