Vancouver has a history pioneering harm-reduction programs. In 2003, it opened North America’s first supervised-injection facility, Insite. In 2014, it moved a prescription-heroin program beyond the confines of an academic study.
Now B.C. will launch its most radical drug program yet. It's a plan that one of the province's top doctors says could be a partial solution to the province's opioid crisis.
Tentatively scheduled to begin in March 2018, Vancouver will dispense hydromorphone—a synthetic opioid similar to heroin—in a way that, if all goes according to plan, will not require a doctor’s visit and possibly not even a prescription for the powerful drug.
In a telephone interview, Dr. Mark Tyndall said the program’s primary goal is not to address an addiction. Rather, its objective is to reduce overdose deaths.
“We’ll put our concerns with fixing addiction on the back burner right now, while we deal with this crisis,” the executive director of the B.C. Centre for Disease Control told the Straight.
“This is a public-health response, not an addiction-medicine response,” Tyndall continued. “People need access to safer drugs.”
B.C. is on track for more than 1,400 illicit-drug overdose deaths in 2017. That compares to an average of 204 deaths per year from 2001 to 2010. In 2017, fentanyl and fentanyl analogues have been detected in more than 80 percent of drug-overdose deaths in B.C.
Searching for answers, Tyndall submitted a proposal to Health Canada’s substance use and addictions program to remove the risk posed by fentanyl. He outlined how B.C. could give people access to a regulated supply of opioids distributed by the government and its partners in health care and social services.
Health Canada approved the application and is providing $1 million to run the program for three years. Tyndall emphasized the details are still being worked out but said the proposal describes three options for distribution. All three create scenarios in which someone addicted to opioids would no longer have to purchase unknown substances on the street but would instead obtain pure and regulated opioids of an exact and known dose.
Hydromorphone pills (sold under the brand name Dilaudid) could be dispensed inside social-housing projects, where non-medical staff already provide residents with methadone and Suboxone (traditional medications for the management of an opioid addiction).
The proposal also suggested a pilot project could see hydromorphone available at certain supervised-injection facilities, such as Insite.
The third option is for select storefront pharmacies to provide access to hydromorphone pills, again similar to how they already provide methadone and Suboxone to registered patients.
Regarding who will qualify to receive hydromorphone as a substitute for street drugs, Tyndall described a group that could be quite large.
“People who are at risk of overdosing and who have an opioid dependency,” he said.
In this respect, the program could differ significantly from Vancouver’s prescription-heroin program, which operates out of a Downtown Eastside clinic called Crosstown.
The average length of time that a patient spent addicted to opioids before they were admitted to Crosstown’s prescription-heroin program was 26.6 years. The average number of times a Crosstown patient failed with a traditional treatment such as methadone was 11.4.
Crosstown’s prescription-heroin program was designed to stabilize the life of a person who was severely addicted to opioids for many years. For Tyndall’s hydromorphone patients, the bar could be set significantly lower.
Another key area where the two programs differ is money.
The average Crosstown patient costs B.C. $27,000 a year. That’s because diacetylmorphine—the medical term for heroin—must be imported from Europe. And because dispensing the drug requires a full-time staff consisting of both doctors and nurses, as well as a standalone building with stringent security requirements specific to diacetylmorphine.
Meanwhile, the cost of an eight-milligram Dilaudid pill obtained via B.C.’s PharmaCare program is just 32 cents. If a patient is given three pills three times a day, the cost of one patient’s drugs works out to about $700 annually. Then, because the distribution model Tyndall envisions integrates the program into existing social services, and because it may not require the involvement of doctors or nurses, administration expenses will likely also be significantly lower than those of prescription heroin.
“It [Crosstown] is not nearly addressing the scale of what we’re up against,” Tyndall said. “The next step, to me, is that we get people something that’s cheap and scalable, which is hydromorphone pills.”
Tyndall named two of Vancouver’s largest nonprofit housing providers as possible partners.
The first is Lookout Housing + Health Society, with which he said talks are progressing. He also mentioned the Portland Hotel Society (PHS) as a potential “natural fit”. (As the Straight reported last June, PHS quietly launched a hydromorphone program of its own in December 2016. It continues today but is different from what Tyndall has proposed in that its primary focus is addictions management rather than preventing overdose deaths.) He added the initiative will begin in Vancouver and possibly Victoria, and then could move out from there.
Tyndall acknowledged the program will not be perfect.
“For some people with high tolerance, this might not be an option for them, because we can probably only give out so many pills at a time,” he said. But he repeatedly emphasized that, several years into the opioid crisis, the provincial government’s response has not slowed overdose deaths.
“It’s fine to say that we’ll increase access to Suboxone and methadone, and we should continue to do that,” Tyndall said. “But we’ve sort of done that experiment and it’s limited in how many people want it. And then we turned to the injectable [prescription-heroin] program, which I think is a really positive therapeutic response, but it’s not a response to the overdose crisis.”
“I’m not critical of that,” he repeated. “But it’s not going to be an answer for us for the current situation.”