Should doctors prescribe heroin to curb opioid deaths?

Last year, the Public Health Agency of Canada says that 4,460 Canadians died from an opioid overdose. The vast majority of the deaths were accidental. A new and controversial Canadian guideline for front-line health-care workers was published Monday in the Canadian Medical Association Journal. Experts are hoping the guideline will help to stem the tide. 

The guideline is a blueprint for doctors and other health-care providers who care for patients with the most severe form of opioid use disorder. It was developed by Dr. Nadia Fairbairn at the British Columbia Centre on Substance Use and the University of British Columbia plus colleagues from across Canada who are members of the Canadian Research Initiative on Substance Misuse.

*The guideline's overarching goals are to help clients enter recovery or at least limit their drug use. From where I sit, the strongest aim is to reduce opioid overdose deaths where the risk is highest.

The guideline's authors said opioid pills taken by mouth are the most effective method to reduce death in people with an opioid substance use disorder. Studies have shown that opioids reduce both the cravings for the user's drug of choice as well as withdrawal side-effects like tremors, sweats, flu-like symptoms and intestinal cramps.

Symptoms such as these motivate people to keep using.

The most controversial part of the guideline is what to do for those in whom oral opioids prescribed by an addiction physician fail to control cravings and withdrawal symptoms. In that case, the guideline states that injectable heroin or hydromorphone should be considered.

The choice between heroin and hydromorphone should be based on the which drug is available. The choice also depends on the patient's impression of which drug works best and on the judgment of the prescriber. Comparative efficacy as shown in studies is another factor.

The rationale for giving these patients injectable heroin or hydromorphone is so they don't buy opioids on the street.

It's the emergence of street fentanyl and carfentanil that have led to an increase in opioid deaths. These illicit opioids are far more powerful and far more dangerous than heroin and morphine. The 4,460 opioid overdose deaths in 2018 represent a nine per cent increase over 2017 and a 48 per cent increase from 2016. Ninety-four per cent of the opioid overdose deaths in 2018 were unintentional.

Steering users away from street fentanyl and carfentanil is an effective way to reduce opioid deaths. Another way to prevent deaths is to distribute naloxone kits that enable bystanders to reverse the effects of an overdose in time to save lives.

There are several challenges in implementing the new guideline. Treatment with injectable heroin is the standard of care in several countries, including Switzerland, the Netherlands and the United Kingdom. But Canada has placed restrictions on accessing heroin. For that reason, hydromorphone (sold under the brand name Dilaudid) has been used to where heroin is not available. The authors say additional research is needed to see which of the two opioids should be used, and under what circumstances.

Expand prescription heroin access

The authors also call for expanded access to heroin across Canada.

Beyond that, policy-makers and health-care people in each province need to plan for the growing number of users who might benefit from harm reduction and provide adequate funding to treat them.

This harm reduction approach has its share of critics; among them, activists, politicians and even some addiction health-care providers. Some say the term harm reduction is vague because it means different things to different people. For instance, in the new guideline, it means preventing overdose deaths. But sometimes, it means preventing sexually transmitted infections and HIV.

A 2017 analysis found that harm reduction policies vary widely across Canada and overall are weak conceptually. Quebec and British Columbia, produced a lot of policy documents on harm reduction, while New Brunswick and Prince Edward Island had only one relevant policy and the Yukon Territory had none.

Another problem is that Canada has a history of moral ambivalence to harm reduction. In 2007, the federal Conservative government excised harm reduction from federal policy. It was brought back when the Liberals regained power in 2015. With a federal election campaign underway, it's worth keeping in mind that a new government might switch things again.

Admonishing people to stop using opioids doesn't work, and it doesn't prevent opioid deaths. Harm reduction saves lives. 

The sooner Canadians get over their moral ambivalence, the more lives that will be saved.

* A prior version of this blog was corrected.