A large group of B.C. nurses can now prescribe a range of opioid substitutes that are used to treat addictions to drugs like heroin and fentanyl.
Today (April 4), the provincial government announced that nurse practitioners can write prescriptions for methadone and Suboxone, as well as for hydromorphone.
The move could widely expand access and lower barriers to medically assisted treatments for a dependence on opioids. It comes at a time when an addition to a drug like heroin has never been more dangerous.
Last year 1,436 people in B.C. died of a drug overdose. According to the province’s coroners service, approximately 83 percent of those deaths involved fentanyl, a dangerous synthetic opioid that has contaminated B.C. supplies of illicit street drugs.
By giving nurse practitioners the authority to prescribe alternatives—clean drugs distributed via Canada’s medical system—the provincial initiative announced today could save people from the greater risks that have come to characterize an addiction to opioids in recent years.
The inclusion of injectable hydromorphone is especially significant. The drug, a prescription painkiller that’s sold under the brand name Dilaudid, is comparable to prescription heroin. Studies conducted in Vancouver have found that for long-time addicts who have repeatedly failed with more traditional treatments such as methadone, hydromorphone can help stabilize their lives and improve health outcomes.
There are already nearly 100 patients receiving hydromorphone for an opioid addiction in Vancouver.
Some 70 of them receive the drug via a program operated by the nonprofit Portland Hotel Society and Pier Health Resource Centre, a pharmacy in the Downtown Eastside. Another 25 or so receive hydromorphone at Crosstown Clinic, the only location in North America where prescription heroin is available (to a select group of patients who were previously part of a clinical trial). There is also a small hydromorphone program that recently launched in Ottawa.
In an April 4 media release, B.C.’s minister of mental health and addictions, Judy Darcy, emphasized that the move is in response to the province’s opioid epidemic.
"Nurse practitioners play an increasingly vital role providing people with life-saving care," she said, quoted there. "This change is an important part of our government's escalated efforts to save lives, end stigma and connect people to appropriate treatment and recovery as soon as possible. It is also one way that we are addressing the gaps and tackling the barriers that people living with addiction too often experience."
Not all B.C. nurses have been given authority to prescribe opioid substitutes. A nurse practitioner is different from a registered nurse, for example, in that the former has received significantly more training.
Today’s media release emphasizes that before a nurse practitioner can prescribe opioid substitutes, they have to receive even more instruction specific to addictions medicine. It notes there are about 450 nurse practitioners in B.C., and 60 of them have already completed or begun that extra training.
"Amidst an overdose crisis, there is a clear need to expand access to treatment for individuals seeking support for their opioid addiction," said the B.C. Centre on Substance Use’s director of clinical activities and development, Cheyenne Johnson, quoted in the release. "We're pleased to provide evidence-based training, in combination with an immersive clinical experience, to ensure that nurse practitioners—and all prescribers—are well positioned to provide safe, effective, and compassionate treatment."
Hydromorphone is widely used across Canada for the treatment of severe pain. Its off-label use to treat an opioid addiction gained attention in B.C. in April 2016 when Vancouver researchers published a paper that said the drug can significantly reduce a long-time addict’s propensity to purchase heroin on the street.
For the study, 102 randomized patients were put on diacetylmorphine (prescription heroin) and 100 were given hydromorphone. Before entering the trial, participants in both groups were addicted to opioids for an average of longer than 15 years. The average number of days they used street heroin during the previous month was about 25. After six months enrolled in the study, the group given diacetylmorphine reported using street heroin an average of 2.64 days during the previous month, and the group put on hydromorphone said they had used street heroin 4.08 days during the previous month.
The paper, published in the Journal of the American Medical Association Psychiatry, concludes: “In jurisdictions where diacetylmorphine is currently not available or for patients in whom it is contraindicated or unsuccessful, hydromorphone could be offered as an alternative.”
For an in-depth presentation of Vancouver’s existing opioid-substitution program at Crosstown Clinic, read the Straight’s “Legal Heroin: As the fentanyl crisis continues, one Vancouver doctor moves people out of the alleys and into a clinic”. An accompanying radio documentary titled “The Heroin Clinic” was recently nominated for a 2018 Canadian Association of Journalists award.