Dr. Perry Kendall is the provincial health officer for British Columbia. He is the former president of the Addiction Research Foundation of Ontario and served on advisory panel for the NAOMI study. In light of Rona Ambrose’s announcement today, I spoke to him by phone this afternoon about heroin-assisted treatment. Here is part of our conversation.
Q. First of all, in terms of the Special Access Program, do you think that in this case it was an appropriate use of the Special Access Program to get this exemption to continue prescribing heroin to patients?
A. Yes, I do. I think that Minister Ambrose and her advisors are taking a very different approach to addictions than they would to any other chronic disease for which there was a really scientifically validated treatment. I can’t imagine them cutting off special access for any of the anti-cancer drugs.
Q. What makes you a believer in this treatment? Is it the research that’s been done? Is it things you’ve seen firsthand?
A. It’s basically the research that’s been done. There have been a number of trials over the years, starting in Switzerland, follow up trials in Holland, trials in Germany and the NAOMI trials in Canada, which show that for opioid addicts who cannot be treated or are refractory to treatment with the first-line treatment, which is methadone and counselling, that they actually do significantly better on heroin. They have less problems, they use less drugs, they have less engagement with the law and their psychological and physical health improves.
Q. Do you think there’s a future then for heroin-assisted treatment in Canada?
A. Well I would certainly hope so, for that small percentage of people who can’t be helped by or who are refractory to treatment by other methods. It’s standard treatment in Switzerland, it’s standard treatment in Germany and Spain … and there’s a small number of physicians in the UK who are licensed to prescribe heroin for people whose addictions haven’t been managed through methadone. So this is an accepted treatment practice in several advanced countries in the world. And I think it’s ethically quite dubious to withhold access to a scientifically proven treatment.
Q. The idea is still going to be there, and I think it was sort of expressed today, the idea that you’re giving heroin to heroin addicts…
A. It doesn’t cure them of heroin addiction. But for many heroin or opioid addicts this is a long-term, chronic, relapsing condition. And so for some people you want to maintain them that meets their sort of physiological needs, if you like, but enables them to function. And so some people stay on methadone for 15 or 20 years, they’re capable of raising families, having jobs, being productive members of society. You take them off methadone, then they relapse and they get their opiate from other sources. So the heroin is really for people who can’t be maintained or weaned off drugs through any other method. And if you have people who are scoring illicit drugs of unknown quantity on the streets, shooting up, getting infected, overdosing, probably involved in criminal activities to support their habits, they become physically very unhealthy and psychologically very unhealthy as well. And what the trials in several countries have shown is that those people, if they’re maintained on heroin, they can maintain at relatively low doses, they don’t increase their doses exponentially, but their lives can stabilize, they can receive psychological counselling or other medical help, their physical health improves, their psychological health improves, they have far fewer interactions with the police. Some of them get clear because they’re able to sort their lives out because they don’t have to worry everyday about getting a fix. Some of them can be transitioned back to methadone once they’re stabilized. And in the Swiss and German studies some of them actually have even been able to get jobs and become relatively functional members of society instead of outcasts.
If your aim is to get people off of drugs, then that is a challenge, there is no magic bullet. And as we saw recently with the tragic death of that young Glee star, even someone who’s very talented and very successful, some of the side effects can be death. So what you’re looking for is something that will stabilize somebody and enable them to manage their lives with less harm. If we use the analogy of adult onset diabetes, part of the treatment for that should involve exercise and weight loss. And if you can exercise and lose enough weight, you probably don’t need to take oral drugs to manage your blood sugar. But we don’t tell people that unless they can cure themselves with exercise we’re not going to give them oral drugs to keep their blood sugar down. We don’t force them to develop complications like losing limbs and going blind or having your kidneys shut down as a punishment for not being able to manage with exercise and medication and we don’t withhold insulin from people who aren’t able to manage their disease through diet, medication and oral drugs. So there are similarities with these chronic, relapsing conditions which have a large behavioural component in them.
Q. Do you think there’s any way to counteract the stigma around heroin?
A. Well, I think it’s been counteracted in a number of other countries. And I think it very much depends on, to some degree, the political ideology of the regulators. So if you’re fairly pragmatic about it and you can show that it works then you just go ahead and do it. But if you’re appealing to your core constituency and linking your decisions to fundraising for a particular political party it tends to raise the temperature somewhat.
Q. Is it possible to quantify how many people you would treat with heroin and would end up being completely off the drug?
A. I think you’d have to go back and look at the original Swiss studies. The numbers were quite small, but the timeframes were relatively short. And the experience is if you look at over a 10-15 year period, people with heroin addiction, many of them will mature out of it. So if you can keep people healthy and functioning for a period of time, at some point it’s like the addiction burns itself out. They get over whatever their issues were and they can be reintegrated back into society without needing that drug as a crutch or whatever it is they’re using it for … but obviously the healthier and better-adjusted you are the more likely it is to happen faster and the less of a burden you’ll be on society. If you’ve burned out your brains and you’ve got HIV and hepatitis C and you’ve had a stroke because you injected particles of chalk, you’re going to be pretty damaged even if you do stop using the drugs.