A Vancouver physician is prescribing fentanyl to patients with opioid-use disorder in the latest effort by the medical community to curb overdose deaths caused by a toxic supply of illicit drugs.
The pilot project began in July with eight patients who sought treatment for illicit-drug use but have not benefited from existing oral or injectable substitution therapies such as methadone, buprenorphine (Suboxone) or hydromorphone.
Each patient gets a fentanyl patch – commonly used to treat chronic pain for conditions such as cancer – that is applied to the skin and changed every two days by a nurse. To address misuse, the patches are signed and dated, and a transparent film is applied to prevent tampering. It is believed to be the first formal program of its kind.
The British Columbia Centre on Substance Use (BCCSU) said the program is still being evaluated. However, no adverse effects have been reported to date, and some improvement has been noted, according to a commentary on the pilot published on Monday in the journal Substance Abuse Treatment, Prevention and Policy.
“Some people are feeling great,” said BCCSU education physician lead Christy Sutherland, who runs the program. "They report that they’re using [illicit drugs] less, that they’re feeling hopeful about this new treatment option, but it’s still quite early.”
llicit fentanyl use in B.C. was once largely limited to smoking patches diverted from hospitals or pharmacies, or unknowingly ingesting it with other opioids such as heroin or oxycodone. But the drug came to replace most illicit opioids in B.C.
At the Harm Reduction International Conference in Portugal this spring, Jane Buxton, epidemiologist and harm-reduction lead at the BC Centre for Disease Control, noted that intentional fentanyl use in B.C. tripled over 3.5 years.
Illicit fentanyl is much stronger than heroin, meaning conventional treatments might be inadequate. A separate 2018 study in Vancouver found illicit fentanyl in 52 per cent of participants on substitution therapy, demonstrating the limitations of existing options.
Geoff Bardwell, a postdoctoral research fellow with the BCCSU and the faculty of medicine at the University of B.C., who co-authored the commentary, said illicit fentanyl has necessitated new strategies to attract and retain high-risk individuals in treatment.
“All of the research around methadone and Suboxone, about their efficacy, have only been done in the era before fentanyl,” Dr. Bardwell said. “We know that these treatment options aren’t working for everyone, so we need to turn to the medical community to come up with new models.”
Substitution therapy – also called opioid-agonist treatment – involves providing patients with medication to prevent withdrawal symptoms and reduce cravings. It can reduce the risk of harm associated with illicit-opioid use – such as involvement in crime, sex work, unsafe drug consumption and blood-borne illnesses – and can help people live more stable lives.
B.C. declared a public-health emergency due to overdoses in April, 2016. In the three years since, according to the centre for disease control, the number of people on methadone in B.C. increased by almost 10 per cent, or 1,342 people; buprenorphine (Suboxone), by almost 142 per cent, or 3,417 people.
Newer treatments include slow-release oral morphine, which 1,581 people are now on; injectable hydromorphone (108 people); and injectable, pharmaceutical-grade heroin (122 people).
The BCCSU’s guidelines for the clinical management of opioid-use disorder note that such treatments have been shown to be superior to simply stopping “cold turkey” in terms of retention in treatment, sustained abstinence from illicit-opioid use and reduced risk of disease and death.
But rather than call for the substitution therapy with fentanyl to be scaled up, Dr. Sutherland is urging government to regulate a legal and safer supply of drugs so physicians are not left to manage problems related to drug prohibition.
“The government has to decriminalize and create a legal, regulated market for drugs in Canada because [while] it’s nice to give medicine to people and to do primary care and come up with these solutions, they’re never going to address the root issue, because the root issue is caused by criminal justice,” she said.