Ariane Litalien is a medical student in the Class of 2020 at McGill University
I was about halfway through my second year as a medical student at McGill University when—for a variety of health-related reasons—life decided I needed to take a break from my studies. I packed up my short white coat, Littmann stethoscope, and practice suturing tools in a square box, wrote “transition to clerkship” in tidy Sharpie letters on the top flap, and started looking for a full-time job.
Like Vancouver and a handful of European countries, Montreal’s public health agency (CIUSSS du Centre-Sud-de-l'Île-de-Montréal) was on the verge of opening four supervised injection sites for intravenous drug users across the city. Given my professional experience related to social work and HIV, I decided to apply for a position as an outreach worker.
For thirty-five hours every week, I watched as people from all walks of life injected cocaine, heroin, ketamine, crystal meth, and prescription opioids into their venous system. Most users would inject their substance of choice in their arm. Other would choose to inject veins in their legs or feet, often to avoid leaving visible signs of their addiction for others to read. A few elected to shoot up their jugular, having exhausted all other veins available to them.
In the spirit of harm reduction, our facility offered clean needles and safety advice to whomever walked through the door, providing naloxone when they’d had too much and referrals to rehab centres when they’d had enough. Over the course of their visit, users often chatted about the drugs they took (legal or otherwise), the work they pursued (sometimes illicit), and the factors that had led them to relapse or start using in the first place.
As a human being, I learned that life can flip in a matter of weeks. You can lose your child, your partner, your job, your house, or all of these—often roughly in that order. Your substance abuse may be the cause for these losses or the way you end up coping with them. Often, it is both. In just the time it takes to stick a needle in your skin and push a plunger into a 1cc syringe, you can command temporary anesthesia from the pain… and that is often the only way you know to stay alive.
As a doctor in the making, I also learned that our healthcare system is grossly maladapted to the needs of one of the most vulnerable populations in Canada. Intravenous drug users who show up in the emergency room in pain, whether for reasons related to their substance use disorder or not, are often automatically stigmatized and unjustly labeled as “drug-seeking”: the medical equivalent of a scarlet letter.
Their fractures and soft tissue infections do not go untreated, but their physical pain remains unrelieved. They are followed into the bathroom, interrogated about whether they injected on the wards, and restrained to their beds if they refuse to cooperate. Often, they leave against medical advice, facing the impossible choice between relieving their pain with illegal drugs or treating their illness with legal ones. For many, those options are mutually exclusive.
As members of the medical community, we often equate self-destructive behaviour like substance abuse with a contempt for life that is incompatible with the purpose of our work. Yet substance abuse, I have learned, is often motivated above all else by a desire to stay alive in the face of adversity. Though the resulting coping mechanisms are unhealthy, the motivations behind them are anything but pathological. Why would someone use life-saving services like supervised injection sites if they did not value their own life?
And so, as it turns out, caring for people living with substance use disorders is not incompatible with our mission as health care professionals. To do so effectively, we must be willing to adopt principles of harm reduction that have historically been embraced by community organizations but snubbed by the medical community. While this may seem counterproductive to many physicians, we could start by providing clean needles to patients whom we suspect are injecting drugs in the hospital instead of trying to catch them shooting up in the bathroom. We could start by ensuring that their pain is controlled and that they aren’t experiencing craving or withdrawals instead of dismissing their complaints altogether or strapping them to their bed.
This does not mean we should be indiscriminately prescribing high doses of opiates to every patient who walks through the door with a broken finger. But we should definitely question our knee-jerk reactions to automatically ignore, dismiss, or even punish those who have a history of substance use disorder. Doing anything else, it seems, runs against the very fabric of our role as physicians.