A plan to provide severe addicts with pharmaceutical-grade narcotics at supervised consumption sites would be costly and likely controversial, but it would protect some of the region's most vulnerable people, says a top health official pushing for the initiative.
The proposal, still in the discussion phase, would see physicians dispense the drugs to users and then supervise their ingestion. This would reduce the risk of users overdosing on street drugs adulterated with substances such as fentanyl, and significantly expand the role of facilities such as Vancouver's Insite, which has never offered drugs to the people who inject there.
Health Minister Terry Lake says a recently convened task force of health and law-enforcement officials will examine the idea further.
Mark Tyndall, executive medical director for the B.C. Centre for Disease Control and B.C.'s deputy provincial health officer, has been in discussions with various health officials about the idea and says there are many details to be worked out. For example, they would need to develop criteria to ensure that the drugs are going only to the most entrenched addicts.
"If tomorrow you offered free drugs on site to people, a lot of people would stop bringing their own drugs," he said. "I think you'd get into a controversy if the government is paying for tens of thousands of people to be on high-dose morphine equivalents. That might be a difficult sell."
The four-year Study to Assess Longer-term Opioid Medication Effectiveness (SALOME), conducted in Vancouver's Downtown Eastside, concluded that hydromorphone, a painkiller roughly eight times stronger than morphine, is an effective maintenance tool in treating a heroin addiction. Its criteria for inclusion required that users had failed with traditional treatments such as methadone numerous times; Dr. Tyndall said the forthcoming initiative will probably require the same.
Officials would also have to figure out a way to pare down costs. Hydromorphone is costly in the large quantities that would be needed, and witnessed ingestion – physicians supervising ingestion on site, as opposed to allowing users to take the drugs home – requires many resources. The SALOME trial cost $7.4-million.
Dr. Tyndall noted that in such a controlled environment, physicians could also develop protocols to slowly wean users off drugs – tapering doses over a certain amount of time, for example.
The initiative "wouldn't necessarily need to be thought of as drugs for life," he said. "For a lot of people, having to go in two or three times a day to a doctor's office to get their drugs is quite limiting. If you work with them, deal with mental-health issues, you could graduate people."
There is no timeline for the program. Provincial Health Officer Perry Kendall says the idea is still "highly theoretical at present, with no moves to implement," while Dr. Tyndall said he would hope to see it up and running within a few months, in light of of B.C.'s current overdose crisis. A public health emergency was declared in April.
"I think the idea is to take some of our interventions that we know work and scale them up quickly," Dr. Tyndall said. "It would be great to think that in three months we have a clinic in some place where more people can access hydromorphone. Fentanyl has changed the playing field quite a bit."
Mr. Lake, who said he will await the task force's recommendations, has long been vocal in his support of SALOME and other harm-reduction measures in B.C.
"When you've got people who have tried [to quit] 10 times, and all of the recognized treatment options have failed – the SALOME trial has proven that having them on a maintenance dose [will result in] fewer hospitalizations, fewer deaths," the Health Minister said. "You're going to have people who can go back to work and be high-functioning members of society."
As of this week, 86 former SALOME participants continue to receive hydromorphone, while 42 continue to receive pharmaceutical-grade heroin.
Eugenia Oviedo-Joekes, SALOME's lead researcher, has emphasized that maintenance therapy is a second-line treatment for the small percentage of addicts who have failed at traditional therapies numerous times. The province has also improved access to Suboxone, a first-line treatment, which health experts say is safer than methadone.