Injectable opioids homegrown solution to fix fentanyl crisis
Crosstown Clinic head shares his views in our series, The Fentanyl Fix, solutions to B.C.'s overdose crisis
When you're in the thick of the B.C. overdose crisis — hearing about, or witnessing firsthand, the daily suffering, overdoses and deaths associated with it — it can be tough to hope for a solution.
However, in B.C., there is more than hope. There is a homegrown solution and it's called siOAT or supervised injectable opioid assisted treatment.
It's fair to say we all wish people would or could stop using illicit opioids. In B.C., we are fortunate to have readily available treatments like Suboxone and methadone to help those with substance use issues.
These therapies are now integrated into the health care system, and the health authorities, specialists and others are working to improve access and care for those with opioid use disorder, a chronic, relapsing disease.
10 percent have severe disorder
But some people — about 10 per cent of illicit drug users — have such a severe disorder that conventional oral treatments don't work.
The good news is siOAT, available at Providence Health Care's Crosstown Clinic (the only one of its kind in North America) is helping these patients regain health and eliminate their risk of overdose. Some even stop using altogether.
Providing opioid substitution treatment helps ensure people will live long enough to reach their potential. Recovery is different for each individual. Attracting people into care is the priority, for one thing is certain: no recovery is possible after a fatal overdose.
Swiss so successful clinics no longer needed
British Columbia is not the first jurisdiction to face an epidemic of illicit opioid use and fatalities. Switzerland struggled with injection drug use in the late 1980s. It recognized that while oral substitution treatment worked for many, it wasn't for everyone.
Someone had the idea to attract people into care with medical grade heroin in a supervised setting. It was a success and siOAT was integrated into the health care system about a decade ago. The epidemic ceased.
Although injectable treatment is available to whoever needs it in Switzerland, over 90 per cent of those receiving opioid substitution treatment are receiving an oral option. The prescription heroin clinics operate at less than capacity and, with the epidemic now under control, some clinics have even been closed as service demands have decreased.
Prescription heroin tested in Vancouver
A study called NAOMI, which investigated prescription heroin, had a site in Vancouver from 2005 to 2008. Its results, published in the New England Journal of Medicine, showed injectable diacetylmorphine (medical heroin) is superior to methadone for those who continue to use illicit heroin, despite attempts with methadone therapy.
The study, however, did not transition to a full program and a public health opportunity was lost.
I worked on that study and saw many who had done well with prescription heroin treatment sadly return to illicit opioid use. Some died of overdoses.
Denmark looked at the NAOMI results and implemented siOAT. Prescription heroin is now integrated into the health care system there. The Danish government is to be lauded for providing care for its most vulnerable citizens.
Users reconnected with family
Researchers then theorized that hydromorphone, trademarked as Dilaudid, might be an alternative injectable treatment and set out to test it.
The SALOME study was run at Providence Health Care's Crosstown Clinic in Vancouver and proved hydromorphone is as good as prescription heroin in treating chronic opioid use. This study successfully transitioned participants to a treatment program.
Nearly 150 people receive treatment at Crosstown, some with heroin, others with hydromorphone. All have regained health. Some have reconnected with family and others have completed schooling. Many are working again, some full-time.
I am thankful for the support of Health Canada and the B.C. government for supporting this treatment approach.
Supervised injectable opioid assisted treatment is not just more effective than other therapies for chronic substance users, it also saves money and reduces harm to society. When you know you will be receiving medical-grade heroin or hydromorphone regularly, as Crosstown patients do, you don't need to commit crimes to get illegal drugs as you once may have done. Policing, court, property damage and other costs decline significantly. In fact, it costs about $25,000 per patient per year. A conservative estimate of costs to our community of illicit drug use is about $45,000 — almost double.
'The overdose crisis will end'
When scientific evidence shows a treatment is safe, effective and cost effective, it should be offered. I was encouraged to hear the mayor of Vancouver, the chief of the Vancouver Police Department, the fire chief and public health officials call for treatment on demand after the worst night ever for overdose fatalities back in December.
To get everyone who needs treatment into care, injectable treatment options are necessary. With adequate resources for siOAT the overdose crisis will end. Care can be provided to the most vulnerable opioid users in our province.
Commitment by health care decision makers for supervised injectable options is the key to making this possible.
Scott MacDonald is the lead physician at the Crosstown Clinic in Vancouver B.C.
The Fentanyl Fix is a week long series exploring potential solutions to B.C.'s opioid overdose crisis. In 2016, 914 British Columbians died by overdosing on illicit drugs.