Prescription heroin, a last-resort treatment for severe addiction currently restricted to only one clinic in all of North America, could one day be dispensed at pharmacies much as methadone is.
The dispensation model is one of three proposed in a draft of B.C. guidelines for the expansion of supervised injectable opioid-assisted treatment (siOAT) obtained by The Globe and Mail.
The document, being prepared by the nascent BC Centre on Substance Use (BCCSU), is a first-of-its-kind in North America and reflects the centre's push to provide a wide range of options for people struggling with substance use. Opioid-substitution therapies such as methadone and buprenorphine-naloxone (Suboxone), taken orally, are the most commonly prescribed medications for people with severe opioid addiction, but those who do not respond to these first-line treatments have few other options.
"It has long been recognized that more intensive treatment involving alternative pharmacotherapy options are required, as some patients will not benefit from oral treatment," the guideline states.
"Research has shown that, among patients who [do not respond] to methadone, prescription diacetylmorphine (heroin) administered in a clinic setting may be beneficial in terms of reducing illegal or non-prescribed opioid use, drop-out, criminal activity, incarceration and mortality."
The document suggests three models: a dedicated treatment program such as Vancouver's Crosstown Clinic, where about 120 people currently receive siOAT; a smaller siOAT program integrated within an existing community health clinic; and a pharmacy-based delegated model, where trained pharmacists would dispense and witness injections.
Considerations for patient eligibility include a history of injection-drug use, severe opioid-use disorder and multiple attempts at first-line treatments such as methadone or Suboxone.
The patient, his or her doctor and "identified relevant healthcare and service providers" would jointly determine the appropriateness of siOAT, which European studies show is suitable for between 5 per cent and 10 per cent of all people on substitution treatment.Injectable treatments are the highest-intensity option available for opioid addiction and require patients to visit a clinic two or three times a day. When patients are stabilized, physicians should encourage them to transition to lower-intensity oral options, the document says. According to data from Europe, where heroin-assisted treatment has been available for decades, the average length of treatment is about three years.
The B.C. guidelines have not been finalized and could still be changed.
Federal Health Minister Jane Philpott supports the expansion of injectable treatments and has said she will review British Columbia's guidelines when they are ready and consider them for federal adoption.
"I think we need to support the provinces and territories as they, hopefully, look to making these types of treatments more available for severe addiction," Dr. Philpott told The Globe in a January interview. "We're working on having a roundtable where [experts will] talk about whether or not these guidelines could be expanded, or could be made available as federal guidelines."
Based on operations at the Crosstown Clinic, it is estimated that a dedicated supervised siOAT program would require 4.5 full-time nurses at a salary of $110,000 each for the clinic to operate 12 hours a day, serving about 150 patients a day, according to the guideline.
Each patient would cost just under $25,000 a year: $14,750 in operational costs and roughly $10,000 in medication. Providence Health Care has estimated that one person using illicit opioids, left untreated, costs society about $48,000 a year in health-care and criminal-justice costs.
Karen Ward, a board member of the Vancouver Area Network of Drug Users, said the continuum of care being developed – ranging from abstinence-based options to siOAT – demonstrates a crucial, patient-centered approach to addiction treatment.
"[Drug users] need to find what works for them," she said. "It's not about the person failing the treatment, but about the treatment failing the person."
Jordan Westfall, president of the Canadian Association of People Who Use Drugs, said the creation of the guidelines is a promising step toward the expansion of a life-saving intervention.
"But without political motivation and political funding," he said, "no one is going to get this treatment."