Drug users, health care staff critical of Alberta’s prescribed opioids strategy

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Ophelia Cara would need to spend a full day on public transit travelling to and from a specialized clinic under Alberta’s new prescribing strategy to access a rapid-acting opioid that she says saved her life. The Calgary woman was prescribed hydromorphone from her doctor nearly two years ago to treat her reliance on fentanyl.

Currently, she picks up her prescription from a nearby pharmacy and takes it home. But the new regulations announced last week mean that she will need to access the drug under supervision at one of 11 Alberta Health Services clinics. Only one is in Calgary.

“It feels like I have to make the impossible choice because while they’re not outright taking my prescription away, but they’re making it completely inaccessible,” said Ms. Cara, a well-known advocate for services that support people who use drugs.

She is among a group of addiction-treatment patients, doctors and advocates who are criticizing the changes to Alberta’s opioid-prescription strategy – which also includes fentanyl and a form of prescription heroin that is not currently used.

The government says the new standards will protect communities by ensuring people cannot trade or sell the narcotics on the illegal market, while allowing more people to access the treatment.

The risk of drug diversion “is simply too high to offer this service in any other way,” Eric Engler, press secretary to Mike Ellis, associate minister of mental health and addictions, said in a statement, pointing to the over-prescription of OxyContin in the early 2000s and resulting deaths.

“The medications that may be provided as part of this program can be extremely dangerous, especially if they are diverted into the community. This service will only be provided to those with the most severe cases of opioid addiction, in a supervised setting, with no opportunity for diversion of dangerous opioids to the community,” his statement said.

Premier Danielle Smith did not respond to requests for comment.

The change takes away the ability for pharmacists, family doctors and other dispensers to prescribe these drugs and it eliminates take-home doses. The new rules also require service providers to have a treatment plan in place for patients, with the expectation to transition them to more traditional, and what are considered lower-risk opioid agonist therapy (OAT) medications, such as methadone.

Typically, people prescribed hydromorphone and fentanyl have been unable to start or stabilize on OAT, according to addictions physicians. They say these patients are at extraordinarily high risk of overdose, and addictions experts say it is unlikely they would be able to adjust to OAT.

Mr. Engler said the new transition program is only for the most severe cases of opioid-use disorder and that the majority of Albertans are able to stabilize on OAT.

Ms. Cara follows a strict schedule taking three doses a day, two of which would not fall within the operating hours of a specialized clinic closest to her – about two hours away each way on transit. She said there won’t be time left in the day for work, hobbies or school.

Studies out of British Columbia last year suggest the use of diverted pharmaceutical opioids can reduce the risk of exposure to uncontrolled opioids and associated harms.

Bonnie Larson, a clinical assistant professor in the Department of Family Medicine at the University of Calgary, said often these complex patients only trust their family physician owing to experiences of trauma and racism in the health care system. She said severing these relationships can destabilize patients.

“The stakes are very high in this scenario – they are life and death,” said Dr. Larson. “The new rules require them to adhere to a punitively structured treatment model that we know can, at best, be difficult or impossible for patients to tolerate and at worst, be fatal because they will return to a poisoned drug supply that is killing so many.”

In Calgary and Edmonton, AHS has already taken control of prescribing hydromorphone, heroin and fentanyl as treatment for opioid-use disorder, though there are no patients currently prescribed heroin. Within five months, current prescribers across the province will have had to transition patients to OAT medications or an AHS clinic.

The regulatory College of Physicians and Surgeons of Alberta said, in a statement, it is currently developing guidance for its members to understand and navigate the changes announced by the government and how it could affect their current practice.

Pharmacist Rich Rego said the transition “pretty much kills” another life-changing program in the province. He helped engineer a mobile version of OAT during the COVID-19 pandemic, which delivered medication under supervision to complex patients who have barriers to accessing specialized clinics owing to cognitive, transportation and financial constraints.

More than 7,400 Albertans have died by unintentional drug overdoses since 2016 – with 900 in the first seven months of this year alone. Fatalities in Alberta reached new highs during the pandemic with a peak in late 2021. Deaths have dipped since but remain far above pre-pandemic levels.

On Thursday, the Alberta Nurses Coalition for Harm Reduction released an open letter sent to Ms. Smith that expressed strong opposition to the new standards, calling them “coercive” and ideologically driven. It says the rules will disproportionately affect rural and remote residents required to travel to the dedicated clinics and will devastate Indigenous communities, which face significantly higher rates of drug poisoning.

Ms. Cara’s mother, Marianna Balogh, said the prescription opioid has not only kept her daughter alive but given her the opportunity to enjoy life.

“My only message is ‘Let my daughter live so she can work out her future,’” an emotional Ms. Balogh said. “In an ideal world she would be clean and drug-free but as long as she is alive, I have hope.”