On February 23rd, PAN sent a letter (below) to the Honourable Adrian Dix, Minister of Health, outlining a call to immediately expand access to Diacetylmorphine (DAM) / Heroin Assisted Treatment (HAT) and other flexible prescribed safer supply (PSS) initiatives for people who use opioids. The letter was developed in consultation with the Coalition of Substance Users of the North (CSUN) and other PAN members on the frontline of the drug poisoning crisis, key experts, and people with lived and living experience.
Despite the evidence showing improved health outcomes of HAT, and that it can save lives, today it is available to only a few hundred people in BC. We urgently call on the Minister to expand the Safe Supply program to include access to inhalable and injectable DAM throughout the province.
If you want to find out more about HAT and DAM, we have produced a short Q&A, as well as a more in-depth backgrounder.
We received a response from Minister Dix on April 20 that notes:
“The province of British Columbia has undertaken a number of measures to address the toxic drug supply including introducing a prescribed safer supply and expanding access to naloxone and injectable DAM in medication assisted treatment for people who use drugs. We welcome Health Canada approval of diacetylmorphine as a treatment option for patients with severe opioid use disorder and the approval of a domestic supply we are currently exploring options to use this domestic supply to help expand treatment options for patients in BC.” Read letter in full.
February 23, 2023
Hon. Adrian Dix
Minister of Health
Parliament Buildings
Victoria, BC V8V 1X4
Sent via email: [email protected]
RE: Call to immediately expand access to Diacetylmorphine (DAM) / Heroin Assisted Treatment (HAT)
Dear Minister Dix:
On behalf of PAN and our members, I write to urge immediate action by your Ministry to make prescription heroin/diacetylmorphine (DAM) available, via heroin-assisted treatment (HAT) and other flexible prescribed safer supply (PSS) initiatives, for people who use opioids.
As you may recall, PAN is a network of more than forty community-based organizations (CBOs) and peer-run organizations providing harm reduction, HIV/hep C/STBBI services across BC, including in many rural and remote communities. Our members are working on the frontlines of the drug poisoning crisis, including in many small urban, rural, and remote communities. Our members excel at relational care, meeting people where they are at and providing services across the care continuum.
There is an abundance of clinical evidence (from across Europe and here in BC via the NAOMI and SALOME studies) demonstrating the value of providing people with access to pharmaceutical grade heroin/DAM, in terms of improved health outcomes and quality of life. Despite HAT having been used successfully for well over 25 years, there are only a few hundred people in BC who are accessing treatment (Vancouver and Surrey).
This lack of treatment access runs contrary to the province’s stated aims on a number of levels. One of the key priorities identified by Premier Eby, and reflected in all ministerial mandate letters, is ensuring safer communities both for people dealing with mental health and substance use challenges, as well as for the general population. The Canadian Agency on Drugs and Technologies in Health (CADTH) has concluded that DAM not only saves tax-payer money with lower ER visits and hospitalizations, but there are numerous public safety benefits with decreased expenditures for public disorder, policing, jails, prisons, courts, and gang violence.
Furthermore, your mandate letter asks that you prioritize working with the Minister of Mental Health and Addictions, to accelerate BC’s response to the illicit drug toxicity crisis across the full continuum of care: prevention, harm reduction, safe supply, treatment, and recovery. HAT, and other flexible PSS initiatives utilizing DAM, can and should be a critical component of the province’s Safe Supply program. In their November 2022 report, the non-partisan Select Standing Committee on Health highlighted the challenges with the current Safer Supply response, and made some unanimous recommendations for action:
“… the Committee heard about several challenges faced by those seeking a prescribed safer supply of substances. These include a lack of prescribers and barriers for users including the need for prescriptions, witnessed daily doses, and pharmaceutical alternatives that are not strong enough to prevent withdrawal symptoms or that are available in preferred modes of consumption, such as smoking. Noting the important role that the regulatory colleges and professional associations of physicians, nurse practitioners, nurses, and pharmacists play in BC’s health care system, the Committee recommends urgent collaboration with these organizations to identify and resolve barriers to prescribing. It also recommends assessing the current policy and clinical guidelines for prescribing safer supply to limit barriers and to ensure a range of appropriate prescribed pharmaceutical alternatives are made available.” (P.8)
With now over 6 British Columbians dying every day from drug poisoning in the last two years, as the illicit drug supply grows more toxic, and given that more overdose deaths occur as a result of smoking rather than injecting drugs, we need urgently to provide DAM in both injectable and inhalable formats as a demonstrated effective, evidence-based alternative to the toxic drug supply. We therefore call upon the Ministry to:
1. Immediately add DAM coverage under BC’s PharmaCare formulary – for iOAT, prescribed safer supply programs, and compounding inhalable DAM.
2. Co-create flexible protocols for DAM via prescribed safer supply programs alongside people who use drugs and program operators.
3. Immediately expand the supply and provision of pharmaceutical grade DAM in both injectable and inhalable formats, including:
a. Assisting Fair Price Pharma (FPP) by providing clarity and guidance to manoeuvre through the regulatory process to allow it to begin compounding inhalable DAM.
4. Immediately expand the supply and provision of pharmaceutical grade DAM in both injectable and inhalable formats, to be available everywhere – especially small urban, rural, and remote communities, and Indigenous communities – including:
a. Clarifying as to whether the Ministry’s Pharmaceutical, Laboratory and Blood Services Division has finalized the supply agreement for the domestic supply of DAM with PharmaScience Inc., so that the treatment can be expanded beyond the Vancouver Coastal and Fraser regions.
b. Ensuring all imported supplies of DAM are released into the system.
c. Taking the necessary steps to increase the number of prescribers able to prescribe DAM and supporting existing prescribers – particularly in locations outside of the Lower Mainland.
d. Establishing distribution and delivery systems for flexible PSS initiatives via supervised consumption sites (SCS), overdose prevention sites (OPS) and community-level outreach.
Minister Dix, in 2016 which is the year the public health emergency of overdose was declared, the rate of death from illicit drug toxicity was 20.4 for every 100,000 people. At the end of 2022 it was more than double that, at 42.7. Our current efforts are failing – we must do more. Expanded HAT/DAM access is an effective, evidence-based solution that would promote public safety, but more importantly, make an immediate difference in the drug poisoning crisis by averting preventable deaths.
Yours sincerely,
J. Evin Jones, Executive Director
CC. Honourable Jennifer Whiteside, Minister of Mental Health and Addictions