Expanding access to diacetylmorphine and hydromorphone for people who use opioids in Canada

Abstract

The increasing incidence of fatal opioid overdose is a public health crisis in Canada. While buprenorphine/naloxone and methadone are the standard first-line of opioid substitution options, limitations, including difficulty achieving long-term retention for some people who use opioids, are well known. For this group, injectable diacetylmorphine or hydromorphone can achieve positive outcomes, including high retention rates, reduced use of unregulated opioids, and reduced criminal activity. In May 2019, Health Canada announced changes to increase the accessibility of diacetylmorphine and hydromorphone, and in September 2019, the CIHR-funded Canadian Research Initiative in Substance Misuse released a national clinical guideline for diacetylmorphine and hydromorphone as additional frontline substitution options. While these developments present opportunities for scale-up, significant financial, structural, and practice barriers continue to impede access. This commentary explores the current state of policy and practice for diacetylmorphine and hydromorphone as opioid substitution options in Canada, outlines the rationale for rapid expansion of access, and highlights clinical and policy changes that must be undertaken or the death toll will continue to rise.

Résumé

L’incidence croissante des surdoses d’opioïdes mortelles représente une crise de santé publique au Canada. La buprénorphine/naloxone et la méthadone sont au premier rang des options de substitution aux opioïdes, mais leurs limites, dont la difficulté de fidéliser à long terme certaines des personnes qui consomment des opioïdes, sont bien connues. Dans ce groupe, la diacétylmorphine ou l’hydromorphone en injection peuvent donner de bons résultats, dont des taux de fidélisation élevés, la baisse de la consommation des opioïdes non réglementés et la réduction des activités criminelles. En mai 2019, Santé Canada a annoncé des modifications visant à accroître l’accessibilité de la diacétylmorphine et de l’hydromorphone, et en septembre 2019, l’Initiative canadienne de recherche sur l’abus de substances, financée par les IRSC, a publié une directive clinique nationale pour la diacétylmorphine et l’hydromorphone comme autres options de substitution de première ligne. Ces développements ouvrent des possibilités de mise à l’échelle, mais l’accès aux produits est encore entravé par d’importants obstacles financiers, structurels et pratiques. Dans notre commentaire, nous explorons l’état actuel des politiques et des pratiques pour faire de la diacétylmorphine et de l’hydromorphone des options de substitution aux opioïdes au Canada, nous expliquons les raisons qui justifient une expansion rapide de l’accès et nous soulignons les changements d’ordre clinique et stratégique qu’il faudra apporter, sans quoi le nombre de morts continuera d’augmenter.

This is a preview of subscription content, log in to check access.

References

  1. An Open Letter calling for Public Drug Coverage of High Dose Injectable Hydromorphone for People Who Use Opioids in Ontario. (2019). Retrieved from https://listhmonodb.wordpress.com/

  2. Browne, R. (2019). More doctors are prescribing opioids to prevent their patients from dying of overdoses. Global News. Retrieved from https://globalnews.ca/news/5412946/safe-supply-opioid-overdose/

  3. Expanding Opioid Substitution Treatment with Managed Opioid Programs. (2019). Toronto: Medical Officer of Health.

  4. Fairbairn, N., Ross, J., Trew, M., Meador, K., Turnbull, J., MacDonald, S., et al. (2019). Injectable opioid agonist treatment for opioid use disorder: a national clinical guideline. CMAJ, 191(38), E1049–E1056.

    Article  Google Scholar 

  5. Government of Canada approves new treatment options for opioid use disorder and supports research, treatment and harm reduction projects in Ontario. [Press release]. Retrieved from https://www.canada.ca/en/health-canada/news/2019/05/government-of-canada-approves-new-treatment-options-for-opioid-use-disorder-and-supports-research-treatment-and-harm-reduction-projects-in-ontario.html

  6. Guidance for Injectable Opioid Agonist Treatment for Opioid Use Disorder. (2017). Retrieved from https://www.bccsu.ca/wp-content/uploads/2017/10/BC-iOAT-Guidelines-10.2017.pdf

  7. National Report: Apparent opioid-related deaths in Canada. (2019). Retrieved from https://health-infobase.canada.ca/datalab/national-surveillance-opioid-mortality.html#AORD

  8. Oviedo-Joekes, E., Guh, D., Brissette, S., Marchand, K., MacDonald, S., Lock, K., et al. (2016). Hydromorphone compared with diacetylmorphine for long-term opioid dependence: a randomized clinical trial. JAMA psychiatry, 73(5), 447–455.

    Article  Google Scholar 

  9. Policy Guide: Injectable hydromorphone maintenance treatment. (2018). Retrieved from http://library.bcpharmacists.org/6_Resources/6-2_PPP/1049-PPP67_Policy_Guide_iOAT.pdf

  10. Rai, N., Sereda, A., Hales, J., Kolla, G. (2019.). Urgent call on clinicians: prescribe alternatives to poisoned drug supply. Retrieved from https://healthydebate.ca/opinions/safer-supply-opioids

  11. Safe Supply Concept Document. (2019). Retrieved from https://vancouver.ca/files/cov/capud-safe-supply-concept-document.pdf

  12. Strang, J., Groshkova, T., Uchtenhagen, A., van den Brink, W., Haasen, C., Schechter, M. T., et al. (2015). Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction. Br J Psychiatry, 207(1), 5–14.

    Article  Google Scholar 

  13. WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users: 2012 revision. (2012). Retrieved from Geneva: https://www.who.int/hiv/pub/idu/targets_universal_access/en/

Download references

Funding

This work was supported by the St. Michael’s Hospital Foundation. Nazlee Maghsoudi is supported by a Canadian Institutes of Health Research (CIHR) Vanier Canada Graduate Scholarship. Jeanette Bowles is supported by the St. Michael’s Hospital Foundation. Dan Werb is supported by a US National Institute on Drug Abuse Avenir Award (DP2-DA040256), CIHR, via a New Investigator Award, the Ontario Ministry of Research, Innovation and Science via an Early Researcher Award, and the St. Michael’s Hospital Foundation.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Dan Werb.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Maghsoudi, N., Bowles, J. & Werb, D. Expanding access to diacetylmorphine and hydromorphone for people who use opioids in Canada. Can J Public Health 111, 606–609 (2020). https://doi.org/10.17269/s41997-020-00315-4

Download citation

Keywords

  • Opiate substitution treatment
  • Heroin
  • Hydromorphone
  • Drug overdose

Mots-clés

  • Traitement de substitution aux opiacés
  • Héroïne
  • Hydromorphone
  • Mauvais usage des médicaments prescrits