Opioid Addiction

Canadian Doctors Can Now Legally Prescribe Heroin To Patients With Opioid Addiction

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While activists and healthcare professionals continue to fight for the legalization of marijuana, or at least its rescheduling, prescription heroin is now legal in all of Canada as a way to manage addiction.

The quiet approval by the Canadian government is already in effect and have made the dealings of Crosstown, a clinic that has a heroin-maintenance program, completely legal and regulated. The clinic is the first of its kind to have this type of program in North America, but it follows the structure of other clinics in some European nations.

The use of medical-grade heroin is only allowed for patients who have a severe addiction to opioids and have not responded to other traditional treatments. Canada’s health department, Health Canada, said this of the decision:

“A number of countries have allowed doctors to use diacetylmorphine-assisted treatment to support the small percentage of patients with opioid dependence who have not responded to other treatment options. There is also a significant body of scientific evidence supporting its use.”

Diacetylmorphine is the name for pharmaceutical-grade heroin and health practitioners and medical facilities can now apply to use the substance in their facility. Physicians will have to apply to Health Canada to be allowed to use the heroin, and nurses will have to inject the drug into the patient 2-3 times per day.

Opponents of the new law have pointed out that treating addicts in this way will not help their condition because the objective isn’t to ween them off over time; instead, it’s to keep addicts controlled when all else fails and physicians believe that the patient can’t be helped.

While it’s easy to oppose the treatment, proponents are typically the healthcare professionals that actually treat these patients and understand what they’re working with. Scott MacDonald, the lead physician at the Crosstown Clinic, has been treating patients since 2005 and his clinic sees 52 patients regularly, operating a court-ordered exemption before the law was passed. MacDonald says some of the people he sees have been addicted to heroin for over 50 years and that traditional treatments have failed numerous times on them.

 

Other positives for the treatment include patients appearing to be healthier, and their participation in the program significantly decreases their involvement in criminal activities, as they no longer need to get their fix somewhere else.

Still, in general heroin treatments are just as addicting as the drug itself. An anonymous person spoke on Wednesday about being on methadone on Humans of New York and said,

“It doesn’t get you high like heroin, but it takes away the urges. But it’s like liquid handcuffs because the withdrawals are just as bad. If I stop for twenty-four hours, it feels like fire in my bones. And they only give you one dose at a time. So I get to the clinic every morning at 6am, and there are already one hundred people in line.”

On Prime Minister Justin Trudeau’s agenda is to also make marijuana legal by next year; he already has a special team to determine how it will be regulated, sold, and taxed. Marijuana has also proven to be an effective treatment in opioid addiction.

AAFP Targets Opioid Addiction

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Family physicians are frustrated with gaps in training for treatment of opioid addiction, as well as lack of access for patients and barriers to prescribing, and they are taking that frustration to the American Academy of Family Physicians (AAFP) Congress of Delegates meeting here.

During a lengthy, and spirited, debate in reference committee delegates pressed for a number of changes including support for enhanced prescribing and training opportunities for family physicians.

“The only person who can write the [naloxone] prescription is the head of the health dept.,” one delegate told a Congress reference committee. “This is creating significant barriers for our patients.”

Another delegate, from Massachusetts, said providers in that state were able to dispense naloxone, but “Folks should know, the auto-injector costs $600, a price increase of 50% over the past 2 years, and the nasal injection only costs $25.”

The Congress approved a resolution supporting use of naloxone by first responders, as well as authorizing doctors to prescribe naloxone to family members of opioid users, and legal protection for those prescribing physicians.

But a resolution on the safe use of methadone for pain management, which proposed that the AAFP advocate that the FDA develop a risk evaluation and mitigation strategy (REMS) to establish minimal competency for methadone prescribers, was not adopted.

A Texas delegate said that when oxycodone was removed from his formulary, physicians started prescribing methadone, “but they weren’t trained to do so.”

“It’s chemically different from morphine and other opioids, so docs need to learn how to prescribe it,” he added.

A New York delegate agreed saying, “The most important thing we can do is work on the formulary issues. Our single first questions should be what is best for the patients. The second issues, is how our members are trained.”

“I’ve encountered docs giving methadone to pregnant women,” he added. “The education we’re getting is not enough”

Because methadone is cheap, the New York delegate warned that it had high abuse potential, which underlined the importance of training.

Another resolution asked the AAFP to support provider education for office-basedtreatment of opioid dependence with buprenorphine.

Maine made national headlines with stats about drug abuse there, and a Maine delegate had this chilling statistic: “Death from overdose is the number one leading cause of death for adults ages 18-30.”

Moreover, that delegate noted that “In our state, there are waiting lists [for buprenorphine treatment], and it’s very sad to see our patients who are on the waiting list to show up in the obituaries.”

But several delegates pointed out that adding such training would require resources and time, both of which are in short supply in FP residency programs.

Moreover, there were varying opinions about the appeal of this special certification.

A pain managment specialist from New York offered his experience. “For every three people I train, I’m lucky if I can get one of them [to follow through to certification]. They tell me ‘we don’t want this population, or these people in our practice.’ They refer their patients to the substance abuse clinics in the community.”

In the end, the resolution proposing residency training for buprenorphine prescribing was not adopted, but an alternate resolution directing the AAFP to develop a position paper in support of family physicians prescribing buprenorphine to treat opioid use disorder was referred to the Board.