Three times a day. That’s how often most of Dr. Scott MacDonald’s patients visit Providence Crosstown Clinic in Vancouver. At each visit, under the supervision of nurses, they inject themselves with a single measured dose of diacetylmorphine, a drug typically known by a different name: heroin.
Essentially, MacDonald treats heroin addiction with heroin—administered under the watch of medical professionals in a tightly controlled dosage and setting. Canada has been studying the use of prescription heroin and injected hydromorphone (Dilaudid) as a treatment for opioid addiction for more than a decade, and they’ve found that it works. Around 80-90 percent of patients given prescription heroin stay in treatment beyond a year, their lives often stabilize, their crime rates plummet, and they’re dramatically less likely to overdose than those obtaining opioids on the black market.
“Our folks are not dying from opioid overdoses,” MacDonald says. “If people are in care, they are protected.”
Now, Canada is beginning to expand access to injectables for patients who’ve tried oral regimens like methadone without success.
That might sound radical in the United States, where cities that want to open safe injection sites are finding themselves in legally murky waters, but in making prescription heroin more widely available, our neighbor to the north is joining countries like Germany, Denmark, the United Kingdom and the Netherlands where diacetylmorphine is just part of the health system, one possible option in the arsenal of doctors trying to help patients struggling with addiction stay safe and alive.
We spoke to MacDonald about who benefits from prescription heroin, how the rise of fentanyl has impacted his work and what Crosstown Clinic has meant for patients’ lives.
How would you describe the current mindset toward opioid addiction in North America?
It is a chronic, manageable illness, but we have thousands of people who are dying from opioid overdoses in North America and who are not attracted or engaged in care.
I think some of that is because we, as a society, have not yet accepted that it is an illness. The most important part of that is that it is a manageable illness, just like diabetes or high blood pressure. If people are offered treatments that don’t have side effects, are attractive to them and that work, they can be attracted into care, retained in care and do very well in treatment
Yes, this more intensive than taking methadone or suboxone or an oral treatment that you might need to pick up once a day. But when nothing else has worked, we’ve got evidence now showing that this is both more effective and more cost effective. When those two conditions are met, it is a treatment that should be expanded and made more available.
Can you tell me a little bit about your patients? What brings them to you?
We start by looking at SALOME (Study to Assess Long-term Opioid Maintenance Effectiveness) inclusion criteria. Using that criteria, we selected folks who had on average been using 15 years and had had 11 attempts at treatment. So, the folks that need this treatment, they’ve tried other things, and they’ve been using for a long time.
Is there more demand? Do people want to get into the program?
Yes. We’re a small clinic. [Crosstown currently has about 130 patients.] We might be able to get to 150 here, but that will be really pushing our capacity at one small clinic. One clinic is not going to take care of all the required need. If we look at the European experience, there’s a number of countries in Europe where injectable opioid agonist heroin treatment is integrated into the health care system. It’s never been more than five to eight percent of people who require oral treatment who would need an injectable treatment.
Here in British Columbia, where we probably have about 30,000 who need or are receiving oral opioid treatment, we predict 2,000-3,000 would need injectable opioid [treatment].
Is prescription heroin expanding elsewhere in Canada?
We’re still the only clinic offering diacetylmorphine, prescription heroin, here in British Columbia, but that’s going to change. There’s currently a number of clinics, at least four in downtown Vancouver now offering injectable hydromorphone and a clinic in Surry now has started in the last couple weeks.
There’s a move to get this expanded across the country. In Ontario, Ottawa has an injectable hydromorphone clinic up and running now, and there’s a Sandy Hill Clinic planning to start in the early fall. Toronto is starting injection clinics. Alberta is also well along in their plans. They hope to have a clinic open in Calgary by the end of the summer and in Edmonton by the fall.
How does this treatment impact patients’ lives?
What we want is for people not to have to inject illicit opioids, which results in behaviors and chaos and engagement in crime, which is dangerous to the individual and highly costly to society. We want our patients, our clients, to have their withdrawal symptoms managed, their cravings managed, so they don’t have to access the illicit stream of opioids, so they can gain stability and get control of their lives back. As they do, we see folks start to reconnect with their family, go to school, working part time, even full time. It’s very rewarding to see that happen, and for some folks it happens fairly quickly.
[Opioid addiction] is a manageable illness, just like diabetes or high blood pressure.
These are folks that have been using for a long time and have a number of structural vulnerabilities. When folks are able to step down and de-intensify the treatment to oral, we certainly support that. Our goal isn’t to get people on treatment for life, but we know that for some people this will be a long-term treatment.
Do you have any favorite success stories?
We certainly have patients who’ve gone from being homeless to now working full time. That’s remarkable. Patients who’ve completed training programs and are now working.
I’ve got one patient who had been in and out of jail over 200 times, and since he’s been with us he’s not been back to jail.
How has the rise of fentanyl impacted your work? Does it make this treatment option more necessary?
Firstly our folks are not dying from opioid overdoses. If people are in care they are protected. The very infrequent times when our nurses have to intervene with oxygen or NarCan, the overdose can be reversed with one vial or half a vial of naloxone. On the street when our colleagues in the emergency medical services are resuscitating people with naloxone in the fentanyl area it can be as much as seven vials to reverse an overdose.
The illicit stream of opioids are poison. As long as people need to access the illicit stream of opioids, they are at risk for morbidity and mortality, and at risk for death.
How has your thinking or understanding changed over the years at Crosstown? What have you learned along the way?
We’ve got solid and extensive evidence showing that this is safe, effective and cost effective. Despite a health emergency being declared two years ago here in British Columbia, it’s been very slow to expand and be accepted.
I’ve had a frustration that things don’t move faster. If there’s anything that I’ve learned, you can’t take the evidence for granted, and evidence is not enough. We need to work actively to translate the knowledge that we have.
There’s limited access to this treatment, and we see our patients lives transformed. But we still have people who would like to be in care knocking on our door every day, and we don’t have capacity for them. I would like to be able to see this expand.
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