Injection stalls at Insite, the legal supervised drug injection site, in Vancouver, British Columbia, Friday July 17, 2015.Rafal Gerszak/The Globe and Mail
Health officials in British Columbia want to provide pharmaceutical-grade opioids to some addicts at supervised-consumption sites to tackle the province's soaring number of overdose deaths.
While they caution that there are no concrete plans yet, such a measure would make British Columbia the first province in Canada to provide prescription narcotics to addicts outside a clinical trial, while significantly expanding the role of facilities such as Vancouver's Insite – the country's first public supervised injection site, which has never offered drugs to users who inject there.
In a series of e-mails released under Freedom of Information legislation, the health officials note that deaths from illicit-drug overdoses are at an all-time high, driven in large part by the growing prevalence of illicit fentanyl, and more aggressive interventions are needed.
Brian Emerson, a medical consultant for British Columbia's Ministry of Health, said a case could be made for making pharmaceutical-grade opioids available to addicts through harm-reduction sites.
"It is clear that people are going to use opioids irrespective of the risk, so giving them small quantities of something of known concentration through a service that can provide them with advice on safer use, and provide them with an overdose kit, is something worth consideration," Mr. Emerson wrote in a Feb. 25 e-mail to provincial health officer Perry Kendall, copying various officials from the ministry and the B.C. Centre for Disease Control.
Overdose deaths have spiked in British Columbia, reaching 371 in the first half of this year. British Columbia has long been seen as a leader in harm-reduction strategies – it is home to North America's only public supervised-injection site, and naloxone, an opioid-overdose-reversing drug, has been distributed free of charge to users throughout the province since 2012. But health officials say more needs to be done to fight the scourge of fentanyl, which is now detected in about 60 per cent of illicit-drug overdose deaths.
Under the proposed idea, addicts who do not respond to traditional opioid substitution therapies such as methadone and Suboxone could receive a drug such as hydromorphone – a powerful painkiller – as a safer alternative to street heroin. It would be ingested in a medical setting, necessitating daily interactions with health-care providers. According to studies from Switzerland and Britain, this demographic makes up less than 10 per cent of all people on opioid-dependence therapies.
In an interview, Dr. Kendall said the idea – still "highly theoretical at present, with no moves to implement" – would be a second-line treatment for a small group of people.
"I think people are saying, in the face of all these overdoses, can we think about it as being something that is not desirable, but better than killing yourself with an illegal drug?"
But there are hurdles. Hydromorphone is commonly used in palliative and acute care, but it is not licensed for addiction treatment. Doctors can prescribe it for this purpose "off-label," but some may be hesitant to do that.
Similarly, the drug is not covered by British Columbia's PharmaCare as an addiction treatment.
To make hydromorphone an approved addiction treatment, its manufacturer would have to file a submission to Health Canada for review and approval. The federal department has not received such a submission to date.
A recent study out of Vancouver's Downtown Eastside, called SALOME, found that hydromorphone is an effective maintenance tool in treating a chronic heroin addiction. Participants could not discern whether they were receiving heroin or hydromorphone, suggesting street heroin – stigma-laden and often cut with other substances – could be replaced with the licensed pain medication.
"There is a lot of focus on the supervised-consumption facilities, and that is very important, but that doesn't resolve the issue that people continue using illicit opioids," Eugenia Oviedo-Joekes, the study's lead researcher, said in an interview.
"What [this initiative] could mean is that, for those people who are not attracted to [traditional] treatment, they are unlikely to overdose because we are prescribing them pharmaceutical-grade injectable opioids and re-engaging them into treatment. They might never have an overdose," she said.
Dozens of former study participants continue to receive pharmaceutical-grade heroin; Dr. Kendall said it is unlikely that prescription heroin would be considered for the initiative due to regulatory hurdles and the stigma that is attached to it.
Mark Tyndall, executive medical director for the B.C. Centre for Disease Control, supported the idea to provide some access to pharmaceutical-grade opioids, responding in an e-mail that some physicians are already doing it, but "it is certainly frowned upon and few patients can take advantage of this."
Dr. Oviedo-Joekes noted that there were 88,000 injections administered as part of SALOME and only 14 people overdosed, requiring resuscitation by naloxone.
"If those 88,000 injections would have happened with a [drug] that was neither hydromorphone or [prescription heroin], can you tell me there would only be 14 overdoses?"
Andrea Woo