Prescription Inhalable Heroin Is Coming to BC. Will the Province Embrace It?

Many drug users could have access to life-saving inhalable prescription heroin for the first time in Canada — if British Columbia’s provincial government gets on board.

The first shipment of inhalable prescription heroin procured by B.C.’s only non-profit pharmaceutical company will arrive from Europe by the end of the month, a step that experts hail as key to curbing the surging overdose crisis.

But provincial government efforts to expand safe alternatives to increasingly poisoned and fatal street drugs have so far stopped short of prescription heroin.

Vancouver’s health authority and a number of clinics are eager to start dispensing it and can do so without provincial sign-off, but will be limited in the amount they can purchase and distribute without provincial support.

“People are dying, so we have not stopped trying to get them what they need. The numbers are worse than ever in terms of overdose deaths,” said Dr. Martin Schechter, co-founder of the non-profit Fair Price Pharma, which has agreed not to name its federally licensed European supplier.

Schechter and former B.C. provincial health officer Dr. Perry Kendall formed Fair Price Pharma last year to offer prescription heroin on their own, in the face of what Schechter called “entirely political” decisions not to pay to expand the project that currently offers injectable heroin-assisted treatment to a small group of people.

“Our strategy in B.C. has not been successful. It really is time to do something different,” he said.

The initial batch could support as many as 400 people for four months depending on dosages, Schechter said, and would more than triple the number of people accessing prescription heroin in B.C. Subsequent shipments are already being arranged, he said.

Fair Price Pharma’s announcement comes after years of Canadian governments citing high costs and lack of a domestic supply as reasons not to import or manufacture more pharmaceutical-grade heroin, known as diacetylmorphine or DAM, for substance users.

In the 20 months since COVID-19 sent the overdose crisis into a tailspin, more than 2,500 British Columbians have died in what will be back-to-back record years for overdose deaths. Vancouver has been the hardest hit municipality in Canada, reporting at least 651 residents dying between January 2020 and June 2021.

Heroin-assisted treatment is a form of safe supply that aims to separate patients from the toxic, unreliable and criminalized street drug market.

Currently, only 150 patients in Canada, all in Vancouver and Surrey, receive two to five supervised injections of prescription heroin at a specialized clinic. The Crosstown Clinic in Vancouver’s Downtown Eastside neighbourhood recently began to allow about a dozen patients to take home their remaining doses after a morning check-in, a first in North America.

Decades of evidence from a number of European countries and two landmark trials in B.C. have shown the treatment to be astoundingly successful at saving lives and improving quality of life for entrenched substance users for whom first-line treatments have not been effective.

Once enrolled in the treatment, patients in B.C. were more able to find and keep jobs and stable housing, had better health overall and were less likely to commit survival crimes or be admitted to the hospital. Treatment costs about $45,000 per patient per year but saves about $140,000 annually in policing and costs per individual, the studies found.

“That’s why it’s so mystifying, why the one injectable treatment that has been studied medically the most is the same one being omitted from the [provincial] guidelines in B.C.,” said Schechter.

The number of patients accessing heroin-assisted therapy in European countries has also remained stable for decades at around five to eight per cent of people who are opioid-dependent. There are about 1,000 patients enrolled in European Union countries and 1,400 more in Switzerland.

“Patients are able to work, care for their families, have more free time and do things that are more conducive to a good quality of life,” said Dr. Scott MacDonald, medical lead at Crosstown Clinic that treats about 90 individuals in the Downtown Eastside. “Even without other changes, [prescription heroin] reduces the cost of the status quo.”

But Vancouver alone is in need of hundreds more spaces in these programs, he said, as are communities across Canada. Only about 0.3 per cent of all 83,000 people estimated to be opioid-dependent in B.C. are able to access prescription heroin, far behind the number that have benefited in Europe for decades.

“The reason it’s not available is really just on willingness to pay, which comes down to stigma,” said MacDonald.

Fair Price Pharma wants to start with inhalable heroin before it begins to process the raw materials for injection, Schechter said.

Providing inhalable in addition to injectable heroin is an important step to ensure there are diverse options to meet people where they’re at, MacDonald said.

Many people who use substances choose to inhale because they feel it’s safer than injecting, he said, but there is still a risk of overdose and dying.

Schechter said there’s been strong support for the medication from Vancouver Coastal Health and clinics who say they are ready to start administering it.

MacDonald said he expects there to be some version of a domestic supply of prescription heroin in Canada by mid-2022, based on conversations with health officials.

But the health authority declined to comment and directed The Tyee’s request for confirmation to the province.

In an emailed statement, a spokesperson for the Ministry of Mental Health and Addictions said the province’s new guidance focuses on pharmaceutical alternatives like fentanyl patches based on guidance from medical experts on what could benefit people using substances the most.

MacDonald said patches and oral medications can be useful for some, but keeping a consistent method of administration, like injection or inhalation, is essential for many substance users to continue treatment.

“If there are hundreds of people accessing supervised consumption sites on a daily basis to inhale their substances, then clearly the current options are not attracting them or keeping them in care,” said MacDonald. “The flexibility and de-medicalizing the access and the options is really key.”

When COVID-19 pushed Crosstown to start delivering DAM to some patients in isolation, and then move to allow some patients to take doses home with them this summer, MacDonald was surprised by how easy it was when patients, doctors, the health authority and government worked together.

It could be just as easy to expand prescription heroin treatment, MacDonald said, if there is the political will.

“It’s been possible for years,” he said, “and all these life-saving treatments are sitting on the bench.”