Vancouver Prescriptions for Addicts Gain Attention as Heroin and Opioid Use Rises
VANCOUVER,
British Columbia — Dave Napio started doing heroin over four decades
ago, at 11 years old. Like many addicts these days, he heads to
Vancouver’s gritty Downtown Eastside neighborhood when he needs a fix.
But
instead of seeking out a dealer in a dark alley, Mr. Napio, 55, gets
his three daily doses from a nurse at the Crosstown Clinic, the only
medical facility in North America permitted to prescribe the narcotic at
the center of an epidemic raging across the continent.
And
instead of robbing banks and jewelry stores to support his habit, Mr.
Napio is spending time making gold and silver jewelry, hoping to soon
turn his hobby into a profession.
“My
whole life is straightening out,” Mr. Napio, who spent 22 of his 55
years in prison, said during a recent interview in the clinic’s
mirror-lined injection room. “I’m becoming the guy next door.”
Mr. Napio is one of 110 chronic addicts with prescriptions for diacetylmorphine
hydrochloride, the active ingredient in heroin, which he injects three
times a day at Crosstown as part of a treatment known as heroin
maintenance. The program has been so successful at keeping addicts out
of jail and away from emergency rooms that its supporters are seeking to
expand it across Canada.
But they have been hindered by a tangle of red tape and a yearslong
court battle reflecting a conflict between medicine and politics on how
to address drug addiction.
The
clinic’s prescription program began as a clinical trial more than a
decade ago. But it has garnered more interest recently as a plague of
illicit heroin use and fatal overdoses of legal painkillers has swept
across the United States, fueling frustration over ideological and legal
obstacles to forms of treatment that studies show halt the spread of
disease through needles and prevent deaths.
Canada
and some European countries have long permitted needle exchanges and
monitored injection sites. Prescription programs like Crosstown’s, for
addicts whom replacement drugs like methadone do not seem to help, have
been available for years in Britain, Denmark, Germany, the Netherlands
and Switzerland. All these countries have reported significant decreases
in drug abuse, crime and disease.
But
such programs have been stymied in the United States, where overdoses
have lately led to 125 deaths per day, by concerns that they would
encourage illicit drug use. In February, the mayor of Ithaca, N.Y., was
criticized by some Republican officials, rehabilitation professionals
and police officers after he proposed to establish the country’s first supervised injection facility.
The
authorities in Vancouver, a bustling metropolis on the coast of British
Columbia, say they turned to such programs after more traditional
criminal justice approaches failed to stop rampant illegal drug use and
sales on the Downtown Eastside, a poor neighborhood notorious for
addiction and crime. “We tried to arrest our way out of it and that
didn’t work,” Sgt. Randy Fincham of the Vancouver Police Department
said. “Clogging up our courts and jails was not the solution.”
The
city started, in 2003, with North America’s first legal injection
facility, InSite, which currently serves around 800 people each day. The
addicts bring their own drugs, and InSite provides clean needles and
medical supervision. The organization has recorded no fatal overdoses on
its premises, and said overdoses near the facility have decreased by 35 percent since 2003, compared with a 9 percent decrease throughout Vancouver.
More
broadly, a study by the British Columbia Center for Excellence in
HIV/AIDS found that people who use safe injection sites are 30 percent
more likely to enter detox programs and 70 percent less likely to share
needles.
Legal
injection sites do not, however, address the thefts, prostitution and
other criminal behavior that participants often rely on to finance their
addiction. And heroin sold on the street is often combined with — or
surreptitiously replaced by — fentanyl,
an opioid up to 50 times as potent that was a cause or contributing
factor in 655 deaths across Canada from 2009 to 2014, according to the
Canadian Center on Substance Abuse.
Participants in the Crosstown prescription program do not have to worry about the purity of their drugs.
To
get a diacetylmorphine prescription from the clinic, patients must have
participated in two earlier clinical trials on heroin maintenance,
whose eligibility requirements included more than five years of
injecting opioids and at least two failed attempts at replacement
therapy, one of which with a treatment such as methadone.
The first trial,
known as the North American Opiate Medication Initiative, followed
users from 2005 to 2008, and found that prescribing diacetylmorphine
could save an average of $40,000 in lifetime societal costs per person
compared with methadone treatment. The second trial, whose results were
published this month in The Journal of the American Medical Association Psychiatry,
found that injectable hydromorphone, a licensed pain medication, can be
as successful as diacetylmorphine in treating a chronic opioid
addiction.
But
advocates say that some addicts cannot tolerate the side effects of
hydromorphone, and worry that anything but heroin itself would send them
back to the streets.
The
diacetylmorphine prescription program is one of several
addiction-treatment services at Crosstown, a squat gray clinic that
opened in 2005. The publicly funded program costs about 27,000 Canadian
dollars, or $21,000, per addict per year. (The Journal of the Canadian
Medical Association published a study
in 2012 that estimated that an untreated, severe opioid user costs
taxpayers at least $35,000 a year in medical care, jail and other
expenses.)
Patients
can visit the clinic up to three times a day, from 8:30 a.m. to 4 p.m.
They enter through a security door and fill a white-walled waiting area
before taking seats in the injection room, where nurses give them a
needle and an average dose of 200 milligrams of diacetylmorphine. The
process takes a few minutes, but the effect is profound.
“We’ve
seen people make dramatic changes in their lives,” said Dr. Scott
MacDonald, the clinic’s lead physician. “They don’t have to hustle or do
sex work anymore, and some are now able to go to school or work. It’s
very rewarding.”
Larry
Love, 65, a gray-haired, jovial former oil rig worker, said he started
using heroin at 13. Decades of addiction destroyed his marriage and
relationships with his children. A $350,000 inheritance he received in
the 1990s vanished in less than four years.
Diacetylmorphine,
he said, has opened up a path back to normalcy. He compared it to the
insulin injected daily by diabetics: just a drug he needs to stay alive.
“It’s
100 percent about stability,” he said. “Now I have money in my savings
account and can get a haircut whenever I want. I’ve even started
investing.”
Advocates
have long wanted to extend heroin maintenance beyond the small group of
patients at Crosstown, but they face formidable bureaucratic hurdles
and a continuing court fight.
In
2013, Canada’s health minister, a member of the Conservative Party,
sought to put in place regulations that would ban the prescription of
heroin and other illegal drugs outside of a clinical trial, reflecting
the party’s broad opposition to harm-reduction policies.
Five
Crosstown patients and the Providence Health Care Society, which runs
the clinic, filed a case with the Supreme Court of British Columbia to
block the move, arguing that the federal regulations violated a
constitutional right to lifesaving treatment. A Supreme Court justice
granted an injunction in 2014 that allowed current patients to continue
receiving prescription heroin until the constitutional challenge could
be heard. A court date is set for October.
At Crosstown, patients continue to try to repair their fractured lives.
Liane
Gladue, 48, was a seventh-grade teacher and a married mother before she
started shooting heroin two decades ago. She said she could not quit,
and spent her waking hours shoplifting and committing other crimes. But
since joining the clinical trials and Crosstown’s program, she said, she
has reconnected with her grown children.
“When
I wake up and think about what I’d have to do for heroin, I feel so
lucky to be in this program,” she said. “Now I can do some healing.”
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