Heroin substitution in Canada: a necessary public health intervention?

In “The Case for a Heroin Substitution Treatment Trial in Canada,” Fischer and Rehm conclude that such a trial is timely, if not long overdue; that there is sufficient evidence both in theory and practice to support such an initiative; and that there is both need and opportunity for improved effectiveness in Canadian opiate substitution policy. In particular, they conclude that there is an urgent need for an expanded continuum of treatment care for opiate addicts, including a broader variety of forms of opiate treatment. While such a position is certain to engender considerable debate in Canada, this is not a new issue. As Fischer and Rehm point out, the landmark LeDain Commission recommended the establishment of a heroin maintenance trial in Canada 25 years ago. Important recent developments help frame consideration as to whether the time is now right for a trial. On Sept. 29, 1997, the Ottawa Citizen reported that (on Sept. 28, 1997) Swiss voters overwhelmingly endorsed their government’s drug policy in a referendum that included the controversial—but seemingly successful—state distribution of heroin to hardened addicts. The Swiss Health Ministry immediately said it would try to put state distribution of heroin to addicts on a permanent legal footing. The results of a three-year study of 1,000 addicts who were supplied with heroin on an experimental basis clearly showed a big drop in crime among junkies on the program, a huge improvement in their health, an increase in the number of those with steady housing and jobs, and promising signs that some would try to kick the habit. On September 25, 1997, the Parliament of the Netherlands authorized heroin distribution to 50 addicts on a trial basis. Germany and Australia are also interested in undertaking trials. It is time for Canada to consider similar policies. Canada is in the midst of a public health crisis concerning HIV and AIDS and injection drug use. The infection is spreading rapidly among injection drug users in Canada. In terms of HIV prevalence among injection drug users, which gives us a snapshot of those currently infected, Montreal has a rate of 20% and Vancouver is at 25%. New infections are occurring at a rapid rate. Currently in Montreal, that rate is 8.2 per 100 person years, and a Vancouver study has documented a rate of 18.6 per 100 person years, the highest in North America. Given that epidemiological data in Canada indicate that those who are becoming infected with HIV are increasingly younger, that Aboriginal peoples are over-represented in groups most vulnerable to infection, that women represent an increasing percentage of new HIV cases, that many are contracting the infection through injection drug use, and that incarceration remains an important risk factor for acquiring HIV because of illicit drug use, it is clear that there is a need to address these urgent public health problems. In recognition of the urgency of the injection drug use crisis, the Canadian Public Health Association and the Canadian Centre on Substance Abuse coordinated a National Task Force which produced the report “HIV, AIDS and Injection Drug Use: A National Action Plan” (May 1997). The report made 90 recommendations for a comprehensive response to the HIV/IDU epidemic in Canada. The Task Force used a harm reduction model for its deliberations and its recommendations flow accordingly. Harm reduction is a well-established public health philosophy. It recognizes that a pragmatic, non-judgemental approach, especially in dealing with addictions, is a more effective way to minimize the harm done by drug use than a model that insists on abstinence as an a priori condition for treatment. While neither condoning nor condemning drug use, the harm reduction model accepts the fact that drug use continues to occur and that it ought not to preclude undertaking preventive initiatives. Needle exchange programs are a good example of an effective intervention that recognizes the reality of injection drug use but offers at least significant protection against the spread of communicable diseases such as HIV or hepatitis C. Heroin substitution and heroin maintenance are reasonable alternatives that have a place in an overall public health approach to injection drug use in Canada. The experience in other jurisdictions, the lessons learned in addictions treatment and the necessity of dealing with an urgent public health problem now mean that Canadians ought to be prepared to try different approaches.