Canada Is in Urgent Need to Expand Opioid Agonist Treatment

Opioid dependency continues to be a public health concern in Canada and worldwide. Despite mounting evidence of effective treatments to reach and treat those struggling with this chronic illness, opioid overdose deaths have increased in the past years. For example, in Ontario, it is one of the leading causes of death among young people, ¹ and in British Columbia, more people died in 2016 of an opioid overdose than from motor vehicle accidents. ²

To date, the most effective treatment we can offer is the provision of opioid agonists, where a medically prescribed dose of pharmaceutical-grade opioid medication is dispensed to patients. ^{3 –6} When we support patients with opioid agonist treatment (OAT), the immediate aim is to treat the craving and withdrawal symptoms and thus stop (or reduce) the use of street-acquired opioids, mostly heroin. The street use of heroin and other opioids holds more dangers than the drug itself. Most of the risk (to the person, the family, and the community) attributable to these drugs goes beyond the intrinsic danger of an overdose in a single dose and is related to unsafe practices (e.g., syringe sharing), social harms (e.g., incarceration, separation from family), and drug policies that are not based on evidence. ⁷ OAT prevents many of the harms associated with street drug use and offer patients the possibility to access care.

In their article, Eibl, Morin, Leinonen, and Marsh ⁸ depict the current state of OAT in Canada. While there are important geographic and cultural differences both between as well as within provinces, it is clear that expansion of OAT is needed. The authors remind us that Canada led the world on the use of agonist opioids for maintenance treatment in the 1960s; however, more than 50 years after, too many of those in need of this life-saving treatment are not reached and treated.

Although Eibl et al. ⁸ highlight that limited access to OAT is common across all jurisdictions in Canada, some regions and populations are disproportionately underserviced, facing structural and program-related barriers sometimes impossible to overcome (e.g., travel 200 km per day for supervised daily opioid dose administration). This observation is a direct reminder that people from all walks of life can be affected by opioid dependency, and yet it does not affect all communities in the same way. Rather, having or not having minimal-barrier access to evidence-based and culturally safe treatment makes a tremendous difference in the recovery capital a community holds. Thus, notable efforts should be made at offering OAT treatments in a fashion that does not further exacerbate social inequalities.

Indeed, expansion and access to evidence-based treatment for opioid dependency are sometimes faced with stigma and discrimination. Like other chronic conditions, most people dependent on opioids respond well to first-line treatments (i.e., long-acting oral opioids such as methadone or buprenorphine/suboxone). Unlike any other chronic condition, second-line treatments (i.e., short-acting injectable opioids such as diacetylmorphine or hydromorphone) face important resistance to be implemented. Bell, van der Waal, and Strang ⁹ report that despite several randomized clinical trials and external reviews showing injectable diacetylmorphine (i.e., pharmaceutical-grade heroin) is effective for the treatment of severe opioid use disorder, policy makers have not shown much interest in expanding this treatment. Patients in these supervised clinics presented to treatment with long histories of poor health, psychosocial problems, incarceration, homelessness, and continued use of street opioids despite access to first-line treatments. After several years of street heroin injection, men and women might find it very difficult to trust the health care system or even be interested in treatment. As the authors state, offering pharmaceutical-grade heroin “was a humane response to people who found themselves in a predicament.” For some, the authors explain, the access to pharmaceutical-grade heroin might be the only motivation to attend and comply with a structured treatment. After so many years of street drug use with the many harms associated with this, the treatment described by Bell et al. provides a tremendous opportunity to offer comprehensive care to an important minority facing many individual and structural vulnerabilities.

The problems of people with an opioid dependence are not merely the dependence on the opioids. Effective treatments and public health approaches are available, and Canada has been a pioneer in testing many of them. The overdose death epidemic is a sad reminder that there is an urgent need for expansion of OAT with a diversified opioid prescription portfolio (i.e., methadone, buprenorphine/suboxone, diacetylmorphine, hydromorphone, slow-release morphine, etc.). Increasing capacity and improving access to OAT needs to focus on creating opportunities for recovery, understanding recovery as a process and not as an end point, and offering OAT in a manner that is sensitive and tailored to the needs of the people it aims to reach and treat.