It was out of fear for their lives that Nanky Rai decided, about eight months ago, to start prescribing hydromorphone tablets to a handful of her patients. They were patients who were using the ever-more potent drugs available on the street, drugs which are considered responsible for the overdose deaths of 11,500 Canadians between 2016 and 2018.
A more recently developed opioid agonist therapy (OAT) is injectable hydromorphone, which was the subject of the 2016 SALOME randomized control trial. SALOME compared injectable hydromorphone with prescription heroin in people who had opioid addictions and had previously stopped taking other treatments, such as methadone. An earlier study, the NAOMI trial, had found heroin to be more effective than methadone at helping people with opioid addictions who had not responded to other treatments; SALOME showed injectable hydromorphone to have similar outcomes to heroin when used as an injectable opioid agonist therapy, or iOAT. This past May, on the strength of this evidence and in light of the worsening opioid crisis, Health Canada approved the use of injectable hydromorphone as an iOAT, becoming the first country in the world to add this indication for the drug.
Safe supply proponents point to the NAOMI and SALOME trials, which showed that participants in those programs reduced their use of street drugs, as the evidence base from which they “push for an emergent response to the crisis by prescribing hydromorphone.” It is important to note that these were trials that used injectable hydromorphone or heroin as part of treatment programs with the ultimate goal of participants reducing their use of opioids (participants were observed taking the drugs), whereas providers of safe supply are using the drug primarily for harm reduction and the stabilization of problematic drug use, with the goal of decreasing the risk that participants will take contaminated street drugs.
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