How Canadian Drug Users Helped Save an Injectable Opioid Agonist Program

    Amid a historic fatal overdose crisis, the Canadian province of Alberta wanted to end an opioid use disorder (OUD) treatment program that met the needs of patients for whom oral opioid agonist treatment (oOAT), like methadone or buprenorphine, had proven unsuccessful.

    But a group of 11 patients enrolled in the government-funded injectable opioid agonist treatment (iOAT) clinics—based in Edmonton and Calgary, and providing supervised hydromorphone injections alongside wrap-around social services—were not going to let their program go down without a fight.

    Although Judge G.S. Dunlop denied, on February 25, the plaintiffs’ request for the Court of Queen’s Bench to stop the Alberta Health Service (AHS) from shuttering iOAT clinics on March 31, AHS plans on continuing to offer its unique services in a new form—while erasing the drug-user advocacy that seems to have helped save the program in the first place.

    A spokesperson for Alberta’s Associate Minister of Mental Health and Addiction Jason Luan, who oversees the iOAT clinics, doubled down on rhetoric in a statement to Filter—saying that the Government of Alberta “defeated” the patients in court and implying that the agency had been planning to continue the same level of services all along.

    This seems to be an example of “gaslighting,” the plaintiffs’ lawyer, Avnish Nanda, suggested in a tweet.

    The spokesperson’s suggestion that the “Government committed to support these clients before the court case, during the court case, and after it completed” seems to not have been clear to Nanda. After all, AHS didn’t confirm that patients could still access iOAT medications—but not the suite of wrap-around services that distinguish the program from others—until November 16, 2020, two months after the plaintiffs’ September 30 filing.

    “I applaud each plaintiff for their courage, honesty in telling their painful stories, for their patience and for their sense of hope.”

    And it wasn’t until March 2, according to email screenshots shared with Filter by Nanda, that iOAT staff and patients received logistical confirmation from AHS that the comprehensive wrap-around services would be continued for another two years—just in the different setting of Opioid Dependency Program (ODP) clinics, essentially Canada’s equivalent of methadone clinics.

    The features that defined the success of the iOAT clinics for the patients will be transferred to the ODP context, thanks to a new $6CA million funding stream. The email appears to say that there will be a dedicated psychosocial team for iOAT patients. The spokesperson confirmed this, saying that patients will have access to “psychosocial supports as determined by their clinical care team.”

    It’s unclear if the primary medical care will be in-house, as was previously the case. Hours for iOAT services, according to the email screenshot and confirmed by the spokesperson, will remain the same (12 hours per day, seven days per week), despite ODP clinics’ different operating hours.

    In January 2021 testimony, government officials had asserted that the iOAT wrap-around services would be continued in ODP clinics. “Well, but I want to be clear, it’s not a proposal. It’s what we’re doing,” said John Cabral, assistant deputy minister for Health Service Delivery, as Judge Dunlop re-printed in his decision.

    But there was some shakiness: For example, Cabral clarified that same level of primary care would not be offered on-site at the ODP clinics, as had been the case at the iOAT clinics. And Mark Snaterse, AHS’s executive director, said that ODP clinics would not be offering iOAT patients “a Cadillac psychosocial service anymore,” or what Judge Dunlop rephrased as psychosocial services on a “reduced scale.”

    The role of the legal advocacy of the patient-plaintiffs and Nanda in influencing the government’s decisions is not entirely clear. The Government’s spokesperson, of course, said that the current plan for iOAT was always the province’s intention. Kym Porter, a member of Moms Stop the Harm who advocated to save the program, certainly felt that this work mattered.

    “It is difficult to say exactly how the work of advocates helped save the program but I want to believe it did. It gives me hope,” Porter told Filter. “My initial credit goes to Avnish Nanda for his courage and advocacy to take on this case. Secondly I applaud each plaintiff for their courage, honesty in telling their painful stories, for their patience and for their sense of hope.”


    The Significance of iOAT

    When Porter first learned the news that iOAT would be carrying on, albeit in a new form, she cried. “I sat down with tears of relief for the plaintiffs and their families using the iOAT program. I also felt a sense of hope for people with OUD as well as for, perhaps, advocacy work.”

    As Nanda, the lawyer, described in a March 2 statement, the news is “life-saving.”

    He seems to mean that quite literally. Patients and advocates feared the consequences of ending a program dedicated to a type of treatment shown to be more effective than oOAT at reducing patients’ reliance on the illicit, adulterated opioid supply driving the province’s record-breaking fatal overdose crisis. In fact, the very announcement of the iOAT program’s closure prompted patients to disengage, and one person who left the program died, according to an affidavit submitted in the case by Dr. Krishna Balachandra, a staff member at the iOAT program.

    “After the news [of the announcement], I returned to using street opioids. I returned to street opioid use because I felt like the system had abandoned me again and that I knew that without iOAT I had no other option to manage my opioid use disorder aside from using street opioids,” wrote the plaintiff known as AFME in an affidavit recounted in the Justice Dunlop’s decision. “It would be safer for me to start using street opioids now rather than immediately after I was cut off from iOAT entirely in March 2021. For this reason, I gradually started introducing them into my consumption habits along with the medication I received through iOAT until street opioids became the primary basis of my opioid use.”

    “iOAT is more than just access to injectable hydromorphone. It is about creating the conditions necessary to make patients feel safe and want to access the medical system.”

    The success of iOAT for patients appears to be more than just attributable to a pharmaceutical. Patient-plaintiffs say that iOAT and ODP clinics are simply not comparable in their services offered.

    “ODP can never provide what iOAT provided patients like me. ODP didn’t work for me when I tried to use the program, largely because it couldn’t cater to my unique needs. iOAT put in real effort to understand and help me address the sources of my opioid use disorder and built trust with me to undertake the treatment,” wrote AFME in a different affidavit. “iOAT is more than just access to injectable hydromorphone. It is about creating the conditions necessary to make patients feel safe and want to access the medical system, which has failed us so many times.”

    John Cabral testified that ODP clinics don’t offer the same services as those offered at the iOAT programs, as Justice Donlop noted in the opinion.

    A 2021 study of the Alberta iOAT clinics showed the importance of the social relationships built in the clinics for positive treatment outcomes. “The results indicate that the iOAT program not only provided participants with effective treatment for OUD,” wrote study author Jennifer Jackson, a nursing professor at the University of Calgary, “but also supported clients in building relationships with iOAT staff, which was crucial in positioning clients to achieve positive outcomes.”

    Because of the access to treatment facilitated by strong relationships, patients reduced their reliance on the illicit, adulterated supply, and enjoyed improvements in their “general health and social well-being, including by improving housing and financial stability, social connections, and access to essential health services.”

    The embedded iOAT program in ODP clinics will not be accepting new patients, which Nanda lamented. Adding more patients could be a way to build trust with the patients who felt abandoned when the initial closure was announced, Porter believes. “I […] believe opening the program to those who, in the future need it, instead of freezing it to just those currently on it, would help gain some trust from those on the program as well as those waiting,” Porter said.

    “My clients believe and will continue to fight for iOAT to be available to any Albertans who need it, and we know there is work going on to ensure that is the case within AHS,” tweeted Nanda, who appealed Justice Dunlop’s decision on March 1, “but forcing the government to step back on its proposal is an achievement worth celebrating.”


    Photograph of the iOAT clinic courtesy of Moms Stop the Harm

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