Pubdate: Sat, 11 Feb 2017
Source: Globe and Mail (Canada)
Copyright: 2017 The Globe and Mail Company
Author: Andrea Woo
Page: S1


Sixteen years after Vancouver formally adopted a 'four pillars'
approach to drug strategy, the city - and the province - finds itself
in the grip of an overdose crisis, Andrea Woo writes

Melody Cooper throws a purple ball across the well-worn grass at the
East Vancouver dog park, sending her dog, Squeak, bounding across the
field. The Jack Russell-poodle cross is wearing a camouflage coat,
pulled taut by a belly that jiggles with each bound.

"I didn't realize how much weight he had gained until recently," Ms.
Cooper says, watching the dog from her seat on a park bench. "My
mother pointed it out. She said, 'Look at him: When he lies on his
side, two of his feet are still dangling in the air.' "

She smiles, breathing in the crisp winter air. Life these days is
decidedly calmer for Ms. Cooper, who is one of just 30 people in
Canada using hydromorphone to treat her long-time addiction. A recent
Vancouver study found the pain medication to be an effective
replacement therapy for an opioid dependency and, outside of the
clinic where that study was conducted, she is the first person to
receive the treatment.

It has turned her life around, she says.

More than 900 people died of illicit drug overdoses in this province
last year - the highest such death toll on record. The powerful
synthetic opioid fentanyl was confirmed in around 60 per cent of these
deaths, and carfentanil - an animal tranquillizer many times more
toxic than even fentanyl - is suspected in a recent surge of overdose

In neighbouring Alberta, new statistics released this week showed 343
illicit drug deaths were linked to fentanyl last year; the number of
total illicit drug deaths is not yet available. Carfentanil was also
detected in 22 of the 343 deaths.

The public-health crisis has spurred a far-reaching discussion on the
public-health response. While some jurisdictions are just starting to
equip first responders with naloxone, or are still debating the
efficacy of supervised injection sites, others are looking beyond
stop-gap measures to identify bold new interventions and regulatory

The Globe and Mail spoke with health officials, addictions physicians,
drug users and others about the next steps being contemplated - and
the hurdles that remain.

Suboxone and methadone

The recently-formed BC Centre on Substance Use (BCCSU) this week
released new guidelines for treating opioid dependency . The guideline
reaffirms buprenorphine-naloxone, commonly referred to by its trade
name, Suboxone, as the new first-line treatment for opioid dependency,
as it is safer than methadone.

As of Feb. 1, British Columbia's PharmaCare began covering the full
cost of Suboxone for those who make less than $42,000 a year.

Hakique Virani, a public health and addictions medicine specialist at
the University of Alberta, says emergency departments should seize the
opportunity to initiate treatment with Suboxone when people are taken
to hospital for overdoses, or in opioid withdrawal.

"We know that patients who have had a non-fatal overdose are highly
likely to have subsequent overdoses, including a fatal one," Dr.
Virani said. "It is better medicine and better stewardship of
resources and it is more humane to offer treatment at every touchpoint
the patient has with the system."

In Vancouver, St. Paul's Hospital and a mobile medical unit
temporarily stationed in the Downtown Eastside both have the
capability to provide rapid access to various addiction treatments,
including Suboxone. However, such treatment on demand is rare.

Heroin-assisted treatment

Heroin-assisted treatment (HAT) is an option for people who have
failed repeatedly with traditional therapies such as methadone or
Suboxone - an estimated 5 per cent to 10 per cent of all people on
substitution treatment. This population is the most vulnerable and
incurs the largest societal costs.

The North American Opiate Medication Initiative (NAOMI) out of
Vancouver found that providing these people with pharmaceutical-grade
heroin to be administered under medical supervision results in
physical and mental-health improvements, reduced illicit drug use and
reduced criminal activity.

In a 2013 report commissioned by Health Canada, Dr. Michael Lester, an
expert in opioid dependence treatment, described HAT as "a promising
treatment of last resort" for this population, noting there is no
other "next step" for people who have failed multiple attempts at
conventional substitution therapy.

HAT has been available for years in several European countries,
including Switzerland, Germany and Denmark. But in Canada, only 92
people - all former participants of the clinical trial - are receiving
the treatment.

The hurdles that exist are not governmental. Federal Health Minister
Jane Philpott supports the treatment and in September overturned the
previous Conservative government's ban on it.

But because pharmaceutical-grade heroin is not manufactured or
marketed in Canada, physicians must access it through Health Canada's
Special Access Programme (SAP), submitting an application for each
prospective patient. If approved, the drug then has to be imported
from Switzerland - a process that can be prone to delays - in
shipments containing no more than six months' supply at a time.
Physicians must resubmit these applications, for every patient, every
six months.

Last month, Dr. Philpott wrote to provincial and territorial health
ministers noting that clinical evidence supports unconventional
treatments such as pharmaceutical heroin, and that Health Canada's
chief medical adviser is available "to further explore with your
officials what they anticipate the needs are and any potential
obstacles to accessing needed treatments."

Providence Healthcare estimates one person using illicit opioids costs
society around $48,000 a year in health-care and criminal-justice
costs. In comparison, it costs about $25,000 to put a person on HAT
for one year at the Crosstown Clinic.


A follow-up study to NAOMI, the Study to Assess Long-term Opioid
Maintenance Effectiveness (SALOME), found that hydromorphone, a
licensed pain medication, is as effective a replacement therapy as
pharmaceutical-grade heroin. It's a particularly attractive option as
it is already available in Canada and does not have the stigma of heroin.

At present, 27 people who participated in SALOME remain on injectable
hydromorphone at the Providence Crosstown Clinic, along with one new
patient who started in August. Christy Sutherland, an addiction
medicine specialist and medical director of the PHS Community Services
Society, has also separately started two of her patients on injectable
hydromorphone - including Melody Cooper.

Ms. Cooper had been a patient of Dr. Sutherland's for many years and
had tried methadone, Suboxone and detox numerous times. Nothing
worked. Dr. Sutherland feared her patient would die.

When the physician read the SALOME research paper, she immediately
thought of Ms. Cooper.

In September, Dr. Sutherland started Ms. Cooper on injectable

"It was just amazing," Dr. Sutherland said. "She hardly missed a dose
and she has stopped using. She doesn't meet the criteria for substance
use disorder anymore."

Ms. Cooper says the change has been drastic.

"Now my life is so happy and relaxed," she said. She now works two
part-time jobs - cleaning and peer support at the clinic in her
residence - and returned to her old hobbies: beading, painting and

"I don't even have the cravings anymore. I'm not out there trying to
find my next fix, not risking my life or going to jail. I'm not one of
those people overdosing on fentanyl."

There are no regulatory hurdles preventing a physician from starting a
patient on hydromorphone as a substitution therapy. Hydromorphone is
licensed as a pain medication, which would make its use as an
addiction medication off-label, but this is permitted by the College
of Physicians and Surgeons of B.C. so long as there are compelling
reasons and the physician has an informed consent discussion with the
patient, said registrar Heidi Oetter.

It costs about the same to put one person on supervised injectable
opioid assisted treatment with hydromorphone at Crosstown as it does
with heroin: roughly $25,000 a year.

Decriminalization and legalization

In 2001, Portugal decriminalized the purchase, possession and
consumption of all psychoactive drugs for personal use, defined as 10
days' worth for an average person. That legislation essentially
formalized the country's existing emphasis on treatment over
punishment for drug users, replacing criminal penalties with
administrative penalties. Those found using appear before a local
Commission for the Dissuasion of Drug Addiction, which then considers
individual circumstances and can impose a noncriminal sanction such as
a referral to treatment or a monetary fine. It remains illegal to
manufacture, sell and distribute drugs.

Three population surveys since 2001 suggest drug use increased
slightly, but then fell to rates lower than before the legislation was
enacted. Drug deaths plummeted; a 2016 report by European Monitoring
Centre for Drugs and Drug Addiction found that fatal overdoses fell to
levels among the lowest in the European Union, as did new cases of HIV
and AIDS among drug users.

In British Columbia, top health officials, including provincial health
officer Perry Kendall, have voiced support for decriminalization.
Patricia Daly, chief medical health officer and vice-president of
public health for Vancouver Coastal Health, said she supports not only
decriminalization, but full legalization, which would entail state
regulation of production, sale and use. Unwanted adulterants, such as
deadly fentanyl and carfentanil, would be obsolete in a regulated market.

Asked about the issue in a November interview, B.C. Premier Christy
Clark said she agreed addiction should be treated as a health issue
but declined to support decriminalization.

"I think we might differ because I know that [Dr. Kendall and Dr.
Daly] do support the legalization of a broad range of drugs and I
don't want to end up in that category, because I'm not," the premier
said. "But I absolutely agree that we need to treat addiction as a
health issue because people who are addicted need their health, and
their mental health, issues addressed and jail is often not the best
place to do that."

Dr. Philpott, the health minister, interviewed on the subject in
January, said drug policy is a sensitive topic for many but that "we
are at the point we do need to talk about all the possibilities."

Asked if a Liberal government would consider decriminalization, the
minister said it may not necessarily be the best route to go.

"If you look to cannabis, on the recommendations of the authorities,
and recognizing the role of organized crime," she said, "we felt that
it was not appropriate to simply decriminalize, that the right step to
do was go to a strict regulatory regime with restrictions for access."

Donald MacPherson, executive director of the Canadian Drug Policy
Coalition and former drug policy co-ordinator for the City of
Vancouver, said regulation must be embraced as the next step in harm

"That is the stated objective behind cannabis regulation: They're
doing this to protect youth, they're doing this to protect public
safety," Mr. MacPherson said. "The same argument applies to all other
drugs, as difficult as that is to put forward. We need to get beyond
the point where we're afraid of that, because what we have now is
absolutely not working."
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