"The crisis is not going to get better unless we address the underlying contaminated drug supply."

I’m old enough to remember the fight to get the Insite supervised drug injection site open on East Hastings Street in September 2003.

It’s an understatement to say it was controversial.

To some, it still is.

I won’t replay the backstory that led to its opening.

But I use that time in the city’s drug fight as a reference point for a parallel push today from health experts, drug users, politicians and police who want to see an expansion of a “safe supply” of medical-grade drugs to combat drug overdose deaths.

We saw some of that expansion occur earlier this month.

Dr. Mark Tyndall’s MySafe Project is an 800-pound dispensing machine secured to a floor in a Downtown Eastside building that allows registered users to access free hydromorphone pills and take them home.

So far, only a handful of users have access to the machine.

Meanwhile, on some desk in Ottawa is a proposal from Vancouver Coastal Health that requests the feds allow chronic drug users to access prescribed medical-grade drugs such as prescription heroin and hydromorphone and take them home, or to wherever they get high.

We’re talking up to 250 users per year at an annual cost of $1.5 million.

That’s kind of a big deal since programs that currently operate in Downtown Eastside facilities — aside from Tyndall’s project — don’t allow users to take the prescribed drugs off the premises.

Some of you reading this might have a problem with the take-home approach, pointing out that users will be given medical-grade drugs paid for by government that they could potentially sell on the street, instead of using it as prescribed.

It’s a valid concern.

But Dr. Patricia Daly, the chief medical health officer for Vancouver Coastal Health, has a response to that and other questions about the proposal, which is called SAFER — Safer Alternatives For Emergency Response.

“Every expert now says we have to get past some of those worries that we have because the crisis is not going to get better unless we address the underlying contaminated drug supply,” said Daly, noting users registered in the program would be monitored, evaluated and have to be stabilized before taking drugs home.

She said current models in place that provide medical-grade heroin (Crosstown Clinic) and hydromorphone (Molson Bank building) to users can be onerous for people who are unable or don’t want to visit a fixed site, sometimes multiple times a day, to consume the drugs.

Colin Ross at Pier Health Resource Centre in 2018. Photo Dan Toulgoet

That was a point made by Colin Ross when I tagged along with him over a few months in 2018 as he made daily trips to inject doctor-prescribed hydromorphone at a Main Street pharmacy.

His daily regimen required him to travel from his West End apartment and visit the pharmacy twice a day, then attend his local drug store in the evening for an oral dose of hydromorphone.

Although grateful for the program, Ross – a longtime heroin user – said it dictated his day and wished he could be trusted to take the drugs home.

The federal government is expected to make an announcement in the next month or so on whether Vancouver Coastal Health’s proposal will be given the green light.

The health agency applied for $6 million to operate a four-year experiment with up to 250 users, and possibly more after the first year of operation.

The proposal is being reviewed under the parameters of Health Canada’s Substance Use and Addictions Program, which provides grants annually of approximately $50 million.

Daly said the proposal has the support of Mayor Kennedy Stewart, Police Chief Adam Palmer, B.C.’s Mental Health and Addictions Minister Judy Darcy and the B.C. Centre on Substance Use.

“It’s building on work we’ve already done, but it would be even lower barrier and it’s trying to get at models where we do have a safer alternative to the toxic drug supply, and it doesn’t have to be through a very medicalized model,” Daly said.

If the proposal is approved, she said, details about type of drugs and where users would access them would be finalized.

Asked whether diacetylmorphine, which is medical-grade heroin, would be considered, Daly said “we will consider any legal alternative to illegal drugs.”

That, she said, will depend largely on availability and preference. Diacetylmorphine is expensive and made in Switzerland, although it was once made in Canada. As for preference, she noted studies have shown heroin is the preferred choice of many users.

“But that’s challenging for a program like this because of the supply issue [of diacetylmorphine],” Daly said.

“So people are using things like Dilaudid pills [the brand name of hydromorphone] because that’s more readily available, easier to come by, inexpensive.”

Added Daly: “But we have not said we’re only going to use one drug or another. I’ve learned through this [crisis] to not be too rigid and see what’s available and what we may be able to use.”

Dr. Patricia Daly, the chief medical health officer for Vancouver Coastal Health. Photo Dan Toulgoet

Some will recall that Vancouver has gone down this road before with what are commonly known as the NAOMI and SALOME trials, which were both seen as successes by health experts.

Prescription heroin and methadone were used in the NAOMI trial, which ran between 2005 and 2008. Hydromorphone and prescription heroin were compared in the SALOME trial, which ended in 2015.

Results of the NAOMI trial, which were published in the New England Journal of Medicine, showed participants given heroin reported improved physical and mental health.

The results also showed 62 per cent of the 251 participants – 192 in Vancouver and 59 in Montreal – were more likely to remain in treatment.

Forty per cent were less likely to take illegal drugs and commit crimes to support their habit than those treated with methadone, according to the study.

Findings of the SALOME trial included:

Injectable hydromorphone is as effective as injectable diacetylmorphine for long-term street opioid users.

Almost 80 per cent of 202 participants remained in treatment for six months.

Participants reported a significant reduction in days of “illegal activities,” from an average of 14.1 days per month to less than four.

Participants on both hydromorphone and prescription heroin reported far fewer days using street heroin after six months – from almost daily use to three to five days per month.

Neither of the trials allowed participants to take drugs home, although it should be noted that drug users across the province have been able to pick up methadone at a pharmacy and leave after a pharmacist witnesses the first dose.

And last year, St. Paul’s Hospital launched a pilot program where some overdose patients could take home Suboxone, a pill composed of buprenorphine and naloxone.

In Ross’s case, neither methadone nor Suboxone gave him the same high he experienced when using heroin. Last time I was in touch with Ross, he was looking to get on the program at Crosstown that provides prescription heroin.

A doctor at Crosstown told me last week there is a long wait list.

Daly said she sees parallels in the fight for the expansion of safe supply to the fight to open the Insite supervised injection site in 2003. Insite became the first legal injection site in North America and survived several legal battles to keep the doors open.

"At that time, the federal government was really innovative and willing to try something new," she said, noting the federal government paid for what was initially a three-year experiment.

Now, injection sites and overdose prevention sites are open throughout B.C. and across Canada, giving access to users who would normally inject in an alley or by themselves at home.

Daly noted federal Health Minister Patty Hajdu was in Vancouver two weeks ago to visit Insite and the PHS Community Services Society-run hydromorphone program at the Molson Bank building.

Daly said the minister commented on Vancouver’s proposal, saying it was a strong application. Hajdu, by the way, is the former drug strategy coordinator of the City of Thunder Bay, Ont.

Prime Minister Justin Trudeau’s mandate letter to Hajdu in her new role as minister of health said the following:

“Work closely with other orders of government, as well as substance use experts, service providers, first responders, law enforcement and people with lived and living experience in order to ensure Canada’s response to the current opioid crisis is robust, well-coordinated and effective.”

We’ll find out soon enough whether that includes another safe drug supply experiment in Vancouver, where programs already exist and doctors, users, politicians and police – who have drawn a straight line between drug use and property crime – sorely want them to expand.

Because right now the news isn’t good.

More than 900 people have died of drug overdoses in Vancouver since 2017.

mhowell@vancourier.com

@Howellings

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