B.C. guidelines for injectable-opioid treatment put hydromorphone ahead of prescription heroin

Prescription heroin receives a lot of media attention but the province is placing the idea on hold and instead expanding access to a similar drug

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      Prescription heroin is a controversial treatment for long-time opioid addiction but one that has received support from both B.C.’s outgoing minister of health, Terry Lake, and his federal counterpart, Jane Philpott.

      Yet a draft document obtained by the Georgia Straight makes it clear that B.C. intends to, essentially, place that idea on the back burner and instead focus on an expansion of access to hydromorphone.

      Hydromorphone, sold under the brand name Dilaudid, is a synthetic opioid very similar to heroin. One key difference between the two is that hydromorphone is widely prescribed across Canada as a painkiller, whereas prescription heroin, which is also known by its medical name diacetylmorphine, is not. Canadian doctors can legally prescribe diacetylmorphine, but it’s a difficult and lengthy process.

      A considerable body of research, some of which was conducted in Vancouver, shows that prescription heroin and injectable hydromorphone can both bring stability and health benefits to people addicted to drugs who have repeatedly failed with traditional treatments such as methadone.

      The provincial government recently recognized that research and tasked the B.C. Centre on Substance Use to revise guidelines for the treatment of opioid addictions in order to, for the first time anywhere in North America, include injectable options.

      The guidelines are now with the provincial Ministry of Health for review. The Straight has obtained a draft copy, dated June 30. The ministry declined to grant an interview but confirmed the document is “nearing completion”.

      “Hydromorphone does not face the same regulatory challenges as diacetylmorphine and faces few barriers to rapidly scaling up treatment,” it reads. “Thus, this document provides clinical guidance for iOAT [injectable-opioid-agonist treatment] with hydromorphone as it currently faces fewer regulatory barriers to expansion.”

      Cheyenne Johnson, director of clinical activities and development for the B.C. Centre on Substance Use, says B.C.'s fentanyl crisis was at the top of officials' minds when they drafted new guidelines for how doctors can treat an addiction to opioids.

      Cheyenne Johnson is director of clinical activities for the B.C. Centre on Substance Use and is involved in drafting the guidelines. She told the Straight that the focus on hydromorphone is partly in response to the province's ongoing fentanyl crisis.

      “What we wanted to do is put together a usable guideline that would expand treatment options as soon as possible for people,” Johnson said in a telephone interview. “So we focused the guideline on something that can be scaled up and is comparatively an inexpensive treatment option that doesn’t have the same barriers to implementation that prescription heroin does.”

      This year, B.C. is on track to surpass 1,500 illicit-drug overdose deaths. That’s up from 965 fatal overdoses in 2016, 517 in 2015, and 368 in 2014.

      Since November 2014, Vancouver doctors have offered prescription heroin and hydromorphone to a select group of patients at one location in the Downtown Eastside. But until very recently, that facility, called Crosstown Clinic, was the only place in North America where injectable options were used in the treatment of an opioid addiction.

      Once the B.C. Centre on Substance Use’s guidelines are officially adopted, it is expected that these treatments will become more widely available.

      On June 13, the Straight reported that one Vancouver doctor has already forged ahead with an injectable-hydromorphone program without waiting for the government to approve the guidelines. In December 2016, Dr. Christy Sutherland began prescribing hydromorphone to one patient who for many years struggled with a severe addiction to heroin. Since then, the program has expanded to include 20 patients who receive daily injections of the drug at Pier Pharmacy on Main Street.

      Jordan Westfall is president of the Canadian Association of People Who Use Drugs (CAPUD). He’s a vocal advocate for an expansion of access to prescription heroin but described the focus on hydromorphone as “good news”.

      “We’re still trying to figure out what to do about heroin-assisted treatment,” he said. “Hydromorphone is already readily available in the province so it is much quicker for us to scale up.”

      Patients at the Downtown Eastside's Crosstown Clinic visit three times a day to receive a prescribed dose of injectable hydromorphone or diacetylmorphine, the medical term for heroin.

      The draft guidelines discuss three models for how injectable hydromorphone might be administered for the treatment of an addiction, which remains an off-label,  use for the drug.

      The first is a “comprehensive and dedicated supervised injectable opioid agonist treatment program”. That’s how Crosstown Clinic operates today, where the building’s primary function is its prescription-heroin and injectable-hydromorphone programs.

      The second is an “integrated or embedded” model, where injectable hydromorphone would be made available at locations where harm-reduction services are already delivered; at Vancouver’s Insite supervised-injection facility, for example.

      The third is a “pharmacy-based” model, where injectable-treatment options would be made available in more common health-care centres alongside traditional treatments such as methadone or Suboxone.

      The idea behind providing patients with injectable opioids is that by doing so, they will stop buying illegal heroin from street dealers, thus eliminating the risks that come with injecting unknown substances that likely contain fentanyl. These patients also no longer have to steal to raise enough money to feed their habits, because the program is covered by PharmaCare. Studies conducted in Vancouver have found that these patients largely leave behind the chaos that comes with feeding an addiction illegally.

      Westfall said that making injectable hydromorphone available as a clean supply of opioids that’s regulated by the government is especially important in light of the ongoing fentanyl crisis.

      “It is critical that we get it out as soon as possible because of how many people are dying,” he said. “The provincial government wants to do their own internal review but we can’t wait for that. We can’t wait for this document to sit on a shelf for six months. We will lose a lot of people in this province waiting for it to be reviewed.”

      Since November 2016, B.C. has seen an average of more than four fatal overdoses every day, up from an average of 2.3 deaths per day during the first six months of 2016 and an average of 1.4 deaths per day in 2015.


      Johnson said the fentanyl crisis was very much in the minds of researchers and policymakers who were drafting the guidelines. She said a process that often takes as long as two years was, in this case, expedited.

      “We were asked, relatively recently—like end of February, early March—to put together this guideline,” she noted.

      “In the midst of an overdose crisis, everything seems to slow,” Johnson added.

      The off-label use of hydromorphone to treat an opioid addiction first 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 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.”

      Travis Lupick is a journalist based in Vancouver. His first book, Fighting for Space: How a Group of Drug Users Transformed One City's Struggle with Addiction, will be published in October 2017. You can follow him on TwitterFacebook, and Instagram.