Methadone from the SALOME trial. Photos courtesy of Providence Healthcare.
There’s at least one recorded casualty in the fight over prescription heroin in British Columbia, Canada. Back in September, B.C. doctors won approval from Health Canada to prescribe diacetylmorphine—the active ingredient in heroin—to 20 hardcore addicts in Vancouver. That decision lasted two weeks.
Health Minister Rona Ambrose is not OK with controlled doses of heroin, even in rare cases of severe long-term addiction where treatments like methadone and Suboxone have failed. On October 3, Ambrose changed the rules that normally allow doctors to prescribe unapproved drugs in life-threatening cases. “It was never intended to provide heroin to addicts,” she said in a press statement. “We are taking action to close this loophole.”
Ambrose claims there is “no evidence” that heroin-assisted treatment is safe, but eight years of peer-reviewed [research in a half dozen countries](https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CDMQFjAB&url=http%3A%2F%2Fwww.emcdda.europa.eu%2Fattachements.cfm%2Fatt154996ENHeroin Insight.pdf&ei=TK5lUqRE8GuiQLcyoGYDA&usg=AFQjCNFtbqbIMzJkxCaRucCWwnnMiOT9lw&bvm=bv.55) say otherwise. “Medically it’s not even vaguely controversial,” explains Dr. Gabor Maté, a Vancouver-based physician and addictions expert. “The decision has nothing to do with medicine.”
Independent clinical trials in Switzerland, the Netherlands, Germany, Spain, England, and Canada have all proven diacetylmorphine therapy works when all other treatments have failed. Prescription heroin is now being used in all of those countries except in Canada.
The feds are resting their entire position on the repeated catchphrase, “don’t give heroin to heroin addicts.” It’s the ideological equivalent of a D.A.R.E. PSA on repeat. Sure, the logic of prescribing heroin seems contradictory, until you remember addiction to smoking is treated the exact same way—with controlled doses of the active ingredient nicotine.
The British Columbia doctors who asked to prescribe heroin weren’t planning to have “socialist bloodsuckers” help them to “hand out drugs to our kids,” as one Conservative MP seems to think. Their patients all have a life-threatening opiate dependence—some habits spanning back several decades. Most of the addicts are finishing up a clinical trial that has administered supervised doses of either heroin or another opiate called hydromorphone for up to a year. They’re basically asking for an extension so they don’t get pulled into the crime, sex work, infection, and overdose associated with illicit addiction.
The Crosstown Clinic
According to a letter from Dr. Patricia Daly, chief medical officer for Vancouver Coastal Health, at least one of those patients has died of a street overdose after being cut off from the treatment. While it’s impossible to say if that patient’s death was the direct result of being cut off from the program, Dr. Daly is obviously concerned: “There can be no greater tragedy at the conclusion of any drug research trial than the death of a participant because they no longer had access to an effective intervention,” Dr. Daly wrote to Health Canada, adding she feared “further tragic outcomes.”
British Columbia’s own Ministry of Health isn’t happy, either. “I think withholding clinically beneficial treatments is unethical,” says Dr. Perry Kendall, provincial health officer at the ministry. “The evidence from randomized controlled trials in Germany, Holland, and in Canada show heroin to be beneficial and cost effective for some patients.”
While prescribing heroin is often seen as a last resort treatment, there may be other, less controversial options on the horizon. Researchers at the University of British Columbia and Providence Healthcare are halfway through the three-year study that will determine whether a legal opiate called hydromorphone is effective enough to replace diacetylmorphine in treating these rare addiction cases. The hope is the drug will do all the same things as heroin, just without the scary cultural baggage. But the study isn't over.
To keep some of the addicts in the health system, some physicians are prescribing hydromorphone—a derivative of morphine—before the clinical trial is finished. “They don’t have access to the drug they believe is most effective,” explains David Byres, vice president of Providence Healthcare. “Physicians at our clinics are experienced with addictions and the use of that drug, in a small number of cases they are prescribing [hydromorphone] for off-label use.” “There’s an argument for giving hydromorphone if they had done well on it,” Dr. Kendall says. “They’re trying that as the next best thing.” Chuck English is one of the lucky few that is accessing the “next best thing” after he finished the UBC-led clinical trial in August. “Methadone has never worked for me,” says English, recalling the sickness and sweats brought on the times he tried and failed to kick the habit conventionally. “I seem to be the kind of person who loses a lot of weight.”
English has a history with heroin, but says his most recent relapse has been especially painful. English was living and working in Cambodia when he was involved in a serious motorcycle accident. “All of a sudden—bam—I separated my right shoulder. I flew about 15 feet,” he recalls, pulling down the collar of his shirt to show the knotted scar. “They had to do emergency surgery, they had to put wires in my arms and my shoulder.”
“Then they gave me heavy duty doses of morphine,” he says. Still injured and out of a job, English returned to Canada with no money and no family support. “I started doing heroin again … I was on the streets, trying to survive by finding bottles. It was humiliating.” English say he failed out of treatment six or seven times before getting into the research program.
Chuck’s experience highlights the links addiction has to poverty, housing, and mental illness—all issues that fester and grow when chasing an illegal habit. The UBC study offered English an opportunity to get off the streets, apply for subsidized housing, and start seeing a counselor. “I don’t have to hustle for my hit,” he says. “I can hold down some work, go to the gym, swim, go for long walks, hang with friends; I won’t be looking for drugs.”
The government may face legal action from both patients and doctors over their refusal to let science or medicine inform their drug policy. “We’re just examining that right now,” Byres says. Pivot Legal Society is also building a constitutional legal challenge with English and dozens of other addicts impacted by the change.
Previously, the Supreme Court of Canada shut down the feds’ efforts to close Vancouver’s safe injection site, another harm-reduction program that is proven both medically and cost effective. “Since that decision, the government hasn’t made it any easier,” says Dr. Maté of the government’s hostile approach to science-based treatment. “Their general warnings to scientists are not to speak publicly about these results.”
With the heroin program prematurely canceled, and the persistence from government to close safe injection sites, hydromorphone may prove to be the solution to keep addicts living the healthiest lives possible. However until the clinical trials are complete, and a program green lit and expanded, there are many more addicts currently at risk who are not getting the treatment they need.
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