From the Editor

“I don’t think that we can sit back and be complacent for one moment,” said Toronto Mayor John Tory in a media interview in which he called for an ‘all hands on deck’ approach to dealing with opioids.

It’s a comment on our times when the mayor of Canada’s largest city is focused on the use (and abuse) of opioids. And so are others – opioid addiction has sparked conversations across North America, from big city Canada to rural America. In 2014, Peter Shumlin, governor of the second smallest state in the U.S., devoted his annual address to the opioid problem striking “every corner” of Vermont.

Vermont: hills, lakes, opioids

How we deal with opioids is complicated, touching on everything from drug regulation to clinician education. But the legal response is particularly interesting – the intersection of the law, addiction, and public policy. And so, in this Reading, we look at the Green Mountain State. In a Wall Street Journal essay, reporters Jennifer Levitz and Scott Calvert discuss Vermont’s experimentation with mandatory treatment for minor drug-related crimes – and the struggles of a young user.

We also consider federal Minister of Health Jane Philpott’s recent essay on the opioid issue, which ran in The Globe and Mail last week. She calls on us to address the roots of the issue – which “are tangled and deep.”


Drugs and Punishment

“Vermont’s Radical Experiment to Break the Addiction Cycle”

Jennifer Levitz and Scott Calvert

The Wall Street Journal, 23 December 2016


RUTLAND, Vt.—Stocking shelves in a local store, Todd Popovitch felt his skin flush hot with worry.

After years of using heroin, sometimes laced with the painkiller fentanyl, he had stayed clean for the summer, landing a job making $10 an hour. But by late September, his work had grown stressful. He and his girlfriend split, forcing him to find a new place to live. He sought help not from family or friends, but from the state’s top law-enforcement agency, which is pioneering a novel program seeking a way out of the country’s drug crisis.

“I’m barely holding sh— together,” he wrote in a Sept. 26 text to Ellen Wicklum, a liaison to the Vermont Attorney General’s office.

“Don’t use,” she wrote back.

Ms. Wicklum and her colleagues are taking a chance on Mr. Popovitch, a 35-year-old former standout high-school basketball player and drug user for 15 years. In May, he was arrested twice in eight days for alleged heroin possession. If convicted, he could have faced up to two years in prison.

Instead, state officials decided to enroll him in a program that steers low-level lawbreakers with drug addictions into treatment and other services, bypassing incarceration and using the threat of prosecution as leverage.

Jennifer Levitz

So begins an essay in The Wall Street Journal.

The authors describe the Vermont experiment: “State lawmakers [in 2014] passed legislation authorizing state prosecutors in each county to design a novel program to send repeat low-risk offenders with substance-abuse or mental-health problems into treatment, using the possibility of prosecution as leverage.”

They note other experiments with this concept:

· “In 2015, University of Washington researchers found participants in Seattle’s Law Enforcement Assisted Diversion program were 58% less likely to be re-arrested than individuals in a control group.”

· “Of 650 people referred to treatment in Jefferson County, Ky., soon after pleading guilty to misdemeanors, 142 picked up new charges, mostly drug offenses, through October. Still, Louisville prosecutor John Balenovich considers the 17-month-old ‘rocket docket’ program a success, because in his experience ‘like 99%’ of heroin addicts generally reoffend because of their addiction.”

· The authors note that, across the U.S., fewer people are being sentenced for drug offences. See figure below.

The essay is enlivened by the story of Popovitch. A high school graduate who had distinguished himself for his athletics (he was the leading scorer for boys’ varsity basketball); his life has been coloured by addiction and loss – of his mother in a car accident and of his sister (to drugs). Caught twice with heroin by police, Popovitch was offered an alternative to jail in the form of a contract. That agreement required sobriety and more: weekly contacts with a social services staffer, ongoing drug treatment, and employment.

The article concludes with Popovitch, sober and nearing the end of his contract’s term, posting a short comment on Facebook: “Happy to be back.”

A few thoughts:

1. This is a timely essay. Consider: in 2015, according to the CDC, heroin-related deaths exceeded gun deaths for the first time in the United States.

2. These experiments in treatment (instead of jail time) are important.

3. The Wall Street Journal essay is for an American audience, published in an American newspaper. I note that there are experiments north of the 49th parallel, too. The Toronto Drug Treatment Court Program offers diversion and treatment through CAMH; a similar program is offered in Ontario’s York Region. Alberta and other Canadian jurisdictions also offer alternatives to jail time in the way of treatment.

4. As is often the case in Canada, access to the Toronto Drug Treatment Court program and sister programs vary greatly by location (the postal code lottery, to use the British phrase).

5. What’s interesting about Vermont isn’t just the insistence on treatment – but a full package of services and requirements.

6. A quick word of thanks to Dr. Maurice Siu and Jawad Bhatti, both of the Scarborough and Rouge Hospital, for explaining to me the Canadian experimentation.

Drugs and Canada

We must turn the tide on Canada’s opioid crisis

Jane Philpott

The Globe and Mail, 13 January 2017


I am deeply disturbed by the escalating numbers of opioid overdose deaths. It is a shocking fact that hundreds of Canadians died of accidental overdose in 2016. As federal Minister of Health, I am determined to work with all partners to combat what is arguably the greatest public-health crisis we face in Canada.

At the federal government level, we took several important steps in 2016. We made naloxone more widely available to help reverse overdoses; We overturned a ban on allowing doctors to use prescription heroin to treat the most severe cases of addiction; We granted an exemption to the Dr. Peter Centre in Vancouver to operate a supervised consumption site and a four-year extension to Insite in Vancouver; We introduced legislation to make it easier to establish similar life-saving facilities in communities that need them.

Jane Philpott

In this essay, the federal Minister of Health outlines her government’s agenda:

· “[W]e need Bill C-37 to move quickly through Parliament, so that those on the ground have the tools they need for prevention, treatment and harm reduction.”

· “Also on the legislative front, we need swift passage of the Good Samaritan Drug Overdose Act, to ensure that those who fear a drug-possession charge will not hesitate to call 911 when they witness an overdose.”

· She notes non-legislative efforts, too, including better collection of data on opioid-related deaths (through CIHI).

She suggests that more is needed, an attempt to get to “the roots” of the problem.

Addiction is not a crime. Addiction is not a mark of moral failure. It is a health issue.

She closes by suggesting that we need a larger response:

Addressing the roots of the opioid crisis demands a whole-of-society response. It means calling out stigma and discrimination as barriers to care. It means building a society where children receive tender attention and adults aren’t so isolated and lonely. It means an international search for effective answers and being willing to discuss bold policy alternatives.

A few thoughts:

1. Despite the calm tone, this essay is quite strong. It declares that addiction is “a health issue.” It’s difficult to imagine that sort of comment coming from Minister of Health in years past.

2. The focus is on the government’s legislative agenda. But the essay notes the larger agenda needed – good.

3. I’ll close with a tweaked version of the comment I made at the opening of this Reading – it’s a remarkable sign of the times that so many are speaking out on this issue. #Nice.

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.