The Opioid Crisis, Humanizing the Homeless & More, with Dr. Jeffrey Turnbull

Solving Healthcare with Dr. Kwadwo Kyeremanteng

The Opioid Crisis, Humanizing the Homeless & More, with Dr. Jeffrey Turnbull

In this tremendous episode with Dr. Jeffrey Turnbull, we celebrate the amazing work his organization Ottawa Inner City Health has done to address the homelessness, the opioid crisis and more.…
November 19, 2019

The Opioid Crisis, Humanizing the Homeless & More, with Dr. Jeffrey Turnbull

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Kwadwo:                             00:43                     welcome back everybody. Super excited about episode nine year with Jeffrey Turnbull. But first I want to tell you about our sponsor. Better help. This is a group of amazing online online counselors that provide online counseling via audio calls, via, via chat, via messaging, and it’s affordable. It is timely, it’s on your schedule. And these guys are great. They reach out after hearing episodes with dr Adrienne Matheson and dr Tamina Eapen. And um, I think they do amazing work. So if you want to sign up, you get a 10% discount using discount code solving healthcare. There are better and uh, I highly recommend these guys. Okay. A couple of housekeeping things. We’ve been busting out episodes every week. And for the sake of my marriage, we’re going to be extending that to every two weeks. Now that we’ve have a few episodes out. Now we’re also going to explore different format.

Kwadwo:                             01:51                     We’ll call them mini casts, where you get 10 to 15 minute episodes of, of innovative things that are happening within healthcare that, you know, there might be quite niche, but the idea is that it could be scalable, it reduces spending and provides better care. And so, um, that’s another format we’re going to explore. Okay. I’m going to tell you about our next guest, dr Jeffrey Turnbull. This guy is a walking angel and as far as I’m concerned is a hero. He works with the homeless population. Okay? He’s done this throughout his career and his whole motivation is to give them a voice, humanize them, provide them with care that they should be receiving in a setting that is optimal for them. So he is the medical director of the Ottawa inner city health program, which provides full range of care to the hump homeless population, including safe injection sites, um, manage alcohol program.

Kwadwo:                             03:01                     And even palliative care and I got to work with him about 10 years ago in that environment. And it was truly, I don’t even know what to what the word is. It was just eyeopening. It was humbling. It was, it was fantastic. The work that they’re providing and it was a real, a true honor to have him on the show. And this guy, let me tell you, he’s a baller. Okay. Like when I tell, let me list off some of his accolades. Order of Canada, order of Ontario queen Elizabeth, the second diamond Jubilee medal. I don’t know exactly what that means, but that sounds proper. He’s been the president of the CPSO, which is a college of physicians and surgeons of Ontario, president of the Canadian medical association, president of the medical council of Canada. And honestly, the other thing that’s amazing about Jeff is he’s truly a nice guy and he’s held all these leadership positions. And I’ve always thought to be, you know, up there, you need to be, you know, you need to be a hard ass. You gotta be that militant leadership approach. And he is the opposite. He’s been a true inspiration in terms of leadership styles and I it, he’s amazing. So without further ado, Jeffrey Turnbull,

Kwadwo:                             04:24                     Jeffrey Turnbull, I got to tell you, it’s a privilege man. A privilege is all mine. Oh, thanks for doing this. This is amazing. We are in, where are we actually?

Jeff :                                      04:35                     So this is our office facility. So we’re in the basement of that. Right beside you. Over there is a nursing station where we draw up injectable hydromorphone for the opioid substitution program. And above all, the next two floors are administrative and where our nurses work and set a, when they’re not out in the shelters.

Kwadwo:                             04:58                     Wow. I mean we’re going to get into this, but I know say right out of the gate, this stuff that you’re doing is stuff that angels do. And I, it really is an honor to be here and it’s, uh, it’s been an honor to work with you in the past. Um, I want to ask you the day in the life of Jeffrey Turnbull in 2019 cause you, I mean if you look at your resume, it’s pretty ridiculous. Uh, what is like not like for you?

Jeff :                                      05:28                     So a very, very different, so it’s not involved in the hospital and it’s not involved in Toronto. So I’m not flying back and forth commuting. Um, I’m here and I’ve devoted my, my week now to the homeless. Um, today began with picking up eggs and at the farm and, uh, doing some farm work and then bringing Charlie to my youngest son to school. And then from there I

Jeff :                                      05:58                     came down for our meeting, which is, I was actually in this boardroom where we go through the list of clients that we have at any one time. It’s about 280 to 300. And they’re in all of the facilities around us and we discuss each case and we have the care providers, but we also have housing people and social workers and addiction specialists, uh, that join us and mental health specialists. Wow. And we all go through each one of those cases about how we’re handling them and what are the challenges that we’re facing.

Kwadwo:                             06:33                     And I, I can’t imagine that these challenges aren’t, uh, many. So maybe give us a sense of if you had this magic wand to, to, to fix some of the issues that you see, like some, what are some of the major concerns that you come across dealing with the homeless population?

Jeff :                                      06:54                     Well, the, the homeless, like many other vulnerable or disadvantaged populations, um, because of their circumstances, the poverty that they live in, the mental health or addictions, lack of education, concept of health, all of those things bring them to this environment, but it’s this environment that prevents them from getting meaningful, reasonable care and moving away from homelessness. So, um, if I had a magic wand, as you said, what would I do? Uh, um, the, I think we really have to address all of those factors that bring people into a world of homelessness, addictions, mental health, and those are the upstream factors. So those are the things like, um, early childhood development, poverty reduction strategies, education, employment, um, uh, intact family structures, um, not having residential school systems, et cetera, et cetera. However, the, my life now is drinking from a fire hose and I just can look at only the complications of that. And so the 300 people that I’m looking after today, um, what’s the best thing for them? It’s improved public health policies. It’s, um, better addictions management. It’s better mental health treatment. Um, and it’s bringing care that is traditionally hospital focused or primary care, uh, in a residential setting into their world on their terms, which is very, very different than what you and I’ve ever experienced before.

Kwadwo:                             08:39                     Can you, can you, can you paint that picture? Like what, what is it like to be taken care of such patients?

Jeff :                                      08:49                     Well, um, can I tell you about a patient from this morning discussion? So he is, um, a guy who came to us yesterdays overdosed three times and the last two weeks, um, had to be resuscitated on two of those three times. The third time just woke up somewhere. Um, and his, when you talk to him, you know, you begin by saying, you know, how much, what’s your addiction like? Well, he’s taking, um, um, not only does he take a Dick, he’s addicted to benzodiazepines. He’s also addicted to, um, Nissan, a gram of Kadian every day, his thousand milligrams. He takes, uh, about two grams of what we call purple, which is, um, fentanyl mostly or all other stuff. So two grams. If you think about that, that’s fentanyl’s a hundred times more potent than morphine. So you can do the math. This is massive doses. And he has this history of mental health.

Jeff :                                      09:57                     Uh, he’s been institutionalized. He was, um, a product to the child welfare system. He was orphaned at a very young age. He’s had a history of abuse and trauma. He has behavior management problems, um, violence and aggression has been in jail. And um, he’s 38 and probably will not see 40, um, probably won’t see three, four more months. And so the challenge for him is how do you actually, you know, turn the clock back for him? How do you start to treat his mental health? Well, he doesn’t have a place to stay. He squats, um, and winter’s coming. How do you treat his addiction? It’s massive. You couldn’t give him enough opioids to control that. And his impulses are such that whenever he has something, he takes it. And so he’s at very high risk of overdose death. And so we were trying to think about could we put him in a housed environment, start treating as mental health, then make inroads on his addiction. Um, and all of these things are, you know, a constellation of impediments for him that will likely lead to his desk.

Kwadwo:                             11:16                     That’s, that’s it. That’s incredible. Like the thing that breaks my heart is, you know, we, the general public, you know, we, we see people in these circumstances, they’re on the street, they’re asking for money and we’re like, Aw man, get a job. Get that gate, get yourself cleaned up. You know what I’m saying? And just as you alluded to at the beginning, it’s like, think about the factors that got them there. You know, it’s like we say like, you know, getting like, get control of your life and do these things. But you got a question when you go through such trauma as you just described, this gentleman going through, is it like how much of his fate is in his hands? You know, like,

Jeff :                                      12:08                     yeah, so, so very little at this point. If there was inroads earlier on when he was six, when he was not abused in foster care or when he was, um, uh, early on developing signs of, um, disordered mental state and, uh, struggling with his trauma. Um, if we had to intervene then in a more supportive environment, wrap services around it, it might’ve been different. But now I have a 38 year old and I have a 38 year old that’s on massive doses of opioids who’s overdosing, who can’t control behaviors, is unemployed and lives in a world of poverty and doesn’t have a place to stay tonight. I can’t even find this guy, you know, like, it’s not as if he’s got a, an address. He can’t get the usual entitlements. He doesn’t have a health card, you know, all of that. So there’s so many other built in obstacles for him to get care that it makes it almost impossible for him to get care. And yeah. You know, what happened to those people that, you know, we, we see, we attend many memorials obviously because of so many people dying. Um, in this context. And almost always there is a young seven year old in a cowboy outfit, a pitcher, you know, that their parents have brought and something happened between that seven year old in keloid pads and a couple of hat to that person who is 25 who just overdosed and died on King Edward and Marie,

Kwadwo:                             13:45                     you know, and this is something that I try and remind our healthcare team is, you know, that patient that we’re seeing that got themselves in this situation, I’m doing this and they’re doing air quotes. That’s somebody’s son. That’s somebody’s brother. Yeah. And you know, I almost wondered if Jeff didn’t like the work you guys are doing is, is, is truly amazing. I wonder how much, like are there stories that you’ve come across or have seen where this has made a difference? Are they too far gone because of all the stuff that has happened? You know,

Jeff :                                      14:26                     so no, there are, they are never too far gone. You can, you can always have an impact on their lives. So are there circumstances where we’ve taken, we’ve seen somebody who’s on the streets, um, and return them to lives that you and I would think are normal employment, paying taxes, you know, um, they’re not many stories like that, but there are, and so in fact that’s, you know, keeps us going a lot. But on the other hand, those people who you see on King handwritten Murray that are in veteran alcoholics are injection drug users. Um, you know, who’ve been doing this for many years, you can improve the quality of their life very dramatically just by simple support, housing care, treat their HIV, treat their Hep C, um, treat their underlying mental health issues, support them, build trust, and do it in a, uh, in a, an environment that allows them to have control of their health outcomes. You know, the, that you may say, well that’s palliative care, but that is in fact we’re taking people and making their lives better, even though they have an underlying problem that probably they will never recover from.

Kwadwo:                             15:49                     Yeah. And the one thing, I mean, I got a chance to work with you over a decade ago and one thing that really stuck to me was how appreciative they are of the care. And I that it’s always stuck with me when I, when I, you know, when you’re, and when we were working, it was in the palliative setting, but when you’re there to, uh, support their medications or that they hear, hear their story, it’s, there was always a thank you. There was a genuine look in the eye and saying how appreciative they were.

Jeff :                                      16:29                     And they are, they’re enormously appreciative. And when you bring care to them on their terms, suddenly there’s a new trust that’s built. Um, you don’t see them in a hospital environment. This is foreign for them. Where authority has always been a challenge for them. You say, Oh, you got a quote, can’t go out for a smoke. Um, you know, and, and that, that bad series of behaviors that we see in a hospital environment are so predictable, but they disappear when you deliver care here. And they are charming, nice collegial people. I mean, they have their moments. There’s no question about it. And they make terrible decisions sometimes, but frankly, nobody ever taught them how to make good decisions. And that’s the world that they live in. And uh, um, it’s not for me to judge what’s right or for wrong. Um, my job is to pry and try and improve the quality of their life as best I can.

Kwadwo:                             17:31                     And I, the one thing I think that must be amazing for them too, and I don’t want to put words in their mouth, but that non judgemental environment in here, like they are treated like human beings, like the way they should be treated, which unfortunately I don’t think it’s all, there’s always the case everywhere. They’re everywhere they go, you know?

Jeff :                                      17:55                     No, and they’re not. And you know, it’s probably the first time in their lives to be honest with you there, where somebody sat down said, Nope, what do you want? Not me. What do you want with your addiction, your mental health, you know, and you know, they’re your future. And sometimes it’s just simple stuff. I want to connect with my family. Once again, I wanted to have a, a room that I can call my own. I want to continue to inject, but I wanted to be safe. Um, I don’t want to die, you know, uh, these are, you know, things that we can achieve.

Kwadwo:                             18:35                     That’s crazy. I, I mean, it’s one thing I’ve been appreciating doing this, the show a bit. Like I just finished a show with a child psychologist and we did, we talked a lot about child like me increasing anxiety and depression we’re seeing in kids. And what really stuck with me was early intervention. How much of an impact if we were to invest more early on in, in prevention, in sewing to her world, if we could have more resources to be able to either treat the kids or to have set up them in an environment for them to thrive. You know what I’m saying? And once again, this is the theme here too. You know, kids that are getting abused, kids that are in foster homes, it’s, you know, it’s, it’s just so sad to hear that this is something that we could be doing better.

Jeff :                                      19:34                     Yeah. And you have to ask yourself, why don’t we do that? Or on those things, because we know financially the return on investment is enormous. Right? So it makes good financial sense if nothing more, you know, to invest into early childhood development, poverty reduction strategies for children, those types of education, you know, community building, stuff like that. Enormous return on investment. So it’s not a financial issue. It’s not, it’s the right thing to do for communities.

Kwadwo:                             20:06                     Absolutely. But I mean this is a bit in your world, like you’ve been in some big wicked men positions. Like I know you’re not like political, but what, what do you think it is? Like why, why aren’t we going there? Like it’s our kids, you know what I’m saying?

Jeff :                                      20:22                     This is our future. These are our children. And so I, on the one hand, you know, there’s an argument to do this for because as good for communities is the right thing to do financially, it’s the right thing to do from a human rights perspective. Children, like any other citizen of this province deserves safety, education, housing, nutrition, you know, that’s what we would expect of our for our children, all those entitlements. So why doesn’t that happen? Um, as there, I think that we are paralyzed in that sense of, um, we can’t move ahead. Um, because of the way our govern is structured and the, um, the lack of vision that some of our leaders have about doing what’s the right thing. I sometimes in my darker moments, wonder about is there a sense of I don’t want to help them because, you know, why do I want to be, have so much equity within our community when I’m a, an influential leader who’s on the upper side of things? Um, but I do believe by and large, Canadians want to live in a more equitable society and they don’t want to see people begging, um, on their streets or children dying of,

Kwadwo:                             21:44                     I don’t know what the answer is too, but I just, I pray and I hope that it’s not because they feel like their, their feed is already written on the wall, whatever the expression is. I hope that’s not the, the, the, the concern cause it’s clear from research, from, from experts that this is not the, this doesn’t have to be, their faith

Jeff :                                      22:09                     does not have to be their fate. However, I can tell you there is certainty that if you do not deal with this, their fate will be addiction, mental health in and out of the hospital, in and out of prisons, uh, on a regular basis. And the cost of that is something that we just cannot afford.

Kwadwo:                             22:30                     Yeah. And it’s true. Like we talked a little bit about this yesterday in preparation. It’s like even the fact that we put a lot of these, uh, I w I don’t want to call them patients with these poor people in an environment where they’re not gonna thrive. Like in prison, we’ve talked about this. You go to prison at a vulnerable age. In, you’re in an environment where there are drugs that are violence. The, the idea of reforming their on papers, ridiculous.

Jeff :                                      23:03                     We know that it’s not very effective. But think of what we do in society. What we do is we take our most vulnerable populations, those populations that are in the greatest need. Um, in my circumstance it says the homeless, but it may not necessarily be the homeless, maybe our indigenous colleagues, whatever. But we, we as a society, we tend to isolate those individuals. We tend to put them into circumstances, out of sight, out of mind. For me, it’s lower town. It might be the lower East side of Vancouver. It may be, you know, region park in Toronto or other places. Um, we put those people in. Those are particularly vulnerable. Um, there’s high risk around them of drugs and violence, et cetera. So we take vulnerable people, put them in circumstances of higher risk. We deprive them of access to reasonable entitlements to help them get out of that circumstance. And then we’re surprised that HIV rates, hepatitis C rates, mental health rates, addiction rates, trauma, suicide, all of that exceeds that of the developing world. And we’re thinking that’s odd. Well, our public health colleagues would say that’s exactly what you would anticipate.

Kwadwo:                             24:21                     Absolutely. You know, I think, um, I want to ask you a bit about the opiate crisis, but just to that point too about, you know, um, the added resources and strain to a system related. Mostly I think to the opioid crisis. I work at more for hospitals, so close to venue and the amount of overdoses, complications from injections, uh, whether that’s endocarditis or infection of the valve or bloodstream infections, cellulitis or infection of the skin has been like, I don’t want the numbers in front of me, but they’re crazy. Like if I even look in the last eight years. And so I wanted to get a sense from you. Are you feeling this? Like what are your, like today you were saying, you know, you’re, you were going over about 300, just under 300 cases. If you were to compare this say to six years ago or whatnot, is there, has it been a dramatic change?

Jeff :                                      25:21                     So our whole world changed in 2016, you know, when the opioid crisis hit, I used to say, you know, we were dealing with alcohol and non beverage alcohol, you know, from mouthwash and stuff like that. So this is pretty tough, you know, and then crack cocaine happened to us and I said, Oh, can never get worse than this. And then we had, you know, I would have a couple of people who are heroin addicts in a month, um, and maybe three overdoses, um, in a month, maybe longer. Well, uh, however, in 2016 in August we had a, we knew it was coming and we had 35 overdoses in August. Wow. We had 70 overdoses in September and we leveled off at five overdoses a day. And so what you’re seeing in the emergency department, uh, the ma for the ICU, we don’t send our people anymore by ambulance when they overdose.

Jeff :                                      26:33                     Wow. We deal with them the last time. Often the ambulance is bring them to us for resuscitation, not to the hospital. So we have a modus, we have, you know, we, I can’t think of the last time we asked an ambulance to come and pick up an overdose. Our staff are skilled at looking after it. Um, and we, um, we deal with all of that. We have a program called targeted engagement and diversion where we divert ambulances to us away from hospitals for addiction. You’re drunk and disorderly. You’ve got other problems. The ambulances would pick that up, the person up normally and go to the hospital. But you know what would happen, we both know what would happen in the hospital. You would wait for offload. The person would slowly recover. Uh, they would probably never be seen. They would leave AMA and do it again and do it again. Um, sometimes hundreds of times in a, you know, six months, uh, that would happen. And so we divert those people to us now. And so we, at any one time in the evening, you’ll see about three ambulances in a squad car outside of our unit. And those are people dropping off, not picking up. We divert 3,400 emergency visits to us every year away from the emergency department.

Kwadwo:                             28:02                     That is absolutely insane. Like, think about this, huh?

Jeff :                                      28:07                     The hook and you go there. That is crazy. 11 or one in the morning. It is off the hook. Like we have 45 beds and they are all full every night.

Kwadwo:                             28:18                     So let me just summarize this and make sure I got this right. So as of three years ago plus the uh, because of the opioid epidemic, the volume of cases that you were seeing puts you in a situation where you are now having to or encouraging ambulance ambulances to, to see, to come to, to hear it for you guys to manage these patients and diverting. That meant you said 3,400

Jeff :                                      28:50                     yeah. Ambulance visits per a year.

Kwadwo:                             28:52                     And, and y’all, you, you guys like your, what your wait times in the merchant long. Now imagine if these guys were coming in. That’s a lot. That’s like what is that 3,400 divided three so like 10 a day, almost 10 a day.

Jeff :                                      29:05                     Oh, at least, remember we have 45 beds and so those are just ambulances. Then there’s the walking wounded who come in and the police, um, OSSI transport. Now it’s not all book. The opioid crisis is people who are dictated to alcohol, mental health crisis, et cetera. But it’s been made worse by the opioid crisis. And so I think the, our world has changed dramatically with the opioid crisis. We have seen, you know, deaths and you know, complications you’ve described of heart infections, of skin infections and bone infections. And we deal with that every day. Uh, we probably have at any one time three people on intravenous six weeks of intravenous therapy for complicated infections as a result of injection drug use. Um, so the, the opioid, it’s just turned a whole world upside down.

Kwadwo:                             30:06                     Yeah. I got to tell you to like, just to put a bit of context in this too, like we would see like you obviously got appreciation of the numbers, but in ICU, you know, we would see maybe one or two patients we would lose or would pass away, like opioid related or overdose related. You know, from knowing IB drug use or from complications thereof. And I can think of at least two cases in the last two months where people under the age of 41 was in the late, late twenties, early thirties. Once again, a mum, a parent, a brother, a sister, a loved one that is now deceased. It’s, it’s crazy and it’s, and it’s so sad and I, I just, I just can’t believe the work yet. You guys do and I mean I might be ignorant cause I didn’t know about these numbers and I F I don’t know if this is well known throughout, you know, the city, but if not you, this needs to be praised because this is amazing work y’all are doing.

Jeff :                                      31:18                     I always like to think of it as a, the problem is one that profoundly affects our community, where we come from and the solutions will come from our community and yes, we’ll draw upon them. Our four hospital, the Ottawa hospital for support. Um, but by and large, they want their care as much as it can be done for them. [inaudible] to their intravenous therapy, whatever, to be provided to them on their terms, in their location. They don’t do well in hospitals or in other institutional settings. They, so if we can do our best to provide that care, it’s cheaper, it’s better for them. We get better outcomes and our community is the better for it.

Kwadwo:                             32:10                     [inaudible] what I love about this is like you guys took it in your own hands, you took it in your own hands. This is a problem. You want the solution. And I think this is a model for a lot of people too, by the way, because we’re in a town where a lot of people b***h and complain about and there’s no action. You know what I’m saying? It’s a lot of dah, dah, dah, dah, dah, dah, dah. And the thing that I, I will always be proud to associate with y’all. It is the fact that you saw the problem. You come up with a solution that works with the patient, with the, with, with the people, not something that you think is best. Not the model that you read them some textbook that says that or this model, this is the way we should approach this problem without booking the P the patient or the people in the eye and saying, what will work for you? You know what I’m saying?

Jeff :                                      33:03                     Yeah. Then, but to do that, you know, our healthcare system and you know, to be given as credit is very good for the majority of people who use it services. You know, these are people like you and I. um, and I’m very proud of that. Very proud of our tertiary hospitals and our primary care. But for visit these people, the vulnerable, the disenfranchised, they just, it has to be on their terms and it won’t be successful if we just say, you know, look, here’s what’s offered to you. Take it or leave it cause it’ll be leave it. And we know the consequences of that. So if you actually sit in and listen to them and say, what would be the care that you need, how would that be delivered? On the one hand that is liberating because now you can start to think of ways that really are successful. You engage them, they start to trust you. Um, but on the other hand, it’s very intimidating and very challenging. So what is appropriate for them? Um, you know, is it right for me to be doing chest taps, um, and giving Ivy therapy to somebody in a shelter environment? You know, and,

Kwadwo:                             34:23                     but you know, it’s a shared decision. It’s a shared decision. That’s what’s beautiful about it. Like, yeah, there’s risk maybe of, you know, it’s not the ideal environment, but you’re two grown ass people saying like, these are what, this is the situation, these are the risks, this is how, you know, this is what our options are. Is this okay?

Jeff :                                      34:47                     Yeah. And they invariably will accept the option of saying, I want you to provide the care that you think is the best for me on my terms. And you know, and you know, frankly, that’s patient centered care. That’s what, um, that’s probably what we should be doing. And that’s why we got trained as physicians to serve that community serve and to serve all, yeah. Not just the people. We kind of like who look like us, but more so to serve people who you know, just are so, you know, they’re, they struggle so much.

Kwadwo:                             35:26                     You know, I, I want to get into a bit of some of these stories as well cause like you’re talking to me yesterday about a lot about their, a lot of these, these uh, the patients you see because on the surface, you know, when you see some of these patients in hospital, because it’s not an environment where they thrive, there’s a lot of attitude, there’s a lot of conflict. And so I think a lot of people get there. Whatever the expression is, guns up or backs up, the humanization is in the waste there. You know what I’m saying? And so can you think like what are some of the mindset that you find when once you make that connection, once you have that rapport, like where their head’s at?

Jeff :                                      36:13                     So I can only give you examples. And so just recently I was chatting with a young lady who would be in her twenties, early twenties, and, um, there was a lot of behavioral challenges that we had encountered with her. And, um, and we, she was a very profound opioid addict, defendable addict. And those behaviors were related to her addiction, either out there searching for the money to feed $150 a day habit, um, or the consequences of injecting and, um, being a fentanyl addict recovering from your injection. Um, and she just, I S chatting with her about, so opioid substitution and how we get better manage this and you know, this person who is at first standoffish and kind of hostile a little bit then just suddenly disintegrated. She was in her young 20s, early twenties, and she said, you know, I never thought this would be what my life was like.

Jeff :                                      37:25                     I squat in housing, you know, out in a parking lot. Um, I’m assaulted on a regular daily basis. Um, I have no belongings. I don’t connect with my family anymore. Um, four years ago I was in school and now I’m a street prostitute. Addicted to fentanyl, this is my life, you know, and you know, it’s hard for me to sort of think about how terrible that would be. You know, I couldn’t conceive of that for any of my children. And it’s very hard to walk away from that and saying, you know, that’s your problem. You made that decision. You know, her mental health, uh, she three or four years ago started to hear voices. That’s what our mental health deteriorated and that’s where it’s led her. Um, so I think we have an obligation not to walk away from that person.

Kwadwo:                             38:24                     I’m really glad to hear this story because once again, you know, a lot of the people listening to this is our healthcare providers and you know, I’ve said it a couple times now, but they are human beings. Yeah. This poor girl did not want to be sleeping with people to make money so that she could pay for her addiction. Right. And, and like, and Jeff like maybe even illustrate like once you’re addicted, what satellite? Like, you know, like we, we judge and say, Oh, they’re just seeking more drugs or whatever. What’s it like not to get that fentanyl.

Jeff :                                      39:05                     So they will say, um, that they can’t conceive of anything worse in their life, um, than to go without, um, one person just recently said, you know, if you gave me the choice of being hit by a car today and dying as a result of a motor vehicle accident or coming into hospital and withdrawing from fentanyl, I would choose any second the motor vehicle accident and death. Rather than that. That’s how powerful and how terrifying withdrawal is for these people. You know, and you know, you’d say, Oh, well why do they inject? Well, they inject because of this terror of withdrawing. They inject because of the high. And when you talk to them about, you know, well, you just can’t keep getting high all the time. Um, they look at you and they say, you know, you think I’m doing this to get high. I do this to get numb.

Jeff :                                      40:11                     I just want one hour out of 24 when I don’t have to be me. A person who is living on the streets, who has no family, poor, um, mental health, committing crime, things that, you know, they thought as they grew up, they would never ever do that would be somebody else. And now that’s who they are. And for 23 hours a day, they have to be that person. But for one hour they get to be known and they have so much history of trauma, uh, throughout their life, um, that they’re just trying to forget that for a very short period of time. So it’s really not up to me to judge when they inject or not inject or it’s only really up to me to better understand the circumstances.

Kwadwo:                             41:06                     Yeah. Even as a health professional, like I don’t know if I fully appreciate how difficult withdrawing can be on, on our patients and like, cause I mean, like most of most things that we see, we’ve all had a family member of broken leg go through, have a deliver baby bursa or appendix or whatever. You know, not everyone’s had a family member withdrawing fentanyl,

Kwadwo:                             41:33                     salt or hopefully not a clinician doing the same thing. But, uh, it’s less, um, what’s the word? Relatable maybe. And so like to hear stories like that I think can go a very long way. I got to ask you, because the work that you guys are doing once again to incredible is this unique to Ottawa, is this, uh, other places doing similar, similar activity.

Jeff :                                      42:04                     So the like we provide sort of comprehensive health promotion, primary care, secondary care, some tertiary care, uh, even end of life care, um, for the homeless community. So, and we have shamelessly borrowed and stole from some of our colleagues when they have good ideas throughout the country and internationally. However, now we’ve sort of moved beyond that and some of the work that we’re doing is almost every week we have somebody from another city, United States, Europe, um, um, Australasia just recently. So it is unique in terms of the overarching comprehensiveness of what we do, uh, that no other city does that. Um, however, um, some aspects of it have been reproduced in other jurisdictions for our managed alcohol program, um, is a program that has now been reproduced in all of the Netherlands. Wow. Um, yeah, we went to the Netherlands and looked at how they deal with opioid addiction, you know, so, um, it’s a, it’s a process of sharing internationally.

Kwadwo:                             43:17                     Yeah. Cause you know, one of the themes of our show is just promoting anything that’s innovative that provides better care, that allows healthcare to be more sustainable. And just hearing this and, and, and hearing the work that you do, hearing the 45 beds and diverting all this, these cases from emerge, like it really, it really needs to be championed that I, I mean, I know every city’s different and, and just like we talked about what each kind of clinical scenario you want to tailor it to the, to the city. But the bare bones of it I think is incredible.

Jeff :                                      44:00                     The principle is one that I think people who are interested in health policy should really adhere to. The principle is moving care to where it’s best applied based on the needs of that unique community and whether you’re indigenous or frail, elderly or homeless. Um, the, the principle is the same. You know, your day is filled with looking after people who probably at the Ottawa hospital could be cared for just as well in another cheaper setting, 100% and so shouldn’t we try and embrace that principle wherever we are now, I happen to have practiced that in a homeless setting and frankly, if you can do it in the shelters over here, and if you can give [inaudible] and oxygen and treat HIV and Hep C and seizures as well as addictions and mental health, and you can do that in a, an an environment of a shelter, you can probably do that anywhere. Wow.

Kwadwo:                             45:06                     That’s a, that’s a frigging powerful statement right there, man. Um, so many lessons there. What would you need to thrive even more than your thriving now?

Jeff :                                      45:20                     So when we started this process, we started with what I’ll call the front end. That’s the stabilization initial treatment, et cetera. Um, so somebody’s out of control because of their addiction, their mental health, living in a world of chaos. Um, it was, our hope is to be able to stabilize that person and get them frontline care for their HIV, their Hep C, their addiction and their mental health. And we did that and we continue to do that on a regular basis. But we never thought much about, you know, because we just weren’t thinking, um, about the back end. Like after that they’d turned to us and said, so what? Now you’ve got me stable, now I want a garden and reconnecting with my kids and I want to, you know, cook for myself. And you know, that led us then to say, okay, well we now have to have a lot of what I’ll call backend services.

Jeff :                                      46:24                     So we’ve got residential housing programs, we have four sites or hotels now that we’ve taken over with individuals. But as we continue to stabilize people and move people out of this environment, which is toxic to them and dangerous and inappropriate for anybody, and we just need 40 hotels, not for, you know, we need to have supportive, subsidized housing where we can take these people and say, here’s a place for yourself. Go and thrive. But we’re onsite, we will continue to help you with your mental health. We will continue to look after addiction. We will continue to look after your HIV and Hep C and endocarditis, whatever it might be.

Kwadwo:                             47:13                     Wow. They have that support there. You know, the thing I think is so beautiful, and I think I might’ve said this already, but it’s the nonjudgmental approach to treating these patients like the, you know, I still remember the days where somebody comes in with alcohol withdrawal. Okay. And you know, they’re usually at rounds and they’re, someone’s talking about giving them more sedatives to try and keep them more calm and all that stuff. And I’ll be, I’ll be like, just give them some alcohol, give them a Labatt blue on ice. Okay. Uh, and this will fix everything. The withdraw stops. We don’t have to give them an increasing level of sedation. So let me just walk you through what normally happens in real life. So if someone comes in with alcohol withdrawal, you treat them with normally a benzodiazepine, more like, uh, uh, Adavan for example, to try and manage their symptoms. Sometimes you need more. Sometimes their level of consciousness goes down. Sometimes they can’t maintain their airway, so now they need to be intubated sometimes that they, uh, they might develop a pneumonia because of the deck, decreased level of consciousness. They’re in ICU for four days. They cost the system probably about $15,000 at that point of ICU costs. And this solution could have been, they get their beer, they get their Brandy, get their alcoholic choice, and they’ll be home in a day.

Jeff :                                      48:45                     And often the solution was they came to you because of a pneumonia, which now because of the sedation that you give them is much worse. And they’re going to stay for a longer period of time with complications. And now they’ve got a seizure as well because of the alcohol withdrawal. In fact, if you just gave the person antibiotics out in the community, they would never have come to you in the first place. I’m willing to have gotten better care. Exactly. And that’s what you and I would have expected for a simple pneumonia. But for some reason we’re going to put those people at huge, risked their lives, withdraw them, and you know, they’re going to, it’s enormously expensive to them, their own personal health and to us as a system

Kwadwo:                             49:32                     cause of it. It all comes down from judgment, from not having that patient centered focus. Get put your ego away. See, look at Charlie or what, or Chuck and say, what do you need now to get yourself out of this? Yeah.

Jeff :                                      49:50                     Wow, man. And you know, when you sit down with Charlie or a Chuck, if I know this guy’s an architect or this guy was the guy who designed the Welland canal, or this guy is an artist,

Kwadwo:                             50:03                     I got to tell you, that was the most mind-boggling thing, Eila. Call me an ignorant a screwball. But that month, that week I spent with you, that was the most touching humbling thing is that you would talk to the 65 year old guy that’s dying, you know, and, and, and dying comfortably, thankfully because of the care that, uh, y’all were providing. But he lived a life. He had, he accomplished some things and he was, uh, uh, you know, a chartered accountant or, or work for the government and how to divorce, got to the bottle and, and that God, the better side of them got homeless, lost his money and had complications there of after, uh, related to that. And you just realize like, yes, these are, I keep saying it, they’re human beings

Jeff :                                      51:02                     and they, you know, frankly could be any one of us maybe of us a step away from those series of events, you know, that brought that person to that seat could be any of us or our families.

Kwadwo:                             51:15                     Absolutely. So just in summary, Jeff, where, how, how can we fix some of these, these major issues that could practically,

Jeff :                                      51:27                     so I think there is something that everyone can do in this. It’s not for healthcare providers or housing people or social workers. This is for our whole community and there’s something that we can all do to contribute. Yes. If you want to fix it, um, work on some of those upstream social determinants. Um, but they’re gonna take time. We’ve still got so many people who need care. Um, but communities can embrace these individuals. We can start to think of better ways of moving care out of the hospital environments, into the communities where we can do it much more effectively. We can listen to this community much more. Yes, we can invest in subsidized housing and we can do better with more addiction counseling and mental health services. All of those things are things we can certainly do. But at the same time, I would argue that we should be starting to seriously think about policy decisions.

Jeff :                                      52:34                     Um, you know, how do we think it’s right to fill our prisons with people with mental health and addictions? It shouldn’t we be trying to deal with that as a, um, uh, an illness rather than, uh, some social aberration. Um, so couldn’t we be thinking of more informed, um, drug policy, more informed, uh, social policy as we look to support these populations? Certainly our indigenous communities, certainly, uh, others who find themselves so disadvantaged, you know, shouldn’t we be reaching out with, you know, or advocating for, you know, evidence informed policy decisions rather than, uh, what seems to be, you know, palatable to a population such as warm, you know, there’s a war on drugs, which does not work.

Kwadwo:                             53:33                     I always liked to, you know, when we get to the end here, a story where you were proud of what you do. You, you got the sense that, you know, this is why I’m here.

Jeff :                                      53:46                     You know. Um, I’ve always thought we spend the first half of our life trying to live up to the expectations of our parents and the second half of our lives living up to the expectation of our children. And I think that time that I feel the proudest of what I’m doing is when, um, my kids see what I’m doing and they just say, you know, what you’re doing is a good thing and I just want you to keep doing it. And I think that makes all the, you know, the late nights, the on call, uh, you know, you know, times when I don’t sleep, that makes it worthwhile. And so I think that that’s probably the times when they’re with them and they say with the homeless and they just say, you know, your dad’s doing a good thing. Wow. That’s what probably makes me the most proud.

Kwadwo:                             54:44                     I mean, I, I, I always, I got to tell you, the life has changed since bringing in some offspring in the world. But I where you’re, where you’re seeing reigns. True. Like I always say all myself, like in general, in life in general, how would the kids react when they’re, if they saw dad in this situation, how would, how would dad want to react if dad was, what,

Jeff :                                      55:07                     how would you like to be viewed by your children? What would they say about you when you know, you’re 70, 80 or gone, but would they say, you know, yeah, you made it a whole bunch of money, you know, or he did the right thing.

Kwadwo:                             55:26                     Okay. And you know what, and that’s what it comes down to. And this is another theme of this show is like, let’s all try and do the right thing. Let’s all be able to look at ourselves in the mirror at the end of the day and say, I did something good here. Yeah, I did something that my kids will be proud of. And, um, I just, I do feel like sometimes we need to say that more, you know?

Jeff :                                      55:53                     Yeah. We have to think that our job, why we were here while we were put on this earth, while we were educated, why we were, you know, society put money into us was to serve. That’s why we’re here. And to serve a community no matter who they are, but those people in need and independent of their income and what they look like. So that’s our job.

Kwadwo:                             56:20                     And, and to be honest with you, like not to get too philosophical on, on

Kwadwo:                             56:24                     your cats, but like in this era where we’re a little bit where we’re seeing more depression and mood disorders and everything, you want to be happier, surf. Yeah. You know, help others and I promise you, you will, you’ll be more content. You’ll find more fulfillment and um, you know, it’s easier. I know for a lot of people it’s easier said than done, but you know, I, I do truly believe you’re moving towards that direction leads to a more fulfilled life.

Jeff :                                      56:58                     How’d you too, I honestly agree that this concept of bringing meaning into your life, we do it many different ways. We can, you know, through children, through relationships. Um, but some of us have this great opportunity to bring meaning to our work and we’re blessed and we shouldn’t squander that.

Kwadwo:                             57:22                     Amen brother. I, I can’t, I mean this was truly special for me, man. Like I, I’ve looked up to you for awhile. I, we didn’t totally get into all the work that Jeff does cause we would be here for three hours and 47 minutes, but you know, how, how many hours do you sleep in a day? I’m not a big sleep. Last time I asked you that you said about four hours and uh, and uh, the amount of work you do, the amount of meaningful work you do, the impact you’re having on so many lives. I am proud to know you already been a great fan of yours too. Thank you. Appreciate it. Thanks so much.

Kwadwo:                             58:08                     How amazing was that? Oh my God, I love Jeff. Um, so in terms of lessons from this episode, from an administrative level, we really need programs to support programs like Jeff’s where we provide care in a setting where the homeless and the vulnerable patient population can thrive. Uh, I think it’s, I think it’s scalable. I think it’s too important and um, we need to, we need more of that from a clinician point of view. Remember, these are human beings. Whatever we could do to support them in an environment that is optimal for them, I think we got to do our best to do that. So let’s work with our homeless population. Let’s work with, our drug addicts and, and, and provide them with care that will allow them to thrive. And then from a general population point of view, honestly, if you have time, volunteer your time, connect with these guys, provide some support. It truly is amazing. You will, you will get as much out of it as you are providing for them a promise you that. Okay. That’s it for episode. So if you want to connect with us, we’re on Twitter @kwadcast, we’re on Facebook at kwadcast. If you have any comments at [email protected] and thanks again everybody for tuning in and we’ll see you in a week or two.


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