Sep 07, 2021
By Ben Fyshe , Tasleem Dewani , Manal Kleib
Prescribing injectable opioids: a necessary and effective treatment to reduce harm
People who use illicit substances are often vilified, devalued, and punished. Abstinence is often considered the only option for treatment (Alberta Health, 2020). This mentality is a product of aggressive and stigmatizing drug policies, which punish and force abstinence on people with substance use disorders, and it has proven largely unsuccessful (Gray, 2012).
Despite this failing, world drug policy remains focused on punishment and abstinence (United Nations Office on Drugs and Crime, 2016). By comparison, socio-economic support and treatment programs tailored to individual needs, such as injectable opioid agonist treatment (iOAT), have demonstrated superior health outcomes (British Columbia Centre on Drug Use, 2020).
Illicit drug supply is increasingly contaminated with fentanyl and other dangerous unregulated substances. Providing access to medical-grade opioids in prescribed doses through the iOAT program has reduced the incidence of overdose and helped persons with substance abuse disorder realize improved health outcomes (Canadian Research Initiative in Substance Misuse, 2019).
- Support for persons who live with substance abuse disorder should be holistic, involving a variety of options, including sobriety-based treatment programs and harm reduction.
- iOAT gives people who are not yet ready to abstain a chance at survival by providing access to a pharmaceutical grade of medication, drastically lowering the risk of overdose.
- iOAT removes the debilitating costs and risks associated with procurement of illicit drugs, helping people to attend to health, occupational, and social needs.
- Provinces should adopt evidence-based policy decision-making with regard to substance use disorder instead of traditional programs that are solely abstinence based.
War on drugs and Portugal
Drug policy remains focused on punishment and abstinence.
Criminalizing possession and trafficking of illicit substances has demonstrated little to no benefit with regard to overdose prevention, drug use cessation, or assistance in recovery. The failure of alcohol prohibition and drug policies of the past and present in the United States offers perhaps the best example of the ineffectiveness of criminalization (Gray, 2012).
By contrast, Portugal is well known for instituting radical change in addressing the high incidence of problematic heroin use and deaths from overdose (da Agra, 2009; Laqueur, 2015). The government pioneered an approach that decriminalized possession of small quantities (equivalent to two weeks’ supply) of all illicit substances (Hari, 2015).
Additionally, the Portuguese government moved on from exclusively punishment to a more supportive approach, while addressing important social determinants of health. Funding that would previously have been allocated for traditional punishment and correction services was now available for initiatives that provided housing, employment, and social supports.
The result was a massive decrease in the rates of heroin use, overdoses, and new HIV infection among people who inject drugs (Hari, 2015). This paradigm shift toward prevention, treatment, and socio-economic support is the paradigm shift that is needed to counter problematic drug use in Alberta, Canada, and the rest of the world.
A landmark study by Alexander, Beyerstein, Hadaway, and Coambs (1981), which was overlooked at the time of its publication, has recently influenced more nuanced views on substance use disorder (Gage & Sumnall, 2019) and its findings are related to the results from Portugal’s revised drug policies. In the study, rats were socially isolated with unlimited access to morphine, which routinely resulted in overdose. However, when rats were provided with social interactions and mental stimulation such as mazes, in addition to unlimited access to morphine, overdoses ceased and overall use of morphine plummeted (Alexander et al., 1981).
The study’s conclusions may have important implications for treatment design of opioid use disorder. If patients with this disorder are supported with improved social determinants of health, such as access to social programs, adequate housing, and employment, while receiving a prescription for opioids, they are more likely to live more productively and eventually decrease or eliminate problematic use of opioids (Hart, 2017).
Injectable opioids as medicine
Oral OAT, such as buprenorphine/naloxone, methadone, or slow-release oral morphine (SROM) alone may be insufficient to manage cravings and prevent withdrawal for some individuals with severe opioid use disorder. A specialist-led treatment option, iOAT is an evidence-based, high-intensity, cost-effective treatment for those with severe opioid use disorder who inject. Multiple cities in Canada and internationally are now using similar strategies (Bell & Strang, 2020; Schaverien & McCann, 2019).
Current evidence demonstrates that iOAT is beneficial in terms of reducing illicit opioid use, premature discontinuation of treatment, criminal activity, incarceration, and mortality (Strang et al., 2015). People who receive this treatment most commonly identify the following key reasons for accessing iOAT: a desire to spend money on other basic necessities, avoidance of high-risk activities associated with buying opioids illegally, and a desire to manage drug use and reduce overdose risk (British Columbia Centre on Drug Use, 2020).
Providing medication in this manner allows people to attend to basic necessities that were not prioritized before due to the need to procure illicit substances through unstable and unsafe channels. Jackson’s (2021) research, interviewing people who access iOAT, identified a consistent trend that this program allows people to focus on securing housing and employment, and improving their overall health.
Current directions in Alberta
iOAT is an evidence-based, high-intensity, cost-effective treatment for those with severe opioid use disorder who inject.
Unfortunately, iOAT may no longer be an option for Albertans. In March 2020, the minister of health released a report that gathered information on the socio-economic impacts of harm reduction strategies, such as supervised consumption sites (SCS) and iOAT (Alberta Health, 2020). The Alberta report committee’s terms of reference explicitly precluded any consideration of “the merits of SCS as a harm reduction tool” (Alberta Health, 2020, p. 2). Community engagement and feedback obtained was a mix of anecdote, opinion, and data taken largely from law enforcement and first responders.
The findings indicated that communities surrounding SCS found lower property values, increased crime, and increased improper disposal of needles in public areas (Alberta Health, 2020). Unfortunately, the committee’s inadequate research design, its restrictive mandate, and its omission of any of the merits of harm reduction suggest that its conclusions lack credibility.
Further, when information was submitted that indicated support for SCS, those positive outcomes were downplayed. For example, one of the championed outcomes from Alberta’s SCS, the reversal of more than 4,000 overdoses (Alberta Community Council on HIV, 2019), was labelled inaccurate (Alberta Health, 2020), and this claim served to devalue the life-saving potential of these sites.
The committee’s mandate, which influenced the manner in which it gathered information, suggests that the review panel was created with a foregone conclusion: to justify a systematic closure of SCS in Alberta, with partial reinvestment of these funds going to more traditional treatment programs. Although abstinence-based treatment is a necessary option on the continuum of care for substance use disorders, this allocation of funding should be done in addition to, not instead of, harm reduction initiatives.
After the release of the committee’s report on March 9, 2020, the Alberta government announced its decision to discontinue funding the iOAT program, eliminating this much-needed treatment modality from future referrals and forcing more than 100 clients into conventional treatment programs that had failed them in the past (Olmstead, 2020). This shift removes support for a vulnerable part of society, even though their participation in the program had already produced signs of stabilization.
Increasing public awareness and advocacy
Increasing public awareness and advocacy for health policy change are key strategies nurses and nursing students engage in to improve health outcomes for all Canadians. The University of Alberta’s Faculty of Nursing undergraduate and graduate programs have created videos and submitted publications to raise awareness and promote widespread knowledge of similar issues.
One example of a useful tool that has contributed to promoting public awareness is an educational video created by Tasleem Dewani (2020), which aims to debunk myths and highlight important positive health outcomes related to SCS and iOAT. This video highlights the potential impact that schools can have on influencing public perception of social issues such as these.
Additionally, organizations of health professionals on the front lines advocate for policy change through various programs and initiatives. The Alberta Nurses Coalition for Harm Reduction (ANCHR) is a network of nurses dedicated to advocating for harm reduction in Alberta. Its mission is “to facilitate research, education, resources and support for frontline nurses in Alberta that seek to integrate harm reduction into their practice” (ANCHR, n.d.). More support is needed for this group, either through additional funds or with the inclusion of other groups of health professionals, such as physicians. There is a need for collaborative efforts to raise awareness of this issue through social media campaigns urging the government to reinstate harm reduction initiatives that have been, and will continue to be, defunded.
The Canadian Research Initiative in Substance Misuse (CRISM) has created national documents for the clinical and operational guidance of iOAT programs to aid in the introduction of iOAT in municipalities across Canada. Their efforts can help pave the way to translate evidence into clinical practice and policy change.
To increase accessibility, these guidelines recommend exploring iOAT delivery across different models including clinics, pharmacies, and doctors’ offices as potential settings for treatment delivery (CRISM, 2019). Promoting iOAT in these settings normalizes the treatment and helps remove stigma associated with accessing it.
Punishing people for using drugs has proved futile, rarely providing a desirable outcome for anyone involved. More nuanced harm reduction approaches, such as iOAT, need to be adopted and implemented in Alberta and across Canada to support persons with opioid use disorder.
Without such initiatives, people unable to stabilize on oral forms of OAT will continue to be at risk for poor health outcomes, permanent injury, and death related to overdose. In addition to individual suffering, society struggles with the financial and social burdens these poor outcomes produce.
It is imperative that policy-makers at the provincial and federal levels take heed of advocacy initiatives and evidence-based research to create or reinstate sustainable iOAT programs.
Alberta Community Council on HIV. (2019). A community based report on Alberta’s supervised consumption service effectiveness. Retrieved from https://crismprairies.ca/wp-content/uploads/2019/08/A-Community-Based-Report-on-Alberta’s-SCS-Effectiveness-2019-08-16.pdf
Alberta Health. (2020). Impact: A socio-economic review of supervised consumption sites in Alberta. Retrieved from https://open.alberta.ca/dataset/dfd35cf7-9955-4d6b-a9c6-60d353ea87c3/resource/11815009-5243-4fe4-8884-11ffa1123631/download/health-socio-economic-review-supervised-consumption-sites.pdf
Alberta Nurses Coalition for Harm Reduction. (n.d.). Mission and vision. Retrieved from http://www.anchr.ca/mission--vision.html
Alexander, B. K., Beyerstein, B. L., Hadaway, P. F., & Coambs, R. B. (1981). Effect of early and later colony housing on oral ingestion of morphine in rats. Pharmacology, Biochemistry and Behavior, 15(4), 571–576. doi:10.1016/0091-3057(81)90211-2
Bell, J., & Strang, J. (2020). Medication treatment of opioid use disorder. Biological Psychiatry, 87(1), 82–88. doi:10.1016/j.biopsych.2019.06.020
British Columbia Centre on Drug Use. (2020). Short cycle iOAT evaluation. Retrieved from https://www.bccsu.ca/wp-content/uploads/2020/02/BC-iOAT-Short-Cycle-Brief-Summary-February-2020.pdf
Canadian Research Initiative in Substance Misuse (CRISM). (2019). National injectable opioid agonist treatment for opioid use disorder: Clinical guideline. Retrieved from https://crism.ca/projects/ioat-guideline/
da Agra, C. (2009). Requiem pour la guerre à la drogue : L’expérimentation portugaise de décriminalisation. Déviance et Société, 33(1), 27–49.
Dewani, T. (2020). SCS and iOAT. Retrieved from https://www.powtoon.com/s/dQOCjP9sViD/1/m
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Gray, J. P. (2012). Why our drug laws have failed and what we can do about it. A judicial indictment of the war on drugs (2nd ed.). Philadelphia: Temple University Press.
Hari, J. (2015). Chasing the scream. Bloomsbury, U.K.: Bloomsbury Publishing.
Hart, C. L. (2017). People are not dying because of opioids. Scientific American, 317(5), 11. doi:10.1038/scientificamerican1117-11
Jackson, J. (2021). “They talk to me like a person”: Experiences of people with opioid use disorder in an injectable opioid agonist treatment (iOAT) program: A qualitative interview study using interpretive description. Qeios. doi:10.32388/8981E5
Laqueur, H. (2015). Uses and abuses of drug decriminalization in Portugal. Law & Social Inquiry, 40(3), 746–781.
Olmstead, J. (2020). Alberta government to end funding for intensive opioid therapy program. Retrieved from https://www.cbc.ca/news/canada/edmonton/injectable-opioid-treatment-alberta-1.5490566
Schaverien, A., & McCann, A. (2019). Glasgow tries to fight drug abuse by prescribing heroin. The New York Times, p. A11.
Strang, J., Groshkova, T., Uchtenhagen, A., van den Brink, W., Haasen, C., Schechter, M. T., Lintzeris, N., Bell, J., Pirona, A., Oviedo-Joekes, E., Simon, R., & Metrebian, N. (2015). Heroin on trial: Systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction. British Journal of Psychiatry, 1, 5–14. doi:10.1192/bjp.bp.114.149195
United Nations Office on Drugs and Crime. (2016). Outcome document of the 2016 United Nations General Assembly special session on the world drug problem. Retrieved from https://www.unodc.org/documents/postungass2016/outcome/V1603301-E.pdf