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By Richard Karel
Faced with a surging death toll from heroin overdoses, Canadian politicians and public health and law enforcement officials are urging a multicenter trial of controlled heroin prescribing. The proposal is being viewed favorably by the Canadian Psychiatric Association (CPA).
The epicenter of the overdose crisis is British Columbia, where more than 200 people have died from heroin overdoses this year. Officials fear the toll could double by year's end.
The Canadian Psychiatric Association "is looking at this proposal with great interest," CPA President-elect Nady El-Guebaly, M.D., told Psychiatric News. He is also the observer consultant and Assembly liaison to the APA Council on Addiction Psychiatry.
Despite such support and that of other public health officials including British Columbia's Provincial Health Officer John Millar, M.D., the British Columbia Medical Association is opposed to the trial, while the Canadian Medical Association has taken no stance, El-Guebaly said.
Spearheading the drive for the controversial trial is Member of Parliament Libby Davies, whose legislative district of approximately 100,000 people includes Vancouver's Downtown East, an economically depressed area where most of the deaths have occurred. Heroin overdose "is now the leading cause of death for men and women between the ages of 30 and 49" in British Columbia, said Davies. British Columbia also has "the highest HIV infection rate-about 27 percent [of injecting drug users (IDUs)]-of any place in the Western world," she said, as well as a hepatitis C rate of 90 percent of the province's estimated 6,000 to 10,000 IDUs. In addition to an influx of potent, cheap heroin, the availability of cheap cocaine has contributed to the spread of blood-borne disease, she said.
The details have yet to be worked out, but Davies said the initial trial would probably involve "a few hundred people" in each of three sites, likely Vancouver, Montreal, and Toronto. Addicts would have to self-administer heroin under medical supervision and on site.
One-third of IDUs who become HIV positive are comorbid for mental illness, "which itself is an indictment of how we deal with mental illness," said Davies. "How can you criminalize those people. . .because they happen to be using illegal drugs?"
As in the U.S., many of the mentally ill in Canada have been deinstitutionalized without provisions for follow-up and have ended up on the street, Davies said.
Davies plans to introduce her proposal when Parliament reconvenes this month.
Mental illness plays a critical role in the current drug crisis, said Millar. "There is a huge overlap-roughly 50 percent [of IDUs]-with the mentally ill population."
While the literature shows that some of the interventions are highly effective, "none of them will be effective unless they go hand in hand with good mental health services," said Millar. "If someone has dual diagnoses of psychosis and narcotic addiction, you've got to deal with both of those at the same time. If a person is drug addicted and has ended up homeless on the streets of Vancouver, you also have to deal with the housing and other social supports, including food, clothing, and socialization."
It is critical that addiction medicine and social policy have realistic goals, said Millar. The aim must be to decrease criminal activity, needle sharing, and unprotected sex. "You're not trying to enforce abstinence. That's crazy."
The evidence is that "methadone alone works but methadone plus counseling works better," said Millar. "The same would apply to heroin maintenance."
The cost of methadone plus counseling a year is about $4,000 Canadian, versus about $34,000 in direct government costs "to leave somebody out there untreated. The cost-effectiveness arguments here are just overwhelmingly in favor of doing it."
Opponents are "applying a moral grid to a medical problem," Millar contended. It is "the moralizing around this issue" that has compounded the impact of drug addiction.
"The concept of heroin maintenance is nothing new," noted El-Guebaly, who practices in Calgary, Alberta. "I have no problem with this as long as it is carefully controlled and monitored, and particularly if it is used as an enticement to treatment. Nobody is saying that it's a panacea."
Prescribed heroin could serve as a step toward getting addicts on methadone, but should not be provided indefinitely, he commented.
El-Guebaly said he favors an approach known as "harm reduction," which deemphasizes law enforcement and aims to reduce the adverse consequences of drug use without demanding abstinence. "I'm having a devil of a time getting the APA Council on Addiction Psychiatry to discuss harm reduction," he remarked. "It is an ill-defined concept that needs tightening up as much as we can. But all I get is 'I don't want to discuss that.' " APA "should have an open mind to various approaches of harm reduction, which must include looking at the results of controlled studies," he added.
Richard Frances, M.D., chairs the Public Policy Committee of the American Academy of Addiction Psychiatry and is a consultant to the APA Council on Addiction Psychiatry. "Issues like this should be reviewed in the light of what our best science tells us," said Frances. "Heroin addiction is a brain disease and should be medically treated. However, the best medical treatment we have, based on many studies, is methadone maintenance."
Martin Schechter, M.D., is a professor of epidemiology at the University of British Columbia in Vancouver. He was the principal investigator for the "Vancouver Injection Drug Users Study," published in 1996.
"In my view the war on drugs is a complete failure," said Schechter. "The sooner we recognize that the harm from prohibition is greater than the harm from drugs, the better off we will be. The second thing I would say is that I am fully supportive of expanding all the drug-treatment options. I think methadone maintenance programs must be much more widely available. But it appears to me that there is a group of addicts for whom methadone maintenance will not work. Unless we have something to offer them, they will be left behind."
The idea is "not to offer heroin maintenance as first-line therapy, but rather as an option for those who have failed existing modalities."
Kenneth Higgins retired last December as deputy police chief of Vancouver. He was a 30-year veteran of the police, and represented the Canadian Association of Chiefs of Police on the National Task Force Report on HIV, AIDS, and Injection Drug Use, which was published last May. Among the report's recommendations was decriminalizing the possession of heroin and cocaine for personal use, said Higgins.
The "main transition has to be for management of the drug issue to move from the justice system to health," said Higgins. The law should "do good for the greatest number of people," said Higgins. "Right now the laws related to narcotics and addiction do the greatest amount of harm to the greatest number of people."
The New York Academy of Medicine will hold a conference on heroin maintenance and other addiction treatments on September 25. The conference Web site is www.nyam.org/heroin/. Other relevant Web sites include those of the National Institute on Drug Abuse at www.nida.nih.gov/ and the Canadian Mental Health Opioid Dependence site at www.mentalhealth.com/dis/p20-sb08.html. The Lindesmith Center has a summary of a seminar on heroin maintenance at www.lindesmith.org/library/preolso.html.