Canadian Medical Association

Nova Scotia physician Dr. Thomas Brothers on the importance of seeking expert advice — outside of medicine

June 1, 2022

Canada’s physicians are increasingly taking on public advocacy roles. Dr. Thomas (Tommy) Brothers — a general internal medicine resident in Halifax specializing in addiction medicine and harm reduction — talks about how he builds bridges with the community outside of medicine to better serve patients.

What motivated you to become a physician advocate in the addiction care space?

Early in medical school I worked with local harm reduction organizations in Halifax. I saw how these organizations did things really well — motivated by love, compassion, inclusion and autonomy and staffed by people with lived experience.

It was different in acute care settings. People working in the hospital weren’t comfortable with medications and had a different understanding of the nature of addiction; the same people I developed relationships with outside the hospital would have negative experiences as patients.

I wanted to become a liaison and bridge that gap by learning from the community and then bringing those lessons into medicine.

In 2021, Dr. Brothers earned a CMA Award for Young Leaders (Resident). Learn more about CMA Award for Young Leaders (Resident).

What are some of the barriers for patients accessing care in hospital?

Our team at the QEII Health Sciences Centre advocates for people who use drugs and are often experiencing homelessness. Despite health care professionals meaning well and having good intentions, there is a lot of misunderstanding and the needs of these patients are sometimes ignored.

Patients have had these horrible experiences in the hospital where they have been discriminated against, feel their pain has not been managed appropriately, or have been left to suffer withdrawal. As a result, they stay away from the hospital.

From an acute care side of things, it has devastating consequences.

For example, a patient who develops an abscess on their skin from injecting drugs may not seek treatment early — to have it drained or get antibiotics — so it progresses and becomes a severe infection.

We have heard feedback from patients locally that when we’ve aggressively treated withdrawal and pain and we’ve offered opioid agonist therapy, they have had more positive experiences. It’s a wonderful thing to hear but we still have a long way to go.

"Even when things are frustrating and discouraging, organizing for advocacy can be a powerful antidote to burnout."

How is addiction treatment changing in acute care settings?

I’m lucky I work in a tight-knit community. I’m not in a formal leadership role, so I don’t really have a way of changing policy or practice directly from above. From the beginning, I have focused on relationship building, team building and inviting people into the conversation.

Initially, my work started through conversations with our local street nursing service, Mobile Outreach Street Health (MOSH). I could see the obvious benefits of how they worked.

In hospital settings, though, some physicians felt out of their depth and didn’t have the knowledge or skills to care for patients who use drugs. But really the clinical tools existed; they just hadn’t necessarily been applied.

Tell me more about the clinical tools physicians are now using in hospital.

Well, all inpatient physicians and surgeons would be comfortable using short-acting opioids to treat pain in the hospital setting. But because of the misunderstandings and assumptions about the nature of addiction, there is hesitancy to prescribe those medications to relieve suffering when people already have an opioid use disorder.

When we work with patients to determine opioid dosage, they can stay in the hospital and avoid needing to access illicit sources of drugs, and they get the medical care they need.

"We can empower fellow doctors and nurse practitioners to learn about the different medication options for opioid addiction; this has also helped to reduce stigma."

With colleagues in emergency medicine, I also helped develop a protocol that is kind of like a checklist. It’s supported by pharmacists and means within a few hours patients can be on a therapeutic dose of buprenorphine/naloxone, tradename Suboxone.

Even for patients briefly in the emergency department, it’s important to be able to offer these medications on demand. First, it helps prevent overdose and withdrawal. Second, if they are interested in treatment this may be a “reachable moment” to start on medications. Starting medications in acute care settings greatly increases the chances someone will continue on opioid agonist treatment once they leave the hospital.

What are you hoping to achieve in the future with these initiatives?

In terms of making these changes permanent and having experts on staff to offer this care, we have been trying to find a source of funding but we don’t have a clear path forward. It’s still relatively new to apply harm reduction practices in hospital settings.

Some of the changes we have made take advantage of existing policies. For example, we introduced take-home naloxone kits at the hospital. That came from an outpatient policy, but we applied some creative thinking to it to make it relevant for an inpatient setting.

We are developing draft policies related to harm reduction and substance use in hospital for local health authorities and hope they will be taken up in a sustainable way.

This interview has been edited and condensed for clarity.

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