The politics of the heroin addict

Rona Ambrose and Pierre Poilievre just say no

Adrian Wyld/CP

If a society is judged by how its cares for its most vulnerable, we are basically faced with a test of what we are willing to try to help the most beleaguered. Consider the heroin addict.

Health Minister Rona Ambrose announced this afternoon that Health Canada will never again allow doctors to provide prescription heroin to patients through the Special Access Program (though she did suggest doctors who wished to do so could attempt to pursue the matter through provincial routes).

This comes two weeks after Ms. Ambrose, named health minister in July, sent out a statement to the press gallery to express her displeasure with her department’s decision to grant doctors involved in a clinical trial in British Columbia the clearance necessary to provide prescription heroin to approximately 15 patients. Ms. Ambrose’s statement doesn’t seem to have been posted to the Health Canada website, so here it is in its entirety.

Our Government takes seriously the harm caused by dangerous and addictive drugs. These drugs tear families apart, promote criminal behaviour, and destroy lives.

That is why our Government is focused on preventing children and youth from using drugs in the first place and strongly deterring existing use of harmful and addictive drugs.

Health Canada has a “Special Access Program,” which is designed to give Canadians with rare diseases or terminal illnesses access to medications that are not otherwise approved for use in Canada.

For example, a doctor who is treating a child with a rare form of cancer can apply to Health Canada for access to potentially life-saving medicines, which otherwise would not have been approved for medical treatment. This is what the Special Access Program is designed to do.

Earlier today, officials at Health Canada made the decision to approve an application under the Special Access Program’s current regulations to give heroin to heroin users – not to treat an underlying medical condition, but simply to allow them to continue to have access to heroin for their addiction even though other safe treatments for heroin addiction, such as methadone, are available.

This decision is in direct opposition to the government’s anti-drug policy and violates the spirit and intent of the Special Access Program.

I am taking immediate action to protect the integrity of the Special Access Program and ensure this does not happen again.

The Special Access Program was designed to treat unusual cases and medical emergencies; it was not intended as a way to give illicit drugs to drug addicts.

Our policy is to take heroin out of the hands of addicts, not to put it into their arms.

Our Government will continue to invest in drug treatment and prevention programs that work to keep our children and youth off drugs, and will continue to protect Canadian families and communities

Prescribing heroin to a heroin addict is not quite a new idea.

From 2005 to 2008, a study known as NAOMI—funded by the Canadian Institute of Health Research and with an exemption from Health Canada to provide pharmaceutical heroin—compared how pharmaceutical heroin—diacetylmorphine—compared with methadone in the treatment of heroin addicts. That study found prescription heroin could be a more cost-effective form of treatment for chronic addicts who had not previously responded to other treatments.

Here is how Andre Picard reported the findings in 2009.

Providing diehard addicts with heroin is far more effective than treating them with methadone, according to the results of a much-anticipated study.

The research, published in Thursday’s edition of the New England Journal of Medicine, shows that patients treated with injectable diacetylmorphine (the active ingredient in heroin) are 62 per cent more likely to remain in addiction treatment and 40 per cent less likely to take street drugs and commit crimes to support their habit than are those treated with oral methadone.

As it is, “supervised injectable heroin” is already legally available in five European countries. Here is how the European Monitoring Centre for Drugs and Drug Addiction summarized the global research in this regard.

A small population of chronic heroin users, once thought to be ‘untreatable’, is now benefiting from a novel type of therapy using medicinal heroin as the substitution drug. In a new report out today from the EU drugs agency (EMCDDA), experts describe the development as ‘an important clinical step forward’. The report, New heroin-assisted treatment, provides the first state-of-the-art overview of research on the subject, examining the latest evidence and clinical experience in this area in Europe and internationally (1).

The prescription of substitution drugs (e.g. methadone, buprenorphine) has become a mainstream, first-line treatment for opioid dependence, with around 700 000 of Europe’s 1.3 million problem opioid users receiving substitution treatment today. But a small minority of entrenched opioid users repeatedly fails to respond to interventions of this kind. Findings from international trials now suggest that the supervised use of medicinal heroin can be an effective second-line treatment for this small, and previously unresponsive, group.

Ms. Ambrose’s announcement includes comments from University of Toronto professor Meldon Kahan, who has questioned the NAOMI study. One of the NAOMI investigators offered this response to Mr. Kahan.

At the same time, NAOMI also provided evidence that a licensed drug—hydromorphone—might also be a more effective treatment than methadone and so the SALOME study—also funded by the Canadian Institute of Health Research, also operating with an exemption from Health Canada—was launched. The researchers operating SALOME explain their study here.

The Globe’s Andrea Woo explains that doctors appealed to Health Canada to continue providing heroin to patients exiting SALOME.

But as the first participants began cycling out of SALOME early this year, doctors in charge of their exit strategies faced a problem: They could either prescribe conventional drugs like methadone – which no trial participant had succeeded with – or hydromorphone, a drug whose effectiveness had not yet been proven as the trial is ongoing. Prescription heroin, while proven in NAOMI to be effective, remains a controlled substance in Canada. Citing the urgency of those SALOME participants’ exit plans, those doctors are now applying to Health Canada’s Special Access Programme (SAP) for what they say is critical treatment for their patients.

Patricia Daly, chief medical health officer and vice-president of public health at Vancouver Coastal Health, said doctors are reluctant to prescribe hydromorphone as it isn’t specifically approved for heroin addiction treatment. “I’ve written to Health Canada and asked that [the patients] be allowed to get injectable diacetylmorphine – that’s injectable heroin – because we’ve demonstrated in a research study, published in the New England Journal, that’s an effective treatment,” she said.

Here is some of what Dave Byres of Providence Health Care, one of the partners in the SALOME study, told me when I asked him to explain the case for prescribing diacetylmorphine.

All of the participants have not responded to standard therapies. Injectable [diacetylmorphine] is their best option to obtain and maintain health, stability and to stop illicit heroin use. Therefore, it is reasonable to ask Health Canada to allow these participants to continue benefiting from a drug that has been proven effective in double blind, randomized control trial that was a Health Canada sanctioned study. No one decides one day to become severely addicted to heroin. These patients have a severe, life threatening illness and deserve to have the best available treatment for their addiction – no different that any other Canadian deserves to have for their particular illness.

At the time of the NAOMI study, an application was filed with Health Canada’s Special Access Program to prescribe diacetylmorphine, but the request was denied. This time, Health Canada apparently agreed with the doctors. For more on that decision see Anna Mehler Paperny’s explainer and Andrea Woo’s follow.

A day after Ms. Ambrose’s statement, the Conservative party sent out a note to its mailing list under the heading “Stop giving heroin to addicts.”

Drug addiction is a very serious problem in our communities.

Drugs like heroin tear families apart, promote criminal behaviour, and destroy lives.

That’s why our government has focused on stopping illegal drug use and treating addicts in a safe way.

But drug treatment programs should be focused on ending drug use – not giving illicit drugs to drug addicts.

That’s why I was shocked to learn today that Health Canada approved funding to give heroin to addicts – against the wishes of our elected government.

We’re going to take steps to make sure this never happens again – but we need your help.

If the NDP or Liberals are elected in 2015, you can bet they would make this heroin-for-addicts program permanent.

We can’t let that happen. We’ll keep fighting to keep our streets and communities safe, but we need your support.

Will you stand with us? Add your name here:


Fred DeLorey
Director, Political Operations
Conservative Party of Canada

So if nothing else should come from this matter—and whatever the merits of pursuing heroin-assisted treatment—at the very least the Conservative party will gain some personal info to mine.

The SALOME study’s website presents hydromorphone as a potentially less-fraught alternative to heroin-assisted treatment—”Should hydromorphone be proven to be as good as diacetylmorphine, the benefits of this form of treatment may be achievable without the emotional and regulatory barriers often presented by heroin maintenance”—but it will two years before researchers know whether the results of SALOME indicate that hydromorphone provides all of the benefits of heroin-assisted treatment and covers all of the potential patients.

Meanwhile, a group in Ottawa is planning to apply to Health Canada for permission to establish a supervised-injection facility. The group is apparently eager to file an application before the Harper government is able to move ahead with new legislation on when such facilities can be allowed.

In a note posted to his website last week, Conservative MP Pierre Poilievre expressed his dismay.

“Giving dangerous drugs to people does not serve public health. Our government introduced tough, new rules that will give local law enforcement, municipal leaders, and residents a voice before a permit is granted for a drug use sites.

Instead of giving addicts more of what is killing them, we should provide treatment. That is why I have backed Harvest House and the Ottawa drug treatment initiative of Senator Vern White.”

The Ottawa facility would apparently be similar to Vancouver’s Insite facility, which does not distribute drugs.

One of Ms. Ambrose’s predecessors, Tony Clement, opposed safe-injection facilities, but, on Insite, he was ultimately rebuked by the Supreme Court.

The Minister’s failure to grant a s. 56 exemption to Insite engaged the claimants’ s. 7 rights and contravened the principles of fundamental justice.  The Minister of Health must be regarded as having made a decision whether to grant an exemption, since he considered the application before him and decided not to grant it.  The Minister’s decision, but for the trial judge’s interim order, would have prevented injection drug users from accessing the health services offered by Insite, threatening their health and indeed their lives.  It thus engages the claimants’ s. 7 interests and constitutes a limit on their s. 7 rights.  Based on the information available to the Minister, this limit is not in accordance with the principles of fundamental justice.  It is arbitrary regardless of which test for arbitrariness is used because it undermines the very purposes of the CDSA — the protection of health and public safety.  It is also grossly disproportionate: during its eight years of operation, Insite has been proven to save lives with no discernable negative impact on the public safety and health objectives of Canada.  The effect of denying the services of Insite to the population it serves and the correlative increase in the risk of death and disease to injection drug users is grossly disproportionate to any benefit that Canada might derive from presenting a uniform stance on the possession of narcotics.

In considering the possibility of a facility in Ottawa, the Ottawa Citizen’s editorial board saw another kind of test.

The coming debate in Ottawa will test the guidelines and the community’s ability to have a productive discussion about this. We need a good debate on the issue, one that provides space for all points of view, but it can’t be based on emotion or ideology.

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