Pubdate: Mon, 13 Feb 2017
Source: Globe and Mail (Canada)
Copyright: 2017 The Globe and Mail Company
Author: Norbert Gilmore
Page: S2


As deaths mount, it's time to think the unthinkable and supply users
with measured doses of pharmaceutically 'pure' heroin

For more than 30 years, until retiring as a physician in Montreal, I
cared for and studied people who became infected, sick or died from
HIV infection. Now, Canada faces a new epidemic.

It is an epidemic of overdose deaths, disease, disability and
destitution from fentanyl-adulturated street heroin. Lessons from the
HIV epidemic might help us to understand and respond quickly and
successfully to this new and seemingly uncontrolled epidemic.

 From its beginning, much of the evolution of the HIV epidemic can be
explained by political, professional and public denial, delay and
discrimination. Responses were too often debated, disputed and
squandered; helpful interventions were often developed too slowly;
deaths mounted until - years later - medications began to control the
situation. The HIV epidemic showed that delay can be costly.

Look at the screening scandals of the HIV epidemic, and of its sibling
hepatitis epidemic, in the 1980s to see that not spending
half-a-million dollars up front to screen blood for HIV, and delaying
hepatitis screening, ballooned into a billion dollars in compensation
and care costs.

The fentanyl epidemic is not the same as the HIV one. It is a
poisonous epidemic, not an infectious one. But central to both is
human behaviour.

One of the best lessons from the HIV epidemic (albeit a delayed one in
Canada and in some other countries) was providing "pure" blood and
blood products free of HIV and hepatitis contamination.

As deaths mount, so does pressure for Canada to respond to the present
fentanyl crisis. What should Canada do? The challenge is to act
decisively and quickly to try to stop the fentanyl epidemic - even in
the face of uncertainty and a lack of statistics and persuasive research.

Responding implies that there are interventions available that can be
implemented rapidly, effectively and will likely succeed, such as when
Canada made available an HIV- and hepatitisfree blood supply. It also
implies that whatever reasonably can be done to prevent premature
death, disease and disability should guide our political, professional
and public decisions.

So what can be done to stop the fentanyl epidemic? First, stop people
from using street drugs that are adulterated with fentanyl. Supply
people using illicit heroin with pharmaceutically pure heroin, either
free or at low cost. Physicians and a national registry can accomplish
this. Second, measure the doses of "pure" heroin that people will use,
so they know what dose is safe for them and will need to be refilled.
This can be done in supervised environments such as
supervised-injection sites. Third, ensure naloxone is on-hand wherever
drug injecting is likely to occur. (No one quibbles about fire alarms
or smoke detectors, and the same should apply for naloxone - a measure
in place in case of emergency.) Fourth, make suboxone and methadone
counselling available and quickly accessible. Finally, have zero
tolerance to delays from jurisdictional disputes, from funding debates
and from bureaucratic demands and concerns.

There are potential advantages from making "pure" heroin widely
available. They include less risk of death, disease and disability
from today's drug supply, especially when even more potent adulterants
are on the horizon; savings from not having to rescue and treat
overdoses, including naloxone costs; less neighbourhood and organized
crime; and less demand on police, first responders, health-care
providers and coroners. Success would mean that more resources can be
freed up for detox, recovery, rehabilitation and helping reduce
vulnerability, especially for addicts living on the street. And, this
approach will send a strong message to users, politicians,
professionals and the public that heroin use is not a crime, but a
medical disorder with interventions available to help users.

It is difficult to imagine other approaches to stop this epidemic that
might be as successful. Interdiction might lessen fentanyl
importation, but even with massive increases in resources, it is
unlikely to stop the crisis. The same applies to trying to stop drug
injecting and heroin use; greater rescue efforts, more naloxone
availability and increased supervised-injection-site access may save
lives but not end the epidemic.

With more and more people dying, and fewer options likely to stop or
slow Canada's fentanyl epidemic, it seems timely to think the
unthinkable - and medically pure heroin might be the answer.
- ---
MAP posted-by: Matt