The politics of the heroin addict - Macleans.ca
 

The politics of the heroin addict

Rona Ambrose and Pierre Poilievre just say no


 

Adrian Wyld/CP

If a society is judged by how its cares for its most vulnerable, we are basically faced with a test of what we are willing to try to help the most beleaguered. Consider the heroin addict.

Health Minister Rona Ambrose announced this afternoon that Health Canada will never again allow doctors to provide prescription heroin to patients through the Special Access Program (though she did suggest doctors who wished to do so could attempt to pursue the matter through provincial routes).

This comes two weeks after Ms. Ambrose, named health minister in July, sent out a statement to the press gallery to express her displeasure with her department’s decision to grant doctors involved in a clinical trial in British Columbia the clearance necessary to provide prescription heroin to approximately 15 patients. Ms. Ambrose’s statement doesn’t seem to have been posted to the Health Canada website, so here it is in its entirety.

Our Government takes seriously the harm caused by dangerous and addictive drugs. These drugs tear families apart, promote criminal behaviour, and destroy lives.

That is why our Government is focused on preventing children and youth from using drugs in the first place and strongly deterring existing use of harmful and addictive drugs.

Health Canada has a “Special Access Program,” which is designed to give Canadians with rare diseases or terminal illnesses access to medications that are not otherwise approved for use in Canada.

For example, a doctor who is treating a child with a rare form of cancer can apply to Health Canada for access to potentially life-saving medicines, which otherwise would not have been approved for medical treatment. This is what the Special Access Program is designed to do.

Earlier today, officials at Health Canada made the decision to approve an application under the Special Access Program’s current regulations to give heroin to heroin users – not to treat an underlying medical condition, but simply to allow them to continue to have access to heroin for their addiction even though other safe treatments for heroin addiction, such as methadone, are available.

This decision is in direct opposition to the government’s anti-drug policy and violates the spirit and intent of the Special Access Program.

I am taking immediate action to protect the integrity of the Special Access Program and ensure this does not happen again.

The Special Access Program was designed to treat unusual cases and medical emergencies; it was not intended as a way to give illicit drugs to drug addicts.

Our policy is to take heroin out of the hands of addicts, not to put it into their arms.

Our Government will continue to invest in drug treatment and prevention programs that work to keep our children and youth off drugs, and will continue to protect Canadian families and communities

Prescribing heroin to a heroin addict is not quite a new idea.

From 2005 to 2008, a study known as NAOMI—funded by the Canadian Institute of Health Research and with an exemption from Health Canada to provide pharmaceutical heroin—compared how pharmaceutical heroin—diacetylmorphine—compared with methadone in the treatment of heroin addicts. That study found prescription heroin could be a more cost-effective form of treatment for chronic addicts who had not previously responded to other treatments.

Here is how Andre Picard reported the findings in 2009.

Providing diehard addicts with heroin is far more effective than treating them with methadone, according to the results of a much-anticipated study.

The research, published in Thursday’s edition of the New England Journal of Medicine, shows that patients treated with injectable diacetylmorphine (the active ingredient in heroin) are 62 per cent more likely to remain in addiction treatment and 40 per cent less likely to take street drugs and commit crimes to support their habit than are those treated with oral methadone.

As it is, “supervised injectable heroin” is already legally available in five European countries. Here is how the European Monitoring Centre for Drugs and Drug Addiction summarized the global research in this regard.

A small population of chronic heroin users, once thought to be ‘untreatable’, is now benefiting from a novel type of therapy using medicinal heroin as the substitution drug. In a new report out today from the EU drugs agency (EMCDDA), experts describe the development as ‘an important clinical step forward’. The report, New heroin-assisted treatment, provides the first state-of-the-art overview of research on the subject, examining the latest evidence and clinical experience in this area in Europe and internationally (1).

The prescription of substitution drugs (e.g. methadone, buprenorphine) has become a mainstream, first-line treatment for opioid dependence, with around 700 000 of Europe’s 1.3 million problem opioid users receiving substitution treatment today. But a small minority of entrenched opioid users repeatedly fails to respond to interventions of this kind. Findings from international trials now suggest that the supervised use of medicinal heroin can be an effective second-line treatment for this small, and previously unresponsive, group.

Ms. Ambrose’s announcement includes comments from University of Toronto professor Meldon Kahan, who has questioned the NAOMI study. One of the NAOMI investigators offered this response to Mr. Kahan.

At the same time, NAOMI also provided evidence that a licensed drug—hydromorphone—might also be a more effective treatment than methadone and so the SALOME study—also funded by the Canadian Institute of Health Research, also operating with an exemption from Health Canada—was launched. The researchers operating SALOME explain their study here.

The Globe’s Andrea Woo explains that doctors appealed to Health Canada to continue providing heroin to patients exiting SALOME.

But as the first participants began cycling out of SALOME early this year, doctors in charge of their exit strategies faced a problem: They could either prescribe conventional drugs like methadone – which no trial participant had succeeded with – or hydromorphone, a drug whose effectiveness had not yet been proven as the trial is ongoing. Prescription heroin, while proven in NAOMI to be effective, remains a controlled substance in Canada. Citing the urgency of those SALOME participants’ exit plans, those doctors are now applying to Health Canada’s Special Access Programme (SAP) for what they say is critical treatment for their patients.

Patricia Daly, chief medical health officer and vice-president of public health at Vancouver Coastal Health, said doctors are reluctant to prescribe hydromorphone as it isn’t specifically approved for heroin addiction treatment. “I’ve written to Health Canada and asked that [the patients] be allowed to get injectable diacetylmorphine – that’s injectable heroin – because we’ve demonstrated in a research study, published in the New England Journal, that’s an effective treatment,” she said.

Here is some of what Dave Byres of Providence Health Care, one of the partners in the SALOME study, told me when I asked him to explain the case for prescribing diacetylmorphine.

All of the participants have not responded to standard therapies. Injectable [diacetylmorphine] is their best option to obtain and maintain health, stability and to stop illicit heroin use. Therefore, it is reasonable to ask Health Canada to allow these participants to continue benefiting from a drug that has been proven effective in double blind, randomized control trial that was a Health Canada sanctioned study. No one decides one day to become severely addicted to heroin. These patients have a severe, life threatening illness and deserve to have the best available treatment for their addiction – no different that any other Canadian deserves to have for their particular illness.

At the time of the NAOMI study, an application was filed with Health Canada’s Special Access Program to prescribe diacetylmorphine, but the request was denied. This time, Health Canada apparently agreed with the doctors. For more on that decision see Anna Mehler Paperny’s explainer and Andrea Woo’s follow.

A day after Ms. Ambrose’s statement, the Conservative party sent out a note to its mailing list under the heading “Stop giving heroin to addicts.”

Drug addiction is a very serious problem in our communities.

Drugs like heroin tear families apart, promote criminal behaviour, and destroy lives.

That’s why our government has focused on stopping illegal drug use and treating addicts in a safe way.

But drug treatment programs should be focused on ending drug use – not giving illicit drugs to drug addicts.

That’s why I was shocked to learn today that Health Canada approved funding to give heroin to addicts – against the wishes of our elected government.

We’re going to take steps to make sure this never happens again – but we need your help.

If the NDP or Liberals are elected in 2015, you can bet they would make this heroin-for-addicts program permanent.

We can’t let that happen. We’ll keep fighting to keep our streets and communities safe, but we need your support.

Will you stand with us? Add your name here:

http://www.conservative.ca/?page_id=3488

Sincerely,

Fred DeLorey
Director, Political Operations
Conservative Party of Canada

So if nothing else should come from this matter—and whatever the merits of pursuing heroin-assisted treatment—at the very least the Conservative party will gain some personal info to mine.

The SALOME study’s website presents hydromorphone as a potentially less-fraught alternative to heroin-assisted treatment—”Should hydromorphone be proven to be as good as diacetylmorphine, the benefits of this form of treatment may be achievable without the emotional and regulatory barriers often presented by heroin maintenance”—but it will two years before researchers know whether the results of SALOME indicate that hydromorphone provides all of the benefits of heroin-assisted treatment and covers all of the potential patients.

Meanwhile, a group in Ottawa is planning to apply to Health Canada for permission to establish a supervised-injection facility. The group is apparently eager to file an application before the Harper government is able to move ahead with new legislation on when such facilities can be allowed.

In a note posted to his website last week, Conservative MP Pierre Poilievre expressed his dismay.

“Giving dangerous drugs to people does not serve public health. Our government introduced tough, new rules that will give local law enforcement, municipal leaders, and residents a voice before a permit is granted for a drug use sites.

Instead of giving addicts more of what is killing them, we should provide treatment. That is why I have backed Harvest House and the Ottawa drug treatment initiative of Senator Vern White.”

The Ottawa facility would apparently be similar to Vancouver’s Insite facility, which does not distribute drugs.

One of Ms. Ambrose’s predecessors, Tony Clement, opposed safe-injection facilities, but, on Insite, he was ultimately rebuked by the Supreme Court.

The Minister’s failure to grant a s. 56 exemption to Insite engaged the claimants’ s. 7 rights and contravened the principles of fundamental justice.  The Minister of Health must be regarded as having made a decision whether to grant an exemption, since he considered the application before him and decided not to grant it.  The Minister’s decision, but for the trial judge’s interim order, would have prevented injection drug users from accessing the health services offered by Insite, threatening their health and indeed their lives.  It thus engages the claimants’ s. 7 interests and constitutes a limit on their s. 7 rights.  Based on the information available to the Minister, this limit is not in accordance with the principles of fundamental justice.  It is arbitrary regardless of which test for arbitrariness is used because it undermines the very purposes of the CDSA — the protection of health and public safety.  It is also grossly disproportionate: during its eight years of operation, Insite has been proven to save lives with no discernable negative impact on the public safety and health objectives of Canada.  The effect of denying the services of Insite to the population it serves and the correlative increase in the risk of death and disease to injection drug users is grossly disproportionate to any benefit that Canada might derive from presenting a uniform stance on the possession of narcotics.

In considering the possibility of a facility in Ottawa, the Ottawa Citizen’s editorial board saw another kind of test.

The coming debate in Ottawa will test the guidelines and the community’s ability to have a productive discussion about this. We need a good debate on the issue, one that provides space for all points of view, but it can’t be based on emotion or ideology.


 

The politics of the heroin addict

  1. The result of this is that the addict will commit crimes in order to be able to purchase illegal heroin. So we get additional crime from the addict, as well as possible turf wars from the dealers and suppliers. Sigh.

  2. Aaron, you can try to appeal to people through their sense of common decency or you can talk to them about dollars and cents. As the UK site on “treating chronic addicts with heroin injections” points out, treating this “5%” of heroin addicts that don’t respond to methadone treatments with the injections is cheap when you compare the cost of a yearly prescription vs. one year of incarceration…which is where they ultimately end up if not treated.

    • I wouldn’t mind seeing this common decency stuff become
      a little more fashionable.

      • I hear you. However, decency like sense is not as common as we would like it to be so we will have to appeal to something that is much more common….the taxpayer’s desire to do whatever costs them the least money.

  3. “Drugs like heroin tear families apart, promote criminal behaviour, and destroy lives.”

    Alcohol also tears families apart, and destroys lives.
    Tobacco too destroys lives, and has a Dependency Rating (D.R.) of 2.82, the same as crack cocaine, and slightly less than the D.R. of 2.89 for heroin.
    And what about big Pharma prescription drugs like opioids, CNS depressants, and stimulants?

    • Although you are very right about the awful fall-out effects of addiction to alcohol, tobacco and opioids, most of us have come to believe that total abstinence from the substance of addiction is the necessary requirement for a successful conclusion to substance abuse treatment. We are not really well schooled in terms of incremental success.

  4. “If the NDP or Liberals are elected in 2015, you can bet they would make this heroin-for-addicts program permanent. …….Will you stand with us?”
    HELL NO! We won’t get CONned again!

  5. Given the pretty big flow of methadone, legally and not so much, I mostly wonder which pharmaceutical co supplies it, who has interests, who’s donating to which political party. These appear to be the true driving forces behind this government’s policies. They spin an issue into a political weapon and simplistic soundbites (preferably framed in the most pious terms) and it becomes a gift from the Gods as a rationale to ignore science, deny better treatment, and score bonus points in key demographics while lining pockets. It is sick.

    • Sorry, soundbite, your theory is not valid. Physicians make the choice to treat with methadone first because it is a well-established, safe treatment that is easily delivered to patients. There is no pharmaceutical conspiracy here.
      Methadone is a very old drug. It was developed in the 1930’s. Therefore the patent is long expired and multiple pharmaceutical companies produce it for sale. Like morphine, it is likely very cheap to purchase and cheap to distribute because it can be given orally so patients can get it at the local pharmacy (the pharmacist serves it up in a drink of juice) or in British prisons they actually get in vending machines that read their finger prints.

      According to the UK site on treating chronic heroin addiction with dicytlmorphine (heroin), only 5% of those addicted need to be treated with injectable dicytlmorphine (heroin). Those patients have to go to injection clinics which of course makes it more costly and of course, injections are always more hassle for patients.

  6. It is clear that there is a substantial lobby behind the development of the heroin maintenance industry, presumaby the pharmaceutical industry is thereabouts somewhere. Maybe the “legalsie all drugs lobby” as well?

    The country with the most experience of maintenance heroin is the UK, 30 years or more from the 1920 to the 60s. It was largely abandoned for very good reasons.

    Research in Scotland (Glasgow University) a few years ago, was clear, most addicts want help to get off heroin.

    To call giving heroin to addicts “treatment” is a contradiction in terms and arguably a breaking of the hypocratic oath by the clinicians involved.

    Would giving alcohol to alcoholics be “treatment”?

    Would giving more Benzos to a benzo addict be treatment?

    Crack cocaine to a psychotic crack addict?

    The trouble with prescribing long term maintenance heroin, or methadone, at public expense is that it represents an increasing drain on public health funding as more addicts join. It is an open ended commitment. It solves nothing.

    • You asked: Would giving alcohol to alcoholics be “treatment”?
      Yes it has already been done and proved effective for those with extreme addictions who have already tried and failed other treatments, just like with these people with extreme heroin addictions who have not responded to other treatments. The science has shown that it can help wean them off the drug.

    • “It is clear that there is a substantial lobby behind the development of the heroin maintenance industry.”

      Ah yes, I can see that now that I look at all the evidence you’ve provided.

      ” It solves nothing.”

      And with the sweep of his hand the brilliant butcomb trumps evidence, expertise and science! Well done! Someone give this man tenure.

  7. “We know better than any doctor what their patients require. It’s called tough love.”

  8. Why prevent crime when it’s politically useful to blame people for their problems and keep the population afraid?

    • Ya, heroin addicts are all blameless victims. I’m sure a quick remedy to the problem would be to make a gateway drug like marijuana much more accessible to society at large.

      • I’m surprised you think so; that’s kind of extreme. I personally think addicts should take some responsibility for their own problems.

        But what we are talking about here, is people who have
        taken responsibility by enrolling in drug rehabilitation. I’d sooner we invested in solutions that improve their success rate rather than creating more barriers based on blame.

  9. I’m so looking forward to Trust Fund Trudeau running on a platform of legalized marijuana and prescription heroin for everybody. Why don’t Liberals just come out and say it: they don’t see any problems with illegal drug use.

    I’m sure Trudeau will have some “science” on hand to show that increasing accessibility to a gateway drug like marijuana will somehow decrease the number of heroin users. “Science” that comes from his own imagination, of course.

    The Liberal Party of Canada: The Party that stands for an awesome party! Whoopeee!

    • Poor NotRick’s reading comprehension just doesn’t get better.

      NotRick, the Liberal Party of Canada is a political party.
      The parties referred to in this piece are medical doctors.

      Science is what those doctors practice and produce.
      “Science” is what you’ll find at Alberta’s Big Valley Creation Science Museum. “Science” is also the portfolio of Minister Gary Goodyear.

      “… a gateway drug like marijuana….”

      *snort*

      Should focus on the gateways with the highest rates of conversion first?
      For example, greater than 99% of herion users are know to have worn pants before becoming users.

    • Reefer Madness is my favourite movie, too.