Health unit, clinic support prescribing heroin
Ottawa’s health unit supports prescribing heroin to treat severe addicts and at least one treatment clinic is considering it as the city fights the rising rates of overdoses from it and similar opioid drugs.
“We really see it as more an extension of our opiate substitution therapy program than part of our supervised injection efforts,” said Rob Boyd, the head of the drug-treatment programs at the Sandy Hill Community Health Centre on Rideau Street. Boyd has been leading the charge to add an injection site to the centre’s existing methadone clinic.
Methadone is the standard way of treating people addicted to opioids — especially heroin but also fentanyl and oxycodone. It tickles the same receptors in the brain but you drink it rather than shooting it with a needle. With standardized dosages and pharmaceutical quality, it’s safer. But it doesn’t work for everybody.
“I’m not sure if I understand completely the chemistry behind it all, but we would look at people who are on the other opiate-treatment programs, who continue to supplement their medication with street-level opioids,” Boyd said.
About 150 people in Vancouver are in a prescription-heroin program after finding methadone and buprenorphine, a similar drug, didn’t help them. Boyd guesses the number of Ottawans who’d benefit from prescription heroin is in the low dozens.
Ottawa Public Health “supports the use of prescribed heroin and it should be incorporated — where clinically appropriate — as a harm-reduction option,” the city’s top public-health official, Dr. Isra Levy, said through a spokesman Wednesday. “Opioid substitution therapy is part of the continuum of care needed to improve health outcomes and is part of the available options to support people in Ottawa wherever they are on the spectrum of substance use.”
The health unit has no intention of dispensing heroin itself, but “we encourage our community partners to actively seek opportunities to enhance services and treatment options as part of the harm reduction continuum.”
Toronto’s health unit is recommending that heroin be prescribed to treat addicts in specialized clinics, including one run by Toronto Public Health. It’s part of an all-in response to increasing opioid overdoses that includes distributing anti-overdose kits more freely, opening supervised injection sites as soon as possible, and tracking overdoses and deaths closely to allow quicker reactions to localized problems. A lot of Toronto’s plan amounts to amping up things the health unit and other agencies already do. Prescribing heroin would be new.
The federal Conservatives forbade prescribing heroin in 2013, on the skull-clutchingly circular grounds that it just enabled illicit-drug addiction, but the Liberal government undid that decision last September. So heroin is legal to prescribe. But while methadone has decades of study behind it, there aren’t clear rules for Ontario doctors to use for heroin. Like most doctors, the Sandy Hill clinic’s are accustomed to prescribing things you swallow, not things you inject.
(An alternative is hydromorphone, yet another opioid, which Boyd said might be more attractive because it’s more synthetic. And its name is imbued with less black magic. But there’s no more guidance for using it to treat addiction than there is for heroin.)
Switzerland and the Netherlands allow doctors to prescribe heroin for heavy-duty drug treatment fairly routinely; the British and the Germans also allow it. Only Vancouver and Montreal have tried it in Canada, and in Montreal it was only an experiment. But there’s evidence it works. Addicts in heroin-prescription programs were healthier, more productive and less crime-prone, a review by European researchers found, using data from Canada and Europe.
They concluded prescription heroin is a poor alternative to methadone for most people. It’s more expensive and riskier, and head-to-head doesn’t produce better results. But it’s useful as a backup if methadone treatment fails.
“Long-term studies have ... found that participants in this treatment had high rates of retention with improved social benefits such as maintaining stable housing and employment,” Toronto’s health unit says.
As with supervised injection sites, heroin clinics led to no increases in crime in their neighbourhoods, the European researchers found. Near the Montreal site, crime went down a little.
The Swiss held a national vote on prescription heroin a few years ago; more than two-thirds of voters said to keep it even as almost as many voted against decriminalizing marijuana. As a medical treatment, it just obviously works. Heroin-abuse rates declined. There’s some thought that prescribing it in treatment programs made it uncool.
Like heroin, methadone can kill you. That’s why it’s given by prescription. Patients have to show up in person for every dose at first and be watched while they take them. Eventually, maybe, they get doses to take home so they only have to go to the clinic every week or so.
It’s a regimen that people whose lives aren’t dominated by a medical condition would find incredibly burdensome, but it’s better than feeding an addiction by buying drugs from street dealers a few hits at a time, switching from one opiate to another when pipelines dry up, often not even knowing for sure what you’re taking.
Eventually, methadone patients can taper off under medical supervision. In the meantime, they can find a way to be normal.
That’s the less ambitious goal of prescription-heroin treatment: letting patients build lives. This is like substituting nicotine gum for cigarettes: You’re still addicted but you’re slashing your chances of lung cancer, and that’s an improvement. When you’re treating addiction, sometimes you have to take what you can get.
Long-term studies have ... found that participants in this treatment had high rates of retention with improved social benefits …