Since November 2014, a small group of Vancouver doctors has administered prescription heroin as a treatment for severe addiction to opioids.
Peer-reviewed studies have found that prescription heroin, also known as diacetylmorphine, can improve the lives of patients who have repeatedly failed with traditional treatments such as methadone. But doctors are only allowed to prescribe diacetylmorphine to a small group of specific patients. (A change in regulations by former Health Minister Rona Ambrose is before the courts; in the meantime, only 202 people covered by an injunction can access the drug.)
Now a new study has found that another drug called hydromorphone—an opioid similar to morphine that doctors are allowed to prescribe in Canada for pain management—can be just as effective as diacetylmorphine in transitioning people off street drugs.
Eugenia Oviedo-Joekes is the paper’s lead author and a researcher with Providence Health Care’s Centre for Health Evaluation and Outcome Sciences. In a telephone interview, she said that patients administered either hydromorphone or diacetylmorphine were both found to use significantly less heroin purchased illegally.
“This means we have a licensed option for those that continue injecting in the street regardless of treatments being available,” Oviedo-Joekes told the Straight. “And, overall, hydromorphone had less related adverse events [such as an overdose] and less related serious adverse events than diacetylmorphine.”
The Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) will see its findings published in the April 6 edition of the Journal of the American Medical Association Psychiatry. The project was conducted at Providence Health Care’s Crosstown Clinic from 2011 to 2015. It builds on a previous study called the North American Opiate Medication Initiative (NAOMI), which ran at the same Vancouver facility from 2005 to 2008.
NAOMI found that heroin-assisted therapy proved more effective than methadone in improving the wellbeing of long-time addicts. Now, Oviedo-Joekes, who is also an assistant professor with UBC’s school of population and public health, said SALOME has shown itself to be similarly beneficial.
According to the forthcoming SALOME paper, 102 randomized patients were put on diacetylmorphine 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.
Crosstown Clinic’s lead physician, Dr. Scott MacDonald, told the Straight that methadone doesn’t work for everybody with a severe addiction to an opioid such as heroin, and that alternatives are, therefore, proving useful.
“It [SALOME] shows that injectable hydromorphone is an additional option—another tool in our toolkit—for helping folks who struggle with severe opioid disorder,” he said in a telephone interview. “They are both now indicated for the treatment of severe opioid-use disorder.”
(In May 2015, the Straight reported that Vancouver Coastal Health was reviewing methadone's usefulness and drafting new guidelines that could expand the number of pharmaceutical therapies available to help people kick harmful opioids.)
MacDonald noted that hydromorphone is only licensed in Canada as a pain medication, so prescribing the drug for addiction treatment will have to be done "off-label". He stressed he believes hydromorphone should be administered under supervision, as it was at Crosstown Clinic during SALOME. That involves patients coming in at regular times every day, getting a pretreatment check by clinic staff, and then receiving the drug under the supervision of nurses.
“We’ve got a working model here,” MacDonald said. He argued that benefits of that model extend beyond the declines researchers saw in the use of street heroin.
“For us, this is not about the drug,” he explained. “It is about getting people into care so we can reduce the chaos in their lives. It is about bringing order to their lives again so that they can become healthier.”
Oviedo-Joekes said the same, stressing that only a small percentage of severe addicts—about 10 percent, she estimated—would be recommend for this form of opioid-substitution therapy.
“But they are the sickest and the most vulnerable,” she added. “Supervised care gives us an opportunity to give comprehensive care to our patients….We can work with them and provide a safe place where we can start working on the many issues that they have carried for 20 years.”