During the era of alcohol prohibition in the 1920s, an average of 1,000 people a year lost their lives from consuming illicitly produced alcohol in North America. The prohibition of alcohol forced its production into underground markets, without regulation or governmental oversight. As a result, the liquor produced was often contaminated, unpredictable in its potency and caused blindness, hallucinations and death.
In 2017, it is estimated that between six and seven Canadians lose their lives to drug overdose every day. In British Columbia, 922 people lost their lives last year, the worst year in its history for overdose deaths, and new data for 2017 shows that the situation is getting worse. Someone in Ontario dies of opioid overdose every 13 hours. Increasingly in both provinces, an unregulated, illicitly produced opioid known as fentanyl is responsible.
How did we get here again almost 100 years after alcohol prohibition? Much of the problem began with the overprescribing of opioid medications and assurances from some in the pharmaceutical industry that these drugs were safe and non-addictive. This spawned an opioid-use epidemic like never seen before in North America.
In response, efforts were made to dramatically curtail the prescribing of opioid medications. Yet research from Vancouver has shown that when denied access to opioid pain medications, many of the most vulnerable people with pain resort to acquiring illegal opioids, such as heroin and fentanyl, through street-based drug markets.
It seems clear that Canada once again has a supply problem related to illegal substances. But what are we doing about it? Although efforts are under way to scale up some evidence-based health interventions, we are risking falling back into a failed war-on-drugs approach focused on controlling the drug supply. Measures such as increased border controls, higher penalties for trafficking and expensive interdiction efforts have all been tried before with limited and often harmful consequences.
Despite the fact that solutions do exist, people often ask what can be done about the fentanyl problem affecting several Canadian provinces. Certainly, many people have had success with existing opioid substitution treatments such as oral methadone or Suboxone, but more options are clearly needed.
As with most other medical conditions, there is not one medication-based approach that works for everyone using opioids. Second-, third- and fourth-line options are a normal part of modern medical care. Yet in many places in Canada, methadone remains the only treatment for opioid addiction, despite its known limitations, including low rates of retention in treatment.
It has therefore become clear that access to newer injectable opioid-assisted treatments must be increased dramatically, especially in light of the overdose deaths occurring each day throughout Canada. Health Canada has taken progressive steps to expand access to some injectable opioid-assisted treatments, and now provincial governments and regional health authorities also need to demonstrate similar leadership. This will of course require significant investment from governments, especially in B.C., where the impact of fentanyl has been felt most acutely. This would be akin to responses to other health emergencies, including SARS and H1N1.
At Vancouver’s Crosstown Clinic, participants receive access to safe, regulated doses of injectable heroin or hydromorphone (i.e., dilaudid). Despite there having been more than 88,000 injections at the clinic, there have been only 14 overdoses, none of them fatal. Evidence derived from rigorous evaluation shows that these approaches have been remarkably successful in reducing drug-related harm, including among those for whom methadone was not successful.
Participants in the Canadian trials, who reported not adjusting well to oral treatments, had high rates of retention in injectable opioid treatments. Further, use of street-acquired opioids went from an average of 28 days a month to less than four days after six months of treatment. The stability gained from these treatments brought other significant improvements, including improvements in physical and mental health, stable housing, social integration and a large reduction in criminal activity. The Crosstown Clinic example illustrates how access to safe, regulated opioids greatly reduces the risk of overdose that is killing Canadians every day.
Today, Canadians can take a sip of liquor and never worry that it will suddenly kill them. A lot has changed on that front, but because of our continued emphasis on drug prohibition, we’re losing far, far too many to needless death. More must be done and it must be done urgently.
Opioid-based treatments represent an immediate and potent solution to the opioid overdose epidemic, and we need to ensure that both oral and injectable treatments are prioritized, including injectable heroin or hydromorphone.
There are no legal barriers preventing the expansion of hydromorphone, and given the current overdose crisis, the lack of expansion of these treatments constitutes a public-health failure. Such approaches will serve to displace reliance on a tainted and dangerous illegal opioid supply, and will help people move toward healthier living.