Deb Mazer argues that current government policy is being driven by more than evidence.
Years ago, the North American Opiate Medication Initiative (NAOMI) – a clinical trial of heroin-assisted therapy with participants in Vancouver and Montreal – showed that people with chronic heroin addiction who had failed traditional methadone programs responded well to supervised injection of prescription heroin. Indeed, initial reports dating back to 2008 indicated a 27% improvement in health scores, a 70% reduction in illicit heroin use, and close to a 50% reduction in other illegal activity.
At the time, this was heralded as an important success by Martin Schechter NAOMI’s Principal Investigator: “We now have evidence to show that heroin-assisted therapy is a safe and effective treatment for people with chronic heroin addiction who have not benefited from previous treatments. A combination of optimal therapies – as delivered in the NAOMI clinics – can attract those most severely addicted to heroin, keep them in treatment and more importantly, help to improve their social and medical conditions.” In addition, studies showing the safety and efficacy of heroin-assisted therapy have been completed in Switzerland, Denmark, the Netherlands, and Germany, among other countries.
Despite available evidence that heroin-assisted therapy benefits people with chronic heroin addiction, the October 16, 2013 Speech from the Throne, includes a commitment to “close loopholes that allow for the feeding of addiction under the guise of treatment.”
Under Health Canada’s Special Access Programme, doctors can prescribe otherwise unapproved drugs to help persons with addictions transition to less harmful substances. The Government of Canada intends to introduce regulations to ban prescription heroin, as well as other medications that contain unauthorized forms of illegal substances such as cocaine, ecstasy, and LSD.
Prior to the introduction of heroin-assisted therapy, heroin addiction was treated with methadone. Methadone and prescription heroin are medical-grade, synthetic, opioid drugs carrying risks of dependency and withdrawal. Both are controlled substances requiring prescriptions, and their main side effects are constipation and dependency. Neither methadone nor prescription heroin is neurotoxic. The biggest difference between these two drugs is that methadone does not produce the euphoric feelings common with heroin use. Additionally, a patient must be supervised while using prescription heroin, whereas patients can take their methadone doses on their own, outside of a supervised facility.
In the media discussion of the government’s decision, lawyer Scott Bernstein is quoted as saying: “Evidence should drive policy decisions, not ideology and stigma against drug users.”
The government’s decision to close what it describes as a loophole in the Special Access Programme clearly shows that current policy is being driven by more than evidence. But what that “more” should be is a matter for debate. In my view, a commitment to harm reduction and to the public interest should guide health policy governing the treatment of chronic addiction. Harm reduction refers to policies and strategies designed to minimize the destructive outcomes of illegal drug use, prostitution, and other behaviours that pose serious health risks. Harm reduction shifts the focus from ‘fixing’ an individual to ‘caring for’ that individual. Examples of harm reduction strategies for heroin users include safe injection sites, needle exchanges, and of course, methadone maintenance programs.
Safe injection sites, such as Insite in Vancouver, have been shown to positively impact the health and safety of both the drug-users and the general public. They reduce overdose mortality in heroin users, improve their overall health, and encourage and facilitate their access to and use of social and health services. From a public health perspective, providing hygienic needles slows the spread of infectious diseases like HIV/AIDS, hepatitis, and syphilis.
Safe injection sites also move drug use off the street. They provide supervision of safe injections, but leave it to the patient to procure their drugs on the black market. Conversely, heroin-assisted treatment provides both a safe and supervised injection site and medical grade drugs. As doctors are able to oversee the drug administration, overdoses are even rarer, and can be treated immediately with Naloxone and other anti-opioids. Safe injection sites and supervised heroin-assisted treatment provide all the benefits of traditional safe injection sites with the added benefit of consistent quality drugs.
Traditional medical ethics focuses on the tenet ‘above all, do no harm’, but what exactly constitutes harm is up for debate. In this case, an action or treatment that cares for an individual and prevents one kind of harm to the person is seen to impose another kind of harm on the public. In my view, however, providing prescription heroin can achieve both the goals of reducing harm to the individual and to the public. This hinges upon reframing the goals of addiction treatment to management and successful reintegration into society, not complete abstinence. Addiction is a chronic disease and chronic diseases require constant management. From this perspective, the benefits of a successful harm reduction strategy justify the provision of prescription heroin as part of a safe and effective treatment strategy.
Deb Mazer is a University of Toronto student studying Bioethics and Philosophy of Science.