With no signs of the opioid overdose epidemic abating, public health officials may need to consider more aggressive strategies to treat high-risk drug users. That could include prescribing the very drug to which users are addicted.

Doctors in Canada are now prescribing pharmaceutical-grade heroin and other prescription opioids to patients with addictions so severe that society had written them off as impossible to treat. While providing heroin to heroin addicts may seem counterintuitive, the practice has helped stabilize patients, reduce their illegal drug use and offer them a path to overcoming their addiction.

“Not everything will work for everybody, and some people need more intensive care,” said Dr. Scott MacDonald, lead physician at Providence Crosstown Clinic in Vancouver, British Columbia. “We need every tool in the toolbox to rise to the challenge the opioid epidemic presents.”

Prescription heroin has been used in Europe for years, but so far, the Crosstown Clinic is the only clinic in North America to prescribe injectable opioids outside of a clinic trial.

The clinic currently treats about 100 patients with pharmaceutical-grade heroin, and another 25 with hydromophone, a semi-synthetic version of morphine sold under the brand name Dilaudid.

Patients come to the clinic either two or three times a day, receive a standard amount of heroin and inject themselves. About a third take a small dose of methadone with their last session to help get them through the night.

All but one of the patients were part of a two-year clinical trial to test whether hydromorphone could be as effective as prescription heroin to treat opioid dependence. The clinic had hoped to continue treating patients after the trial ended, although a delay in getting federal approval created a slight delay.

The people recruited for the trial had been using heroin an average of 15 years and had tried medication-assisted treatment two to three times in the previous five years but were still actively using. For the first few days of treatment, doctors slowly adjusted their doses, finding a level that prevents withdrawal from kicking in but allows them to leave the clinic safely and continue with their day.

“We see people just get to a stable dose and stay there,” MacDonald said. “It’s a myth that people will just go up and up on their doses. When we prescribe, some people don’t even take the full dose.”

Patients must inject at the clinic where nurses can screen them for health issues and reverse an overdose if it occurs. But overdoses are a rare occurrence because patients know exactly what they’re getting with prescribed doses. And there’s no risk of contamination with fentanyl, which is driving the growth in overdose rates. Over the six-month study period, nurses had to intervene in only 14 out of more than 88,000 injections.

Despite injecting up to three times a day, total opiate use for those in the study went down. They reported using illegal drugs only three to five days per month, compared with almost daily illicit use before entering the study.

“They‘ve been using illicit opioids for many years, and sometimes, it’s just old habits. They walk by an old friend and they’re offered something,” MacDonald said.

He expected the clinic will be able to expand the treatment, taking on 25 to 50 new patients before the end of the year.

“We’re still in the early days here,” he said. “We’ve already seen people stepping down to oral options.”

In Europe, where prescription heroin has been in use much longer, somewhere between a third to a half of people step down to less intensive options, including abstinence, over time.

The treatment is time-consuming for patients, who must return to the clinic two to three times each day. But it’s less disruptive to their lives than trying to satisfy their addictions on the street.

“There are a number of people who have found part-time employment or full-time employment despite that time commitment here,” MacDonald said. “It’s also been encouraging to me that some schools and some employers here in Vancouver have accommodated their schedules so that our folks could continue to work and continue their schooling.”

While patients preferred the prescription heroin, many said hydromorphone worked just as well, and that could make it a better option for North American clinics. Prescription heroin has no other use and must be imported from overseas labs. Canadian regulations require federal approval for every patient who is prescribed heroin. Hydromorphone, on the other hand, is a commonly used pain reliever and is covered under the pharmaceutical plan in British Columbia. Canadian regulations also allow it to be used off-label, while U.S. regulations limit its use for pain management.

Other clinics in Vancouver have started hydromorphone treatments, and health officials are looking to expand that capacity.

MacDonald said the treatment protocol with either drug lowers the patient’s risk for infection or overdose and keeps them from turning to crime to support their addiction.

“I really don’t think there’s a downside,” MacDonald said. “If we can get people into care, they get healthier.”

There’s also significant cost savings for the health system. The treatment currently costs about $27,000 per year, compared with about $48,000 to treat someone in a methadone clinic. If prescription heroin could be produced domestically, MacDonald said the cost could drop even further, maybe below $16,000 a year.

MacDonald cautions that prescription heroin or hydromorphone shouldn’t be considered a first line treatment. But it’s an effective alternative for the small percentage of patients for whom more standard medication-assisted treatment, such as methadone or buprenorphine, doesn’t work.

Sarah Blyth, a consumer activist who runs an overdose-prevention site not far from the Crosstown Clinic, believes the prescription heroin model could be the answer to overcoming Vancouver’s overdose epidemic.

“We think that expanding that is the key to helping people,” she said. “If you have heroin-assisted treatment, then you’re giving them the drugs they need so they don’t have to steal. They don’t overdose. You don’t have to have someone standing around making sure they don’t die.”

Without having to come up with the money to support a drug habit, people aren’t reliant on crime or the survival sex trade.

“I’ve seen people’s lives change 100 percent,” she said. “They can start to build on a real life. They can watch Netflix like the rest of us.”

While prescription heroin may be a hard sell in many areas of the U.S., some addiction experts believe it could be a vital part of the nation’s path out of its current overdose crisis.

“The only way any country has ever succeeded in ending a heroin or opioid epidemic was what you saw in Switzerland or the Netherlands, in Europe generally,” said Scott Burris, a law professor at Temple University in Philadelphia. “They made treatment available to everybody. They particularly directed a net of services at the most severely impacted people and took care of them. There is still supervised heroin maintenance treatment in both Switzerland and in the Netherlands, but it worked.”

— Reporter: 541-633-2162, mhawryluk@bendbulletin.com

Markian Hawryluk is reporting this series during a yearlong Reporting Fellowship on Health Care Performance sponsored by the Association of Health Care Journalists 
and supported by The Commonwealth Fund. For the rest of the series so far, visit bendbulletin.com/opioids