Edmonton doctor, patient concerned as government plans to defund intensive opioid therapy

Rick Majoros didn't know where he was when he woke up under fluorescent light in early September. 

His breath was shallow and his body was limp. The naloxone flowed towards his brain, pushing heroin off his opioid receptors and reversing the effects of the overdose. 

The nurse at the Boyle Street supervised consumption site rubbed his shoulders, calling him back to consciousness. The decision to inject at the consumption site likely saved the 51-year-old's life.  

"Thank God this place was here," he said. "That's my life, my kids, my grandkids — they wouldn't have seen me. I had to do something to change that." 

Majoros says he started using street drugs to self-medicate as a teenager after a traumatic childhood in Alberta foster care, disconnected from his Métis family in Yellowknife.

He tried suboxone therapy in the past to treat his opioid dependency, but the cravings persisted and he reverted back to a street supply.  

When he was revived at the supervised consumption site, the medical staff looked to a relatively new referral option: injectable opioid agonist treatment, or iOAT. 

The treatment, offered at a downtown Edmonton clinic since March 2019, is a last resort for people with severe addictions when other treatment options fail. 

"From the first day I got here, they made me feel at home, I wasn't judged and it just felt like a place I needed to be. From the time I got here until now, it's been a whole change in my life," he said in an interview on Wednesday. 

Under a nurse's supervision, Majoros injects a prescribed dose of hydromorphone three times a day, every day, to curb his withdrawal symptoms.

Medication is just the start of the clinic's intervention. 

The staff help him file paperwork for disability assistance, arrange medical appointments and apply for government-issued identification. He has not lived in a place of his own since he was 16, but with the advocacy of clinic staff, he is on a path toward stable housing. For the first time in years, he is in regular contact with his children. 

"I credit all of that to this program here. The people who work here, they're life savers. They're angels," he said. "They back you. They'll go right to fight for you." 

But Majoros fears his recent progress is in jeopardy after the Alberta government said it would defund iOAT clinics in Edmonton and Calgary in March 2021. 

"This place helps a lot and I'm scared when it's gone what I'm going to do," he said. 

'Makes no sense' 

The government says the two Alberta clinics will no longer take new referrals as iOAT patients are transferred into other treatment programs. 

"I don't know how we can transition this population into a treatment from which they've already failed," said Dr. Krishna Balachandra, a physician at the Edmonton iOAT clinic. 

"They're stabilized now because we have an effective treatment. We finally have something that is supported by the literature. So, to take that away makes no sense to me because we have no other option."

The program was launched in 2018 as a $14 million pilot by the previous Alberta government in the midst of the opioid crisis, when more than two people in Alberta died from overdoses every day on average. The two-year grant was set to expire this month, but was extended by the government until the end of March 2021. 

In all, doctors estimate there are around 100 patients on iOAT in the province. The clinics in Edmonton and Calgary are funded for 50 patients each and are operating at or above capacity, according to staff. The government has said there are only 65 active clients on iOAT.

The latest numbers from Alberta Health Services show opioid overdose deaths in the province are at the lowest level in three years. Balanchandra says the province developed a reputation across North America as a leader in opioid treatments. 

"To cancel this program is taking us steps back for decades and I think it's something we'll never recover [from]," he said. 

With the help of a team of nurses, physicians, pharmacists, psychiatrists and peer-support workers, Balachandra says the clinic is able to retain patients at higher rates than many other opioid dependency programs. 

Stand on the side of evidence, doctor says

Trials have found iOAT programs typically retain roughly 80 per cent of their patients over 12 months, compared to around 50 per cent for methadone programs. High retention rates combined with the intensive, daily nature of the program means physicians can then also address other healthcare needs, Balachandra says. 

We want to see a solution. We want to continue this.- Dr. Krishna Balachandra

And with a safe, regulated medical supply of opioids, patients no longer have to turn to illicit drug markets. 

Research shows iOAT cuts rates of illicit opioid use, criminal activity and death among clients who resisted methadone treatment, according to a review by the Canadian Research Initiative in Substance Misuse. 

"We want to stand on the scientific-evidence and not base these decisions on ideological matters," said Balachandra, who is also an assistant clinical professor at the University of Alberta. 

"What I realize is we need to have a spectrum of services, and this is not for everybody. But for a select group this is a very good solution and that seems to be working." 

Kassandra Kitz, press secretary forJason Luan, the associate minister of mental health and addictions, says the government anticipates a final report from iOAT providers when the program ends. 

"That is how we make funding decisions," Kitz said in an email. 

Doctors have suggested the government could continue the program outside a clinic-based model, with patients administering doses at a pharmacy or safe consumption sites. Balanchdra says the government could also look to reduce costs without cutting the program entirely. 

"We want to see a solution. We want to continue this," he said. 

Majoros, the client, issued a similar plea to the government.

"Come out here and live a day in our life and listen to our stories. We need this place," he said.