Front Burner - Why B.C.'s former health officer wants to produce legal heroin

Episode Date: July 16, 2020

British Columbia's former provincial health officer, Dr. Perry Kendall, has been a harm-reduction advocate for decades. Now, he's planning to launch a company to produce a domestic supply of affordable, legal and pharmaceutical-grade heroin to be used "as a medication for therapy and treatment, but also … to try and cut down the number of unfortunate and preventable deaths that we're currently seeing." Today on Front Burner, a conversation with Kendall about a safer supply of drugs and the overdose crisis.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hi, I'm Josh Bloch. Dr. Perry Kendall never expected he'd be launching a pharmaceutical company. For almost 20 years, he served as British Columbia's provincial health officer. In 2003, he was involved in the opening of Insight, North America's first legal supervised injection site

in Vancouver's downtown Eastside. In 2016, he declared BC's overdose crisis a public health emergency. And now he's helping start a company called FPP, short for Fair Price Pharma. And while it's not there yet, its goal is to produce one drug, diacetylmorphine, also known as pharmaceutical

grade heroin. Today, a conversation with Dr. Kendall about how decades in harm reduction advocacy led him to this point. This is FrontBurner. Dr. Kendall, thank you so much for joining me. Oh, my pleasure. I think maybe it would sound surprising to some people that the former BC medical officer of health is getting into the pharmaceutical or thinking about getting into the pharmaceutical business to produce essentially heroin. I want to start by asking you, who is this pharmaceutical grade heroin for? I want to start by asking you, who is this pharmaceutical-grade heroin for? Well, pharmaceutical-grade heroin is a treatment option that has been available in Europe for a quarter of a century.

For people who do not respond to the standard treatment of methadone or buprenorphine suboxone, heroin has proven to be a really stabilizing medication for their lives. It stabilizes them, keeps them away from the illicit drug markets, it keeps them healthier. Their physical and mental health improves and so does their social functioning. And in the 25 years that Switzerland, Holland, Germany, etc. have been offering this treatment, people have transitioned to methadone, have come off drugs, have improved their life and their functioning

and returned to recovery. Not everybody, of course, but many people. So it is a proven route that is available to many people in Europe, but not currently to more than about 120 people in Canada. Your partner in this venture, Dr. Martin Schechter, actually led two studies into this. Can you tell me about that? Sure, yes. The first study was called NAOMI, which is the North American Opioid Medication Initiative, which is essentially a randomized controlled trial. He recruited people who were at least 25 years of age who injected heroin daily, who had had at least two trials of methadone.

Then he randomized them into two groups. One would receive heroin and counseling, and the other would receive optimal methadone treatment and counseling, and followed them up for a year. And people on Darostalmorphine, nearly 90% of them were still in treatment at the end of the year versus about 50% in the methadone program. And they were doing considerably better when it came to not using illegal drugs, not being engaged with the police and physical, social and mental functioning.

Being part of NIAOMI, I got my life back together. I got another job, I started being responsible and taking care of myself. That amazing stress that was in my life of having to find that drug every day was gone. It was just like this weight was lifted off my shoulder. The newer thing is with the highly toxic drug supply with fentanyl and other synthetic analogs, which has swamped the illegal market, as you know, we are seeing a huge toll of deaths and overdoses. And so if we could add heroin to the safer supply risk mitigation guidelines, we know that many people, we know from talking to people who are actually engaged in active drug use or past drug use, we know that many of those people would accept diastole morphine

as a substitute and get away from the fentanyl, and they would be safer. They would be engaged in some form of care. This, you don't have to play Russian roulette. You know what you're getting. And who knows, at some point in time, they may be more engaged in the therapeutic program. So we would need it as a medication for therapy and treatment, but we also, I think, it would be a real boon to try and cut down on the number of unfortunate and preventable deaths

that we're currently seeing from people using fentanyl. Well, and that crisis has only been aggravated by COVID-19. COVID-19 is not our only health crisis. This morning, the V.C. coroner's office announced 170 people in British Columbia died from overdoses in the month of May. I cannot express how difficult this news has been to hear. May was the deadliest month for overdoses on record in B.C., but before COVID, the numbers were still staggering. Five and a half thousand people in B.C. alone have died since 2016. There's been 15,000 deaths nationwide in that time.

15,000 deaths nationwide in that time. That was unthinkable until fentanyl came on the market. So what do you hope your company will provide? We hope that we will provide a domestic supply that is accessible, affordable, not subject to the global market or the pricing and the necessary profit-taking that pharmacies, larger pharmaceutical companies do to keep their stakeholders, their shareholders happy. We think we can produce medication in a more appropriate dosing, free-filled syringes, doesn't need special care, doesn't need to be formulated, would be a lot less difficult and cumbersome to produce locally than it is to import it from a Swiss manufacturer

via sort of international trade routes, etc. And so to be clear, this is a non-profit-making enterprise? Yeah, I think we'd be doing this on cost recovery. And just walk me through a little bit more about how this is actually distributed. I know that there's been pushes to get safe supplies to people, especially during COVID, where we've seen such an uptick in overdose deaths, as you've mentioned. But those have been alternatives like methadone and hydromorphone.

as you've mentioned, but those have been alternatives like methadone and hydromorphone. How does this fit into the pushes to get safe supplies to people with addictions? Well, under the Controlled Drugs and Substances Act, all these controlled substances have to be prescribed. Currently, Physicians Act is the gatekeepers. We would like to work under the Control, Justice and Substances Act with Health Canada to see if we can make them equally accessible or more accessible by adding to the numbers of people who can prescribe these medications. So licensed nurse practitioners, pharmacists, et cetera.

That would require some changes, I think, to the Control, Justice and Substances Act. I think we are training physicians and encouraging physicians during the COVID emergency, and I think it should be through the overdose emergency as well, to provide these safer medications under a kind of a public health rubric, so that we're not necessarily expecting people to engage in therapeutic relationships right away, but we can engage people in a lower barrier program and keep them alive, keep them in contact, and hopefully as lives get stabilized

and away from the illegal drug market, people will be safer and people will start thinking about, you know, maybe they'll have a time to get their lives in order. They won't be worried about falling into withdrawal. They won't be worried about where do I get my next money from? Do I have to sell a little bit of drugs to get enough to buy myself some drugs? Do I have to get involved in the sex trade? Do I have to steal things?

So life could become a lot stabler for many of these people. If I wasn't here, I'd probably be in an urn or underground. There's a lot of people who are just in desperation. They just give us enough so that we're functionable and so we can feel what it is to have a chance at being human again. What do you mean by that? Before, it almost felt like I was just existing. I think it would be a really good idea

if we added to this some aspects of the Portuguese model where there is decriminalization of small amounts of currently controlled substances so that people aren't labeled as criminals and spend far less time in court, but are seen as people with health chronic relapsing health problems, and we can put a care system around them. Very interestingly, every one of these heroin treatment programs has been assessed for its cost-benefit analysis. It clearly shows that it saves society considerable amounts of money compared to leaving somebody out on the street or untreated or at the mercy of an illicit drug supply and whose primary contact with health care is possibly through the police or the jail system. Well, right.

So, you know, you talked about how it can save money. It's been well studied. It's a medically approved harm reduction measure. And you mentioned before that there are a limited number of people in Canada, specifically in British Columbia, I believe 130 people who are receiving injectable legal heroin. Why isn't it a more common practice right now? That is a very good question. That is a very good question. Partly it is, I think, the issues around pricing and difficulty in accessing. But I think as well, there's a kind of political, heroin has a lot of sort of baggage with it. I mean, you will recall that the Harper Conservative government, one of the first things they did when they got into power, Tony Clement said

the party's over, and one of the things that he clamped down on was all harm reduction. And the Harper government passed legislation making it illegal to prescribe heroin to anybody. And that was only overturned by the Supreme Court of Canada decision. So there's a lot of political baggage. People don't see it as a legitimate part of the pharmacopoeia, if used

properly. It's time to be straight with Canadians so Canadians who use drugs can get straight. Because narcotics destroy lives. They rob young people of their futures, they tear families apart, and they lay waste to our communities. I came across an article from McLean's in 2013 when the Harper government was attacking one of those, the safe supply programs that you've been talking about. And you said at that time that you think it's ethically quite dubious to withhold access to a scientifically proven treatment. I mean, it must have been frustrating then, and I wonder if it's frustrating now, to run up against these kind of political obstacles.

Yes, it is, particularly when other countries have sort of overcome that barrier and can provide interventions that have seen to work and work well. But that means, I mean, public health faces a lot of these obstacles. It's part of the sort of history of public health, and it takes time to bring these initiatives to bear. I mean, look at Insight from the first report that was written for the Health Canada and the federal provincial territorial Ministers to opening Insight took all of four years. And you look at the trials and tribulations that Insight had to keep going. The narratives that people were believing in were based on false assumptions that had been created out of this war on drugs mentality.

That the drugs themselves are responsible. on false assumptions that had been created out of this war on drugs mentality, that the drugs themselves are responsible. Most significantly, people came to accept that you can't reach people if they're excluded and we need to bring them in. But now, supervised consumption sites are a feature across the landscape in Canada. We're still hugely contentious in the United States, and we have some provinces that, for political and ideological reasons, I think, are not happy with them. But we have to change people's opinions, I think, one mind at a time. I'll see you next time. as entrepreneurs through angel investment and industry connections. Hi, it's Ramit Sethi here.

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In my new book and podcast, Money for Couples, I help you and your partner create a financial vision together. To listen to this podcast, just search for Money for Couples. You mentioned that the other barrier of expanding these programs is being cost. Is that where you and Dr. Schechter are hoping to come in? Yes, it is. Some of the cost projections that we could come in, looking at a third to a half of the cost of the current drug supply, and potentially compared with drugs that have to be prepared and compounded and delivered considerably lower cost for maintenance.

And why has this fallen to you rather than a more traditional pharmaceutical manufacturer? That's a good question. Health Canada have put out calls to the more commercial pharmaceutical companies for interest in opening up a manufacturing center in Canada. I think it's because they don't see the market as being large enough or profitable enough to go into it. I think we also might be worried about concerns about if people overdosed on it, for example, they might be liable. And I think there is just not enough of a profit margin in it for them. I want to ask you more about the opioid crisis.

What was it like to be the B.C. Medical Officer of Health as the overdose crisis really took hold? It was really very, very, very, very disturbing. Illegal drugs were killing people and are killing people at a rate that far exceeds that of influenza or currently COVID. And so the challenges are to try and get a response that's adequate to the mortality and the morbidity

because I think that people who use illegal drugs and people who are addicted or dependent, they bear a huge stigma. I just didn't decide one day, hey, I think I'm going to become a heroin addict. I think I'll give up my family, my friends, everything I ever owned, all the life I made for myself. I think I'll give all that up and just, you know,

sleep on a cardboard box and inject heroin every day. It's a huge kick in the balls, man. You know, when people just don't want to look at you. Right? I want to choose life. And on top of that, if it's a controlled substance you're addicted to, then you're also subject to the criminal law.

And so there is little sympathy for you in the public. It's seen as a moral failing or a criminal failing. And it's been 30 years now that we people who have addictions knowledge have been trying to make the point really that this is a chronic relapsing health condition with changes in brain chemistry. And that many of the people who have the most serious problems, they're treating some kind of a pain, whether it's a physical pain or a psyche pain or an emotional pain, and they are using this as self-medication, and you need to understand that.

These are not weak or stupid people who made bad decisions. These people need assistance and help and compassion. They are brothers, children, sisters, parents, friends. And the anti-Sigma campaign is something that really has to be addressed. I don't understand why this safe, effective, cost-effective treatment has not expanded, given the knowledge that's existed since the early 90s. My concern is that the barrier is discrimination. I think it's still the stigma that blunts our compassion

and willingness to spend the resources that are really required or change the policies and the direction that really is required if we're going to address this by changing the regulations and the attitudes, because it could be done. Portugal has shown an example of one approach, which has had a really significant impact. We have managed to do it with cannabis in recent history. So I think that if we are serious about this, and we need to be, that this is a conversation that we have needed to have for at least two decades. Well, how many lives do you think could have been saved

if there was this kind of safe legal prescription heroin available 20 years ago? Thousands. I think we're at the turning point around drug laws and access to a safe supply and treatment. I mean, we need to put access to treatment along a continuum of care. We need to put prevention in place as well. We need harm reduction, we need treatment, we need safe supply, and we need recovery options to meet people where they are. So we need all of those things. The diastole morphine piece is a small piece of a complicated puzzle, but I think we're actually at the point now where we were in the late 1990s and the 2000s, where we were engaged

in this debate around supervised consumption sites, whether or not they were acceptable, whether or not they'd work. And we've come a long way in 20 years since then. Well, not even 20 years, 17 years. I think it's time to have an adult discussion about what works, what doesn't work, and why. And as I say, the Health Officers Council of BC called government to look at a regulated legal supply of what are currently legal substances. supply of what are currently legal substances. Given that the current law, I would argue it puts people at far more risk nowadays than a legal supply would. Dr. Perry Kendall, thank you so much for speaking with me. Thank you for listening to Fremper. For more CBC Podcasts, go to cbc.ca slash podcasts.