Vancouver doctors discuss prescription heroin as a safer alternative to fentanyl-laced drugs on the street

This Christmas, Dianne Tobin will celebrate one year free of heroin. It will be the longest she’s remained off the drug in 40 years.

“It’s been touchy at times, because I went down [in dosage] so fast,” she told the Georgia Straight over coffee in the Downtown Eastside. “It was tough at first, going down so much at one time. But it was working for me.”

Tobin owes her success at getting off street heroin to an unconventional therapy: since the winter of 2011, a doctor has prescribed her diacetylmorphine, or prescription heroin.

At the nearby Crosstown Clinic, Tobin is one of a small group of patients who received the drug under the care of a physician and nurses. Then, last December, she transitioned to oral hydromorphone, a synthetic opioid that is prescribed for pain.

“Today I wouldn’t put a needle in my arm—after 40 years—for nothing,” she said. “Nothing. I wouldn’t do it. It’s just a change in your attitude.”

Crosstown’s prescription-heroin program began as an experiment. When two studies there showed promise for select patients, Vancouver doctors tried to expand access. But they encountered stiff opposition from the former Conservative government in Ottawa. It attempted to shut the program down and barred new patients from enrolling. That door was finally reopened last September, when Health Minister Jane Philpott revised regulations to allow doctors to apply for special access to diacetylmorphine.

In a telephone interview, Crosstown’s lead physician, Scott MacDonald, stressed that the treatment is not for everybody. (When diacetylmorphine was offered in clinical trials, the average number of years a participant had spent addicted to street heroin was 26.6, and the average number of times they had tried and failed with a conventional treatment, such as abstinence or methadone, was 11.4.) But he revealed that prescription heroin for entrenched addicts is now being discussed at the highest levels of B.C.’s health-care system.

MacDonald explained that with the fentanyl problem and an unprecedented number of overdose deaths, health officials understand that prescription heroin administered in a clinical setting is a safer alternative to addicts buying drugs of unknown purity on the streets.

“That is being widely discussed now,” MacDonald told the Straight. “Terry Lake, the minister of health here in British Columbia, he indicated that the government sees the benefits of this treatment.”

In a September interview with Kamloop’s Radio NL, Lake explained his support for prescription heroin in the context of the province’s spike in overdose deaths.

“Given the opioid epidemic that we’re facing, we need every single tool available,” he said. “And for some people, the prescription heroin, diacetylmorphine, is an important tool and can return them to a more normal life, make them more productive, and keep them healthier.”

During the first 10 months of 2016, 622 British Columbians died of an illicit-drug overdose. According to the coroners service, that’s up from 510 fatal overdoses the entire previous year and 370 in all of 2014. Fentanyl has been detected in 60 percent of such deaths this year.

As the Straight went to press on Tuesday (November 22), the Vancouver Police Department confirmed it had found carfentanil on a drug dealer in the Downtown Eastside. Another synthetic opioid, it is significantly more toxic than fentanyl and last October was responsible for two deaths in Alberta.

“To me, it is not a fentanyl issue, it’s an opioid issue,” MacDonald said. “People are using fentanyl because it is what is available. It is the opioid that will meet their needs so they don’t feel sick.…So people that are using illicit opioids every day, we just need to get people into care.”

Today, there are 88 long-time addicts receiving prescription heroin at Crosstown, plus another 35 receiving injectable hydromorphone. Tobin is one of five patients who have transitioned from intravenous drugs to oral hydromorphone. Another 13 have transitioned to methadone or Suboxone.

MacDonald said that with the Harper administration’s restrictions removed, he wants to see those numbers grow. But so far, only one new patient has entered the program. MacDonald explained that’s because plans are on hold due to renovations at Crosstown. Those should be complete by March 2017, he said, at which point the goal is to expand access to a total of 200 patients.

“It’s a dent in the need,” he said. According to MacDonald, there are an estimated 500 heroin addicts in Vancouver for whom diacetylmorphine or injectable hydromorphone would be deemed appropriate.

“This space can only manage 200 at the most,” he said. “So if we’re going to meet the need in Vancouver, we need to expand that capacity. There needs to be more clinics or places that can provide supervised injectable opioid-assisted treatment.”

Establishing a prescription heroin program in Canada remains complicated by federal drug-laws from which a clinic requires exemptions if it is to provide diacetylmorphine legally. There are also security arrangements needed to ensure the drug’s safe keeping, and a learning curve among physicians who might not understand how heroin-assisted treatment, or HAT, as it’s often referred, can benefit long-time addicts.

Crosstown’s one new patient was referred there by Vancouver Coastal Health (VCH), the regional care provider that operates Vancouver General Hospital and Insite, the city’s low-barrier supervised-injection facility. In a telephone interview, the organization’s lead on harm reduction and substance use, Dr. Mark Lysyshyn, said VCH would like to expand access to prescription heroin but lacks the infrastructure that this requires.

“I have to say, it is not being discussed as much as it should be,” he told the Straight. “It hasn’t featured prominently in the provincial response to the opioid-overdose emergency.”

Lysyshyn stressed that, ideally, prescription heroin is only a first step in a patient’s long-term recovery.

“The hope, over time, is to convert people to oral therapies and then, potentially, off therapies completely,” he explained. “But in order to engage people right now, and to prevent them from injecting fentanyl right now, it is a really great option.”

Over coffee in the Downtown Eastside, Tobin emphasized the stability that she’s seen a prescribed regiment of opioids bring to fellow Crosstown patients’ lives.

“Every day, I see changes in people,” she said. “People that used to go to jail every week for petty theft, they are not going to jail anymore. Almost everybody has got housing….I see them getting healthier, getting jobs, working in the community.”