Overdose

by Benjamin Perrin

  I could see Westfall’s point. While drug checking did seem like a good measure to help give both regular and occasional users information that can reduce the risk of overdosing and dying, the drug supply is still just as contaminated as ever.

  –11–

  IS PROVIDING “SAFE DRUGS” GIVING UP ON PEOPLE?

  The lineup started to grow at 9:25 a.m. on Vancouver’s Abbott Street at the corner of West Hastings. It was a sunny morning, the first of June, 2018. The doors to the Providence Healthcare Crosstown Clinic would open at 9:30 sharp, but only for five minutes before closing again for another half hour.

  A middle-aged man walked out of the laundromat next door with a bucket of water and tossed it out onto the sidewalk. Another man strode by smiling, his boom box blasting “You Spin Me Round (Like a Record),” that 1985 hit by Dead or Alive. He walked past an elderly Indigenous woman wearing a red hoodie and lying slumped over on the sidewalk. A cane rested beside her. Her eyes were so puffed up she could barely open them.

  A thirtysomething man arrived on his bicycle, locked it up, and joined the queue. His bright blue T-shirt read “Safe Drugs. End Prohibition. Expand Injectables.” Then the doors swung open and a half dozen people slowly walked inside, the doors closing shut behind them. I went to the side entrance to meet Dr. Scott MacDonald.

  The Crosstown Clinic was the first place in North America to offer prescription opioids in a supervised clinical setting to people with long-term, severe opioid use disorder. The two medications it provides are used traditionally for pain relief: diacetylmorphine (also known as “prescription heroin”) and hydromorphone (also known as Dilaudid). Along with the clinic’s physicians and nurses are social workers and counsellors to help clients with life-skills counselling and housing referrals and connect them with legal assistance.

  Years ago, when I first heard about giving prescription heroin to people addicted to drugs, it sounded totally nuts. I assumed that it was only enabling drug use and perpetuating the problem. But now, in the midst of the opioid crisis, I knew I had to take a closer look at the controversial program and examine the evidence for myself.

  As thousands of people across the country die from using illegal contaminated street drugs of unknown contents and potency, the Crosstown Clinic provides legal pharmaceutical drugs of known contents and precise potency, dispensed and administered under medical supervision to qualified patients. No one has ever died at Crosstown.

  This type of approach has been used in Europe for years. So how did the idea of providing those who are addicted to illicit opioids with prescription opioids get started in Canada? Does it work? Should it be expanded? And isn’t giving someone drugs who’s addicted simply giving up on them?

  * * *

  ——

  In 2005, Dr. Martin Schechter from the UBC School of Population and Public Health led the North American Opiate Medication Initiative (NAOMI)—a randomized controlled trial (the gold standard of medical research) carried out in Vancouver and Montreal. Its focus was on long-term, daily users of injection heroin who hadn’t responded to multiple treatment efforts and had been extensively involved in criminal activity—people whom society had basically given up on.

  These individuals were randomly assigned to receive either oral methadone (the withdrawal management drug) or injectable diacetylmorphine (“prescription heroin”) up to three times per day under medical supervision. Both carry risks that need to be managed, so researchers monitored their use in the event of an overdose (which is a greater risk when people are using other substances).

  The results of the NAOMI study were published in the New England Journal of Medicine in August 2009. It found that patients who received diacetylmorphine made greater improvement on all metrics than those receiving methadone, including their retention in the study, medical and psychiatric status, economic situation, and family and social relations.

  “When people start on this kind of treatment they’re using illicit opioids, injecting multiple times a day,” explained Dr. MacDonald, physician lead at the Crosstown Clinic. We were sitting in one of the clinic’s medical examination rooms, so I kept expecting him to check my blood pressure or something. Dr. MacDonald had short grey hair, black-rimmed glasses, and wore a long-sleeved checkered shirt with jeans. He spoke with the precision and calm of a clinical physician with decades of experience, but he was clearly passionate about helping his patients despite their seemingly insurmountable odds.

  Since the NAOMI patients were being provided with known drugs under medical supervision, their lives were no longer dominated by the quest for contaminated street drugs and the often criminal or risky things they needed to do to get the money to pay for them. “People can instead focus on housing, their self-care, food. And ultimately we have had people go to school and work,” said Dr. MacDonald. “We have a few people who have completed training programs at Vancouver Community College and other schools. People reconnect to families. We’ve had people who have had families and moved on, who are not on injectables anymore.”

  The NAOMI study also reported an impressive public safety benefit. Twelve months into the study, two-thirds (67%) of the patients who received diacetylmorphine had reduced their illicit drug use or other illegal activities, with an average reduction of illicit heroin use from 26.6 days a month to 5.3 and of monthly illicit drug expenditure from US$1200 to US$320. For those patients on methadone, illicit drug use or other illegal activities went down by 47.7%, illicit heroin use went from 27.4 days a month to 12.0, and monthly illicit drug expenditure went from US$1200 to US$400. In other words, patients using diacetylmorphine fared better on each of these metrics than those using methadone.

  In short, NAOMI was a breakthrough study—the first to use prescription heroin as a means of treating severe, long-term opioid use disorder. But if the researchers and patients wanted to move the idea forward, they were in for a fight.

  “We applied to Health Canada when people were leaving NAOMI to have continued access to diacetylmorphine, but Health Canada at that time said no,” Dr. MacDonald told me. “So the study shut down. I think very many went back to the street and [its] associated consequences and risks. Many had found at last something that worked for them, and yet it was taken away.”

  * * *

  ——

  With diacetylmorphine facing significant political and regulatory barriers in North America and elsewhere, researchers next set out to see whether hydromorphone—a more accessible prescription opioid pain relief medication—could also be beneficial for people with long-term, severe opioid use disorder who had failed multiple other treatments. That was the question posed by the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME), which ran from 2011 to 2015.

  Some 202 patients in Vancouver who qualified for the study randomly received either injectable diacetylmorphine or injectable hydromorphone up to three times a day under medical supervision for six months. They weren’t told which medication they were receiving. They were also given access to physicians, nurses, addiction counsellors, and social workers. And they could choose to pursue other treatment options, such as methadone (to alleviate withdrawal symptoms) or detox. I asked Dr. MacDonald to tell me more about the patients enrolled in the SALOME study.

  “Hepatitis C. Homelessness. Mental illness. Criminal involvement—80% of our folks had been in jail for at least a month. Some have been in jails for years,” he said. “We selected folks who had an average 11 attempts at treatment and have been using for 15 years.”

  The findings from the SALOME study were published in the Journal of the American Medical Association Psychiatry. Interestingly, while most patients had initially said they’d prefer diacetylmorphine (prescription heroin), researchers found that most were unable to tell whether they were receiving it or the hydromorphone. Researchers also found that, overall, the two medications were equally effective in reducing illicit drug use. They concluded t
hat when diacetylmorphine isn’t available or hasn’t been successful for a patient, hydromorphone could be an alternative. “If hydromorphone is all we have, it will work for a lot of people,” Dr. MacDonald told me. “But here in Canada we’ve got access to both drugs.”

  Just as when NAOMI had ended a few years before, when SALOME wrapped up researchers tried to help maintain the treatment for those patients who were benefiting from it. The researchers had to ask Health Canada for special permission to keep offering each one diacetylmorphine under medical supervision. “We started sending in requests to access the Special Access Program [SAP] through Health Canada. There was a lot of back and forth,” said Dr. MacDonald. “Ultimately, at the end of September 2013, we got the first SAP approvals for diacetylmorphine. The same afternoon the minister of health at that time, Rona Ambrose, stood up in Toronto and held a news conference.” That’s when Ambrose announced she was intervening to halt the approvals, saying, “This decision is in direct opposition to the government’s anti-drug policy. Our policy is to take heroin out of the hands of addicts, not to put it into their arms.”

  Even though SAP approvals had already been secured for some SALOME patients, the federal Conservative government quickly brought in regulations to prohibit physicians from prescribing diacetylmorphine. The Conservative Party even went so far as to send out a fundraising blitz to its members, with a spokesperson writing, “I was shocked to learn today that Health Canada approved applications to give heroin to addicts—against the wishes of our elected government. We’re going to take steps to make sure this never happens again.”

  Just as when it had tried to shut down Insite, the Conservative government was again taken to court for trying to shut down an initiative that had proven to be not only safe and cost-effective but also reduced the risk of fatal overdose and actually reduced crime.

  Larry Love was one of the SALOME patients who sued the federal government. While serving in the Canadian Armed Forces his knee had been injured, and he was honourably discharged in 1969. He moved to Vancouver and started using heroin to relieve his pain. Love even spent time in jail for activities related to his illicit drug use. He tried methadone but was unable to function on it. Love attempted detox over 50 times.

  “It was a life of hell,” he said.

  Finally, during SALOME, his life stabilized. Love’s doctor applied to Health Canada for Love’s continued access to physician-supervised diacetylmorphine after the study ended, but was denied. Love returned to illicit heroin.

  On May 29, 2014, Chief Justice Christopher Hinkson of the BC Supreme Court ruled against the federal government in the case. He held that physicians for Love and other SALOME patients should be able to continue to seek permission from Health Canada to provide supervised access and use of diacetylmorphine.

  “We started getting SAP approvals again. It was funny. All these [approval] faxes used to come on a Friday before a long weekend,” said Dr. MacDonald. “Ultimately the health authorities, pharmacare and the ministry, stepped up and said we can continue the program.”

  * * *

  ——

  Today, the Crosstown Clinic has 150 patients who have long-term, severe opioid use disorder. About 80% of them receive diacetylmorphine and 20% receive hydromorphone; they inject it themselves, under medical supervision, at pre-set times every day. “They have seven minutes to inject and then we monitor them for 10 to 20 minutes afterwards. They’re good to go at the end of a half hour or less, and the next group starts,” said Dr. MacDonald. “People need to come two or three times a day for this to work. Most take a little bit of methadone or some long-acting morphine to sort of bridge them overnight.”

  In BC, owing to the opioid crisis, Health Canada recently added diacetylmorphine to its “List of Drugs for an Urgent Public Health Need.” This means that physicians like Dr. MacDonald don’t need to apply for special permission for every single patient they deem to require access to the drug. “We’ve been taking new patients since August,” he told me. “We have a waitlist of over 300 people.”

  During the opioid crisis, access to injectable hydromorphone has started to slowly expand to some other clinics in BC. Not only are these interventions effective at saving lives, improving quality of life, and reducing illicit drug–related criminality, they’re also cost-effective. A major study of the economic implications of these medications concluded that “[t]he costs saved through reduced involvement in violent and property related criminal activity and hospitalization outweigh the costs of both HDM [hydromorphone] and DAM [diacetylmorphine], and provide more benefit.”

  I asked Dr. MacDonald about the claim that providing prescription heroin to someone who’s addicted is tantamount to giving up on them.

  “Well, firstly, there’s no recovery from a fatal overdose. That’s painfully obvious,” he said. “This needs to be managed just as a chronic manageable illness. And if somebody is coming here three times a day, and no longer having to engage in the illicit stream of opioids, they get housing, they may be working part time. It’s a total success. What’s the alternative? Using illicit opioids daily and being engaged in criminal activity just about every day. This treatment provides relief from that. It transforms people’s lives and reduces the burden on taxpayers. If you’re concerned about costs and crime, you need to expand injectable treatment options.”

  * * *

  ——

  Dr. Schechter, who launched the NAOMI project that started it all, also points out that these programs don’t just substitute illicit street drugs for drugs of known content and potency; they also provide other intervention opportunities as well: “It is the application of a ‘bundle’ of interventions that includes not only the provision of the pharmaceutical, but the opportunity for patients to benefit from up to thrice daily contact with doctors, nurses and counselors; the breaking of their cycle of criminality, sex work, jails, and hospitalizations; and the stabilization of their previously chaotic lives which made improved health outcomes extremely unlikely.”

  Dr. MacDonald concurs. “Opioid use disorder is a chronic manageable illness, just like diabetes or high blood pressure—and just like somebody with high blood pressure or hypertension, you’ve got first-line therapies that will work for most people. Sometimes people require more intensive treatment. If somebody had to take a blood pressure pill or a combination of blood pressure pills for 20 or 30 years or longer, would you question that? No. The management of opioid use disorder is exactly the same. The treatments we have—including injectable opioid agonist treatment with hydromorphone or diacetylmorphine—we can show that when the other treatments haven’t worked, this is better care.”

  In fact, European studies have found that the average length of diacetylmorphine treatment is three years. It’s prescribed for opioid use disorder in the United Kingdom, Switzerland, Germany, Denmark, and the Netherlands.

  “If this were any other disorder or medical condition or illness, do you think we’d still be in the position of this being the only place on the continent where you can access these medications?” I asked.

  “Absolutely not,” replied Dr. MacDonald.

  “Why is that?”

  “Stigma. Stigma against people who use injection opioids, stigma against injectable treatments, and stigma against prescription heroin.”

  * * *

  ——

  “Get people access to clean drugs.”

  For Dr. Mark Tyndall, that’s the simple answer to what needs to be done today to stop more people from dying during the opioid crisis.

  Dr. Tyndall’s demeanour is measured and professional, but his frustration is evident, and for good reason. With 20 years of clinical experience, he’s now BC’s deputy provincial health officer during a public health emergency—which means that not only is he the main public face of the province’s response to the opioid crisis, but he also bears responsibility for coming up with innovative ideas. I
recognized his angular face and straight brown hair from the times I’d seen him on TV talking about the issue.

  Poster programs aimed at reducing stigma, housing and social services for users on the street, opioid summits, drug decriminalization—these are just a few of the ideas that have been proposed for dealing with the opioid crisis. However, for Dr. Tyndall, they’re all too late to help those at risk of overdosing today. “We are really trying to focus the conversation back on how we address the poisoned drug supply,” he explained. “Focusing on treatment as usual or other harm reduction as usual—it’s just not going to cut it. As long as we’re asking people every day to play Russian roulette with these drugs, people are going to continue to die.”

  The BC Centre for Disease Control is launching a pilot study in which a select number of people in Vancouver and Victoria at high risk of overdosing will receive hydromorphone pills two to three times a day at supervised consumption sites or supportive housing facilities. It’s expected that participants will crush the pills and inject them rather than using contaminated street drugs. The pills are also substantially less expensive than the injectable form of the medication. “The idea,” said Dr. Bonnie Henry, “is that you would transfer into this safe prescribed opioid instead of using toxic street drugs. Which is why we have some of the pilot projects that we’re looking into really pushing some of the boundaries around provision of hydromorphone pills to people who are addicted—to enable them to use a safe supply rather than street drug supply.”